Malnutrition and Poor Physical Function Are Associated With Higher Comorbidity Index in Hospitalized Older Adults

Understanding the role of nutritional status on the outcomes of nonvariceal upper gastrointestinal bleeding: Findings from a retrospective cohort analysis

BACKGROUND & AIMS

Nonvariceal upper gastrointestinal bleeding (NVUGIB) is a common cause of hospitalization worldwide. Malnutrition, on the other hand, varies in prevalence and closely correlates with age and comorbidities. Though malnutrition is linked to poor outcomes generally, its impact on NVUGIB patients remains unexplored.

METHODS

Using the National Readmission Database (NRD) from 2016 to 2020, we employed the International Classification of Diseases, 10th revision, Clinical Modifications (ICD-10-CM) codes to identify adult patients (aged ≥18 years) admitted with a principal diagnosis of NVUGIB. We further stratified NVUGIB hospitalizations based on the presence and severity of malnutrition. Utilizing a multivariate regression model, we assessed the impact of malnutrition on NVUGIB outcomes. STATA 14.2 was utilized for statistical analysis.

RESULTS

Out of the 742,592 adult patients admitted with NVUGIB, 76,603 (10.32 %) had malnutrition, categorized as mild to moderate (3.01 %), severe (4.00 %), and malnutrition of unspecified severity (3.29 %). After adjusting for confounding variables, all-cause in-hospital mortality due to NVUGIB was significantly higher in malnourished patients, corresponding to the severity of malnutrition (adjusted odds ratio [aOR] 1.83 & 3.52 in mild-moderate malnutrition and severe malnutrition respectively; P < 0.01). Similarly, malnutrition was associated with progressively higher odds of acute kidney injury (aOR 1.39 & 1.54 for mild-moderate and severe malnutrition, respectively), septic shock (aOR 2.41 & 5.12), hemorrhagic shock (aOR 1.71 & 2.16), and intensive care unit (ICU) admission (aOR 2.00 & 2.97), all increasing with malnutrition severity (P < 0.01). Procedural analysis showed lower odds of diagnostic EGD (aOR 0.95 & 0.92), EGD within 24 h (aOR 0.75 & 0.67), and overall EGD (aOR 0.80 & 0.66) in malnourished patients, but higher odds of rebleeding requiring repeat EGD (aOR 1.12 & 1.19) and radioembolization (aOR 2.04 & 2.75), both rising with malnutrition severity (P < 0.01). Finally, resource utilization estimated by total hospitalization charges, length of stay, discharge to rehabilitation facilities (aOR 1.99 & 2.66), and 30-day readmission rates (aOR 1.29 & 1.38) were also significantly higher among patients with malnutrition (P < 0.01).

CONCLUSION

Malnutrition exacerbates the outcomes of NVUGIB including higher in-hospital mortality rates, morbidity and resource utilization. Early identification and targeted management of malnutrition in NVUGIB patients are crucial to reducing adverse outcomes and optimizing healthcare resources.

Frequency and implications of malnutrition in systemic sclerosis

OBJECTIVES

To quantify the frequency and impact of malnutrition in systemic sclerosis (SSc), as diagnosed by the Global Leadership Initiative on Malnutrition (GLIM) criteria, based on weight loss, BMI and muscle atrophy.

METHODS

Australian Scleroderma Cohort Study participants meeting ACR/EULAR criteria for SSc with ≥1 concurrent weight and height measurement were included. The chi-squared test, two-sample t-test or Wilcoxon's rank-sum test was used for between-group comparison as appropriate. Multivariable logistic regression models were used to establish the determinants of malnutrition diagnosis. Kaplan-Meier and Cox proportional hazard models were used for survival analyses, based on malnutrition diagnosis, and individual GLIM criteria (percentage weight loss, BMI thresholds and presence of muscle atrophy).

RESULTS

In this study of 1903 participants, 43% were diagnosed with malnutrition according to GLIM criteria, of whom 33% had severe malnutrition. Participants diagnosed with malnutrition were older, and more likely to have diffuse cutaneous SSc (dcSSc), higher SSc severity scores and RNA polymerase-3 positivity. Gastrointestinal (GI) involvement, multimorbidity, cardiopulmonary disease, raised inflammatory markers, hypoalbuminaemia and anaemia were more common in malnourished participants (P < 0.01). Multimorbidity (odds ratio [OR] 1.6; 95% CI: 1.2, 2.0; P < 0.01), pulmonary arterial hypertension (OR 2.1; 95% CI: 1.4, 2.0; P < 0.01) and upper GI symptoms (OR 1.6; 95% CI: 1.3, 2.0; P < 0.01) were all associated with malnutrition. Health-related quality-of-life (HRQoL) and physical function were poorer in malnourished participants. Survival was worse in those with malnutrition after adjusting for age, sex and dcSSc (hazard ratio 1.4; 95% CI: 1.1, 1.7; P < 0.01).

CONCLUSION

Malnutrition is common in SSc and confers poorer survival, HRQoL and physical function.

Approaches to characterising multimorbidity in older people accessing hospital care: a scoping review

PURPOSE

An increasing proportion of older adults accessing hospital care are living with multimorbidity, with a high degree of complexity of multimorbidity in older hospital populations expected. We aimed to assess approaches taken to characterise multimorbidity in older adults accessing hospital care, including how complexity is considered.

METHODS

Following established scoping review guidelines, all published studies that characterised multimorbidity in a hospital population, with average age ≥ 65 years, were identified via a prespecified search strategy. Six electronic databases were searched to identify peer-reviewed literature published to September 2023 meeting eligibility criteria. Screening was undertaken by two independent reviewers, and data extracted using a standard proforma.

RESULTS

Of 5305 titles and abstracts screened, 75 papers, reporting on 72 unique study populations across 24 countries, met inclusion criteria. There was heterogeneity in most aspects of characterisation. Multimorbidity was defined in 43% (n = 31/72) of studies; most (n = 59/72, 82%) aimed to describe a multimorbidity-outcome association. Number of conditions considered ranged from 2 to 285 and weighted indices were used as a measure of multimorbidity in 75% (n = 54/72) of studies, with 56% (n = 40/72) using a version of the Charlson Comorbidity Index. Complexity was explicitly studied in 17% (n = 12/72) of studies.

DISCUSSION

Our review highlights heterogeneity in characterisation of multimorbidity in older adults accessing hospital care, with limited consideration of complexity. As the proportion of older adults accessing hospital care who are living with multimorbidity increases, better characterisation of their multiple conditions and associated complexity is a priority to ensure delivery of appropriately tailored care.

A Longitudinal Decline in Walking Speed Is Linked with Coexisting Hypertension and Arthritis in Community-Dwelling Older Adults

Objective: The aim was to investigate the association between baseline coexistence of hypertension (HTN) and arthritis, HTN alone, or arthritis alone, and their impact on longitudinal physical function measures among community-dwelling older adults over 5 years of follow-up. Methods: Ours was a longitudinal prospective cohort study from the second wave (2010-2011) and third wave (2015-2016) of the National Social Life, Health, and Aging Project (NSHAP). Data for older adults were used. Participants were categorized based on self-reported diagnoses into four groups: coexisting HTN and arthritis, HTN only, arthritis only, or neither. Physical performance measures included walking speed using the 3-Meter Walk Test and the Five Times Sit-to-Stand Test (FTSST). Multiple generalized estimating equations with linear regression analyses were conducted, adjusting for age, sex, race, body mass index (BMI) educational level, pain severity, and baseline use of pain and hypertension medications. Results: Data for 1769 participants were analyzed. Slower walking speed was only associated with coexisting HTN and arthritis (B = -0.43, p < 0.001) after accounting for covariates. The coexisting HTN and arthritis group showed no significant association with FTSST (B = 0.80, p = 0.072) after accounting for covariates. Conclusions: The coexistence of baseline HTN and arthritis in older adults is associated with a gradual decline in only walking speed as a physical performance measure in older adults.

Identifying Malnutrition Risk in the Elderly: A Single- and Multi-Parameter Approach

Malnutrition is a significant concern affecting the elderly, necessitating a complex assessment. This study aims to deepen the understanding of factors associated with the assessment of malnutrition in the elderly by comparing single- and multi-parameter approaches. In this cross-sectional study, 154 individuals underwent a comprehensive geriatric assessment (CGA). Malnutrition risk was determined using the mini nutritional assessment (MNA). Additional factors assessed included sarcopenia, polypharmacy, depression, appetite, handgrip strength, and gait speed. Phase angle (PA) and body composition were measured using bioelectrical impedance analysis (BIA). The MNA identified a malnutrition risk in 36.8% of individuals. The geriatric depression scale (GDS) and PA demonstrated moderate effectiveness in assessing malnutrition risk, with AUC values of 0.69 (95% CI: 0.60-0.78) and 0.62 (95% CI: 0.54-0.72), respectively. A logistic regression model incorporating handgrip strength, skeletal muscle mass, sarcopenia, osteoporosis, depression, specific antidepressant use, mobility, appetite, and smoking achieved superior performance in predicting malnutrition risk, with an AUC of 0.84 (95% CI: 0.77-0.91). In conclusion, this study demonstrates that integrating multiple parameters into a composite model provides a more accurate and comprehensive assessment of malnutrition risk in elderly adults.

Establishing Normative Values for Performance-Based Tests in Older Thai Adults: A Nationwide Cross-Sectional Study

OBJECTIVE

To determine normative values and identify contributing factors for physical performance tests in older, Thai, community-dwelling adults.

DESIGN

Nationwide cross-sectional study.

SETTING

Thai older community-dwelling adults.

PARTICIPANTS

Thai older community-dwelling adults aged ≥60 years who had no major health problems (N=1430) between March 2021 and August 2022.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Normative values for the timed Up and Go (TUG) test, gait speed test, and 5-times sit-to-stand (5TSTS) test were determined for sex and age groups. Multivariable quantile regression analysis was employed to evaluate the participants, considering factors that may influence physical performance, such as height, and Charlson comorbidity index (CCI).

RESULTS

The study included 1430 eligible participants. Their mean age was 68.4±5.8 years, and 58.5% were women. Men demonstrated superior physical performance in the medians (p50) of the TUG (10.0 s vs 11.0 s), gait speed (0.98 m/s vs 0.91 m/s), and 5TSTS (14.0 s vs 16.1 s) tests compared with women. These differences were consistently observed across age groups. Moreover, age, sex, and height were significantly associated with poor physical performance.

CONCLUSION

This study observed variations in the normative values of TUG, gait speed, and 5TSTS tests among different age groups of older, Thai, community-dwelling adults. Additionally, our findings identified age, sex, and height as significant contributing factors to physical performance in this population.

Breast cancer insights from Northern Israel: a comprehensive analysis of survival rates among Jewish and Arab women

This study investigates breast cancer survival rates between 2000 and 2022 in northern Israel, focusing on ethnicity, socioeconomic status, age at diagnosis, and the Charlson Comorbidity Index. Analyzing data from Clalit Health Services, we studied 8,431 breast cancer patients (6,395 Jewish, 2,036 Arab). We compared five- and ten-year survival rates across different demographics. Ethnicity showed a minor impact on survival (OR 1.12, 95% CI: 0.93 - 1.35). Socioeconomic status had a significant effect, with a higher level of improving survival (OR 2.50, 95% CI: 2.04 - 3.08). Age was crucial; women 18-39 had better survival than 60-100, but no significant difference was found between the 18-39 and 40-59 age groups [OR (CI 0.90 - 1.53, p = 0.231)]. For the Charlson Comorbidity Index, women with scores of 3-10 showed lower survival compared to scores of 0 and 1-2. There was a notable improvement in five-year survival rates among patients aged 18-59 diagnosed from 2009-2018 (90.7%) compared to 2000-2008 (86.9%) (p = 0.0046), but not in patients aged 60-100. The study highlights that socioeconomic status, age, and comorbidity scores are significant in determining survival rates for breast cancer. The improvement in survival rates for younger patients diagnosed more recently reflects advancements in treatment and care. This research provides valuable insights into the factors affecting breast cancer survival rates, underscoring the role of socioeconomic status, age, and comorbidities while also highlighting the progress in breast cancer treatment over recent years.

Clinical implications of frailty assessed in hospitalized patients with acute-exacerbation of interstitial lung disease

BACKGROUND

Approximately 50% of patients with interstitial lung disease (ILD) experience frailty, which remains unexplored in acute exacerbations of ILD (AE-ILD). A better understanding may help with prognostication and resource planning. We evaluated the association of frailty with clinical characteristics, physical function, hospital outcomes, and post-AE-ILD recovery.

METHODS

Retrospective cohort study of AE-ILD patients (01/2015-10/2019) with frailty (proportion ≥0.25) on a 30-item cumulative-deficits index. Frail and non-frail patients were compared for pre- and post-hospitalization clinical characteristics, adjusted for age, sex, and ILD diagnosis. One-year mortality, considering transplantation as a competing risk, was analysed adjusting for age, frailty, and Charlson Comorbidity Index (CCI).

RESULTS

89 AE-ILD patients were admitted (median: 67 years, 63% idiopathic pulmonary fibrosis). 31 were frail, which was associated with older age, greater CCI, lower 6-min walk distance, and decreased independence pre-hospitalization. Frail patients had more major complications (32% vs 10%, p = .01) and required more multidisciplinary support during hospitalization. Frailty was not associated with 1-year mortality (HR: 0.97, 95%CI: [0.45-2.10]) factoring transplantation as a competing risk.

CONCLUSIONS

Frailty was associated with reduced exercise capacity, increased comorbidities and hospital complications. Identifying frailty may highlight those requiring additional multidisciplinary support, but further study is needed to explore whether frailty is modifiable with AE-ILD.

Development and Validation of a Risk Prediction Model for Frailty in Patients with Chronic Diseases

The occurrence rate of frailty is high among patients with chronic diseases. However, the assessment of frailty among these patients is still far from being a routine part of clinical practice. The aim of this study is to develop a validated predictive model for assessing frailty risk in patients with chronic illnesses. This study recruited 543 patients with chronic diseases, and 237 were included in the development and validation of the predictive model. A total of 57 frailty related indicators were analyzed, encompassing sociodemographic variables, health status, physical measurements, nutritional assessment, physical activity levels, and blood biomarkers. There were 100 cases (42.2%) presenting frailty symptoms. Multivariate logistic regression analysis revealed that gender, age, chronic diseases, Mini Nutritional Assessment score, and Clinical Frailty Scale score were predictive factors for frailty in chronic disease patients. Utilizing these factors, a nomogram model demonstrated good consistency and accuracy. The AUC values for the predictive model and validation set were 0.946 and 0.945, respectively. Calibration curves, ROC, and DCA indicated the nomogram had favorable predictive performance. Altogether, the comprehensive nomogram developed here is a promising and convenient tool for assessing frailty risk in patients with chronic diseases, aiding clinical practitioners in screening high-risk populations.

Polypharmacy and malnutrition in older people: A narrative review

Polypharmacy is the simultaneous use of multiple medicines, usually more than five. Polypharmacy is highly prevalent among older individuals and is associated with several adverse health outcomes, including frailty. The role of polypharmacy in nutritional status seems to be crucial: although a clear association between polypharmacy and malnutrition has been widely reported in older people, the magnitude of the effect of increased number of drugs in combination with their type on the risk for malnutrition remains to be largely explored. Therefore, this review aims to discuss the association between polypharmacy and malnutrition in older people and to provide suggestions for its management. Polypharmacy is prevalent among malnourished frail patients, and the relative contribution of comorbidities and polypharmacy to malnutrition is difficult to be determined. Several mechanisms by which commonly used medications have the potential to affect nutritional status have been identified and described. Deprescribing (i.e., a systematic process of identification and discontinuation of drugs or a reduction of drug regimens) could be an essential step for minimizing the effects of polypharmacy on malnutrition. In this regard, the literature suggests that in older patients taking several medications, the best method to solve this problem is the comprehensive geriatric assessment, based on a holistic approach, including drug review, to find potential unnecessary and inappropriate medications. Nutritional and deprescribing interventions must be tailored to patient needs and to the local context to overcome barriers when applied in different settings.

Can Leucine Supplementation Improve Frailty Index Scores?

Sarcopenia and frailty are important conditions that become increasingly prevalent with age. There is partial overlap between the two conditions, especially in terms of the physical aspects of the frailty phenotype: low grip strength, gait speed, and muscle mass. This study examined whether administration of the essential branched-chain amino acid leucine, besides improving sarcopenia, may reduce frailty assessed by frailty index (FI) in older institutionalized people living in nursing homes. We conducted a secondary analysis of a placebo-controlled, randomized, double-blind design study (ClinicalTrials.gov NCT03831399). The study included fifty males and females aged 65 and over who were living in nursing homes and did not have dementia. The participants were randomized to a parallel group intervention of 13 weeks' duration, with a daily intake of leucine (6 g/day) or placebo (lactose, 6 g/day). The outcome of this study was to evaluate whether there was a change in the level of a 95 item FI compared to the baseline and to compare the effect of the leucine group versus the placebo group. A significant inverse correlation was found between FI and performance of the activities of daily life, cognitive function, gait and balance, muscle function parameters, and nutritional status (p < 0.001 in all cases). There were no statistically significant differences in FI levels at baseline (placebo group FI 0.27 ± 0.08 and leucine group FI 0.27 ± 0.10) and at the 13 week follow-up (placebo group FI 0.28 ± 0.10 and leucine group FI 0.28 ± 0.09). There were also no significant differences between the leucine and placebo groups in the mean FI difference between baseline and follow-up (p = 0.316, Cohen's d: 0.04). This pilot study showed that a nutritional supplementation with leucine did not significantly modify the frailty index in older nursing home residents.

Decline of instrumental activities of daily living is a risk factor for nutritional deterioration in older adults: a prospective cohort study

BACKGROUND

The association between functional capacity and the subsequent risk of nutritional deterioration is yet to be understood. The purpose of this study was to elucidate the relationship between functional capacity, comprising instrumental activities of daily living (IADL), intellectual activity, and social function, and future decline in nutritional status.

METHODS

The current study is a two-year prospective cohort study. A total of 468 community-dwelling older adults without nutritional risks were enrolled. We used the Mini Nutritional Assessment Screening Form. Functional capacity, including IADL, intellectual activity, and social function, was assessed using the Tokyo Metropolitan Institute of Gerontology Index of Competence at baseline. The nutritional status was reassessed at a 2-year follow-up. Risk ratios (RR) of functional capacity for the incidence of nutritional decline were estimated.

RESULTS

Low functional capacity was significantly associated with future deterioration of nutritional status (RR 1.12, 95% confidence interval [CI] 1.02-1.25). Of the subdomains of functional capacity, IADL decline (adjusted RR 2.21, 95% CI 1.18-4.13) was an independent risk factor for the incidence of nutritional risk. Intellectual and social activities were not significant.

CONCLUSION

Decline in functional capacity, especially IADL, is a risk factor for future deterioration in nutritional status. Further studies are required to elucidate the effect of interventions for IADL decline on maintaining nutritional status in older adults.

"Diet for the prevention and management of sarcopenia"

Sarcopenia is a geriatric condition characterized by a progressive loss of skeletal muscle mass and strength, with an increased risk of adverse health outcomes (e.g., falls, disability, institutionalization, reduced quality of life, mortality). Pharmacological remedies are currently unavailable for preventing the development of sarcopenia, halting its progression, or impeding its negative health outcomes. The most effective strategies to contrast sarcopenia rely on the adoption of healthier lifestyle behaviors, including adherence to high-quality diets and regular physical activity. In this review, the role of nutrition in the prevention and management of sarcopenia is summarized. Special attention is given to current "blockbuster" dietary regimes and agents used to counteract age-related muscle wasting, together with their putative mechanisms of action. Issues related to the design and implementation of effective nutritional strategies are discussed, with a focus on unanswered questions on the most appropriate timing of nutritional interventions to preserve muscle health and function into old age. A brief description is also provided on new technologies that can facilitate the development and implementation of personalized nutrition plans to contrast sarcopenia.