Impact of nutritional status on the evolution of Alzheimer's disease and on response to acetylcholinesterase inhibitor treatment.

BACKGROUND: Weight loss is frequently observed in patients with Alzheimer's disease (AD), as observed in clinical practice and reported in the literature. However, information on the evolution of nutritional status and its impact on the prognosis of AD is still scarce. OBJECTIVE: Our aim was to determine the impact of nutritional status on the evolution of AD and on the response to treatment with acetylcholinesterase inhibitors (AChEI) by prospective one-year follow-up of AD patients living at home. METHODS: We studied a cohort of 523 patients with Alzheimer's disease referred from 1994 to 2002 to an Alzheimer centre. After diagnosis, they were followed for one year in a prospective observational study in clinical practice. At entry and every 6 months, patients underwent standardised neurocognitive and geriatric evaluation (MMSE, ADAS-cog, IADL, MNA, caregiver burden). These evaluations were accompanied by complete clinical examination, standard paraclinical investigations and recording of treatment received. RESULTS: Of our patients, 25.8% presented at inclusion a risk of undernutrition with an MNA score of 23.5 or less. During follow-up, the number of patients with rapid loss on the MMSE (3 points or more in one year) was higher in subjects who presented a risk of undernutrition at inclusion (53.6%) than in well-nourished subjects (43.2%) (P = 0.07). Similarly, increased dependence at one year was more frequent in subjects at risk of undernutrition at inclusion (57.7% versus 44.4%, P = 0.0219). The beneficial effect of AChEI treatment on cognitive function was not influenced by initial nutritional status; on the contrary, among the subjects at risk of undernutrition at inclusion, the risk of rapid loss on the MMSE in one year was decreased in subjects treated during follow-up compared with untreated subjects (43.9% versus 73.1% ; OR = 0.29; 95% CI = 0.10-0.83; P = 0.0219). This relationship was not found in subjects whose initial MNA score was greater than 23.5. CONCLUSION: Our work indicates that AD patients living at home with a caregiver are frequently at risk of undernutrition. Undernourished patients seem to present more rapid aggravation of the disease, but paradoxically, these patients appear to be those who best respond to AChEI treatment.

The practice of obtaining approval from medical research ethics committees: a comparison within 12 European countries for a descriptive study on acetylcholinesterase inhibitors in Alzheimer's dementia.

Across Europe the protection of research subjects with dementia has to meet a variety of national legislation and ethical codes. This research project compared how in different EU countries one single descriptive multinational study on dementia treatment strategies was evaluated by medical ethical committees and how the issues of informed consent and capacity to consent were dealt with. The study that was evaluated is the ICTUS study, which studies the impact of treatment with acetylcholinesterase inhibitors (AChE-I) on Europeans with mildly or moderately severe Alzheimer's disease (AD). Participating centres in all 12 countries that take part in the study received a questionnaire with items on the process of approval by the ethical committee and the informed consent procedure. From the 29 centres we received 21 completed questionnaires (response rate of 72%). There were great differences in valuation of the study, varying from the judgement that the ICTUS study was 'no experimental study' to the judgement that it was a phase IV drug trial. All centres got approval, after 3-90 days. Informed consent was addressed very differently by the researchers. There was no formal informed consent procedure required by the ethical committees. The data from this survey suggest that there should be more consensus across the EU about which studies or interventions do and which do not require approval of an ethics committee. Procedures for the assessment of informed consent in dementia research should be harmonized by central national or European bodies.

A nutritional education program could prevent weight loss and slow cognitive decline in Alzheimer's disease.

BACKGROUND: Weight loss is a common problem in patients with Alzheimer's Disease (AD). It is a predictive factor of mortality and it decreases patients' and caregivers' quality of life. OBJECTIVE: To determine if a nutritional education program can prevent weight loss in AD patients. SUBJECTS: 151 AD patients and their caregivers were enrolled to follow the intervention and 74 AD patients and their caregivers constituted a control group. METHOD: Caregivers in the intervention group followed 9 nutritional sessions of one hour each, over one year. Caregivers in the control group didn't follow any sessions but were offered advice provided in a normal follow-up. Patients weight, nutritional state, cognitive function, autonomy, mood, behaviour disorders at baseline and at 6- and 12-month follow-up. Caregivers burden, nutritional and AD knowledge at the baseline and at the 12-month follow-up. RESULTS: During the year follow-up, the mean weight increased in the intervention group (0.7+/-3.6 kg) whereas it decreased in the control group (-0.7+/-5.4 kg) (p<0.05). The nutritional status (MNA) was maintained in the intervention group (0.3+/-2.6) whereas it decreased significantly in the control group (-1.0+/-3.4) (p<0.005). After adjustment for baseline differences between the two groups (caregiver age, nutritional state, eating behaviour disorders, depression), the weight change between the two groups was not significant (0.6+/-0.4 kg vs. -0.6+/-0. 6 kg respectively in intervention group and control group). However, the percentage of patients with significant weight loss is decreased. The MMSE change became significant between the two groups: -2.3+/-0.3 vs. -3.4+/-0.4 respectively in intervention group and control group (p<0.05). CONCLUSIONS: These results suggest that a nutritional educational program intended for caregivers of AD patients could have a positive effect on patients weight and cognitive function.

Nutrition assessment in the elderly.

The prevalence of malnutrition, which is relatively low in free-living elderly persons (5-10%), is considerably higher (30-60%) in hospitalized or institutionalized elderly persons. As a result, nutritional assessment should be part of routine clinical practice in elderly patients who are frail, sick or hospitalized. A comprehensive screening tool for assessment of nutritional status is needed that is clinically relevant and cost-effective to perform. A number of simple and rapid tests for detecting or diagnosing malnutrition in the elderly have recently been developed. If malnutrition is suggested by such screening tests, then they should be supplemented by conventional nutritional assessment before treatment is planned.

Relationships between nutritional markers and the mini-nutritional assessment in 155 older persons.

OBJECTIVE: To investigate the relationships between nutritional status measured by a comprehensive nutritional assessment including anthropometric measurements, nutritional biological markers, evaluation of dietary intake, and the Mini-Nutritional Assessment (MNA) nutrition screening tool. DESIGN: A prospective study. PARTICIPANTS: One hundred fifty-five older subjects (53 men and 102 women; mean age = 78 years; range = 56-97 years). These participants were hospitalized in a geriatric evaluation unit (n = 105) or free living in the community (n = 50). MEASUREMENT: Weight, height, knee height, midarm and calf circumferences, triceps and subscapular skinfolds, albumin, transthyretin (prealbumin), transferrin, ceruloplasmin, C-reactive protein, alpha1-acid glycoprotein, cholesterol, vitamins A, D, E, B1, B2, B6, B12, folate, copper, zinc, a 3 day food record combined with a food-frequency questionnaire; the MNA nutritional screening. RESULTS: The MNA scores have been found to be significantly correlated to nutritional intake (P < .05 for energy, carbohydrates, fiber, calcium, vitamin D, iron, vitamin B6, and vitamin C), anthropometric and biological nutritional parameters (P < .001 for albumin, transthyretin, transferrin, cholesterol, retinol, alpha-tocopherol, 25-OH cholecalciferol zinc). An MNA score between 17 and 23.5 can identify those persons with mild malnutrition in which nutrition intervention may be effective. CONCLUSIONS: The MNA is a practical, noninvasive, and cost-effective instrument allowing for rapid nutritional evaluation and effective intervention in frail older persons.

[Falls, frailty and osteoporosis in the elderly: a public health problem]. / Chutes, fragilité et ostéoporose chez la personne âgée: un problème de santé publique.

INTRODUCTION: Elderly people can be subdivided into three groups: healthy elderly persons (65-70% of the population), elderly subjects with diseases (about 5%) and frail old people. Frailty represents "age-related physiologic vulnerability resulting from impaired homeotasic stock and a reduced capacity of the organism to withstand stress". It could lead elderly subjects to pathological, barely reversible, ageing. CURRENT KNOWLEDGE AND KEY POINTS: One of the main objective of geriatricians is to develop useful screening tools to identify people at high risk, thus allowing them to benefit from preventive interventions as early as possible. It has been suggested that the decline in homeostatic stock involves numerous physiological systems. Those at the core of frailty would be neuromuscular changes resulting in sarcopenia, neuroendocrine dysregulation, and immune disorders. A recent study has shown that increased levels of interleukin 6 is a risk factor for frailty. FUTURE PROSPECTS AND PROJECTS: Work in progress aimed at identification of at-risk patients should: lead to early detection; draw attention on underestimated fields such as the nutritional status, sarcopenia, or gait disorders; promote the development of the standardized gerontological evaluation in order to identify the different components of frailty; and promote the development of non-pharmacological programmes including physical training, nutritional managing, and optimal social life.

Body composition and osteoporosis in elderly women.

OBJECTIVES: To study body composition in elderly osteoporotic women to determine the relationship of body weight, body fat mass and lean mass to bone mineral density (BMD), and to investigate the association between one-leg balance, osteoporosis and sarcopenia. DESIGN AND SETTING: A cross-sectional study of a community-based population in Toulouse, France. METHODS: For each participant, whole body composition and BMD were estimated using a dual-energy x-ray absorptiometry scanner. We investigated balance using a one-leg balance test. PARTICIPANTS: 129 healthy women aged 75-89 years, volunteers, ambulatory and living at home. RESULTS: Total fat mass and appendicular skeletal muscle mass (ASM) were significantly lower in osteoporotic women than in the age- and sex-matched non-osteoporotic controls [18.7 +/- 4.6 vs. 22.2 +/- 6.6 for total fat mass (p < 0.01); 13.1 +/- 1.6 vs. 13.8 +/- 2.2 for ASM (p < 0. 05)]. We did not find a positive association between osteoporosis and sarcopenia (OR = 0.75, CI 0.3-1.84), osteoporosis and one-leg balance (OR = 1.27, CI 0.51-3.17), or sarcopenia and one-leg balance (OR = 1.31, CI 0.52-3.36). There were significant positive correlations between BMD in all areas and body measurements (weight, fat mass, lean tissue mass), but fat mass accounted for more of the variance in total body and femoral BMD than lean tissue mass. Total fat mass alone, in a multivariate model, was correlated with whole body BMD, whereas femoral BMD was associated with both fat mass and lean tissue mass. CONCLUSION: Higher values of fat mass and lean tissue mass may have a protective effect on femoral bone density. Sarcopenia and osteoporosis are not necessarily linked with balance.

Protein-energy oral supplementation in malnourished nursing-home residents. A controlled trial.

OBJECTIVES: To validate a nutritional intervention programme for elderly people living in nursing homes. DESIGN: In a prospective, randomized, controlled study of 88 residents, we determined nutritional status at day 0 and day 60 using a record of dietary intake, anthropometry, hand-grip strength and mini-nutritional assessment. Dietary intake, grip strength and body weight were also recorded at day 30. We divided subjects into four groups according to their mini-nutritional assessment score. Those with a score 24 received no oral supplementation. Those at risk of malnutrition (with a score of 17-23.5) were randomized to oral supplementation. Those with a score <17 received oral supplementation. We recorded the amount of oral supplements consumed daily. RESULTS: Compliance with oral supplementation was good, and daily intake averaged about 400 kcal. The total energy intake on day 60 was significantly higher in both of the groups that received supplements. Following supplementation, most subjects at risk of malnutrition improved their mini-nutritional assessment score and increased their weight (by 1.4 +/- 0.5 kg). Neither the mini-nutritional assessment score nor weight improved in subjects at risk of malnutrition who did not receive supplements. Supplementation in the malnourished group resulted in a mean mini-nutritional assessment score increase (from 13.9 +/- 2.6 to 17.1 +/- 3.9) and a mean weight gain of 1.5 +/- 0.4 kg. CONCLUSION: Oral nutritional supplements are well accepted and result in increased daily protein and energy intake, body weight and nutritional status in most malnourished patients and in those at risk of malnutrition.

[A tool for nutritional anamnesis of elderly patients]. / Testwerkzeuge für die Ernährungsanamnese bei älteren Personen.

Malnutrition is frequent in the elderly, especially if frail or hospitalized. Nutritional evaluation tools allow the early detection of malnutrition and should be incorporated into the standard gerontological work-up as a basis for preventive action or rapid appropriate intervention. We review the various nutritional evaluation tools available, in particular the Mini Nutritional Assessment (MNA) which both evaluates nutritional status and guides nutritional intervention.

The Mini Nutritional Assessment (MNA) and its use in grading the nutritional state of elderly patients.

The Mini Nutritional Assessment (MNA) has recently been designed and validated to provide a single, rapid assessment of nutritional status in elderly patients in outpatient clinics, hospitals, and nursing homes. It has been translated into several languages and validated in many clinics around the world. The MNA test is composed of simple measurements and brief questions that can be completed in about 10 min. Discriminant analysis was used to compare the findings of the MNA with the nutritional status determined by physicians, using the standard extensive nutritional assessment including complete anthropometric, clinical biochemistry, and dietary parameters. The sum of the MNA score distinguishes between elderly patients with: 1) adequate nutritional status, MNA > or = 24; 2) protein-calorie malnutrition, MNA < 17; 3) at risk of malnutrition, MNA between 17 and 23.5. With this scoring, sensitivity was found to be 96%, specificity 98%, and predictive value 97%. The MNA scale was also found to be predictive of mortality and hospital cost. Most important it is possible to identify people at risk for malnutrition, scores between 17 and 23.5, before severe changes in weight or albumin levels occur. These individuals are more likely to have a decrease in caloric intake that can be easily corrected by nutritional intervention.

Changes in dietary intakes with age.

The aim of this study was to describe changes in dietary intakes with age in subjects aging normally within the Toulouse study. Daily caloric intakes were constant in both sexes and in the three age classes considered. Energy distributions among the meals were rather clearly modified in men: the contribution of breakfast and afternoon snacks increased while those of lunch and dinner decreased. Observations among women were less consistent but the contribution of dinner also decreased with age (from 33.3 to 30.7%). This decreased contribution from dinner was due to a change in its nutrient composition (fewer lipids and more carbohydrates) which change the nutrient constitution of the entire daily diet, and also from a change in structure (reduced contribution by the main dish and increased role of desserts). These results pose questions concerning the reasons behind this change (loss of appetite, more pronounced taste for sweets?) and requires additional study.

A prospective study of changes on nutritional patterns 6 months before and 18 months after retirement.

To present results from a two year prospective study on diet, 6 months before and 18 months after retirement. The studied population exhibited an increase in social and physical activities over time after retirement. A significant decrease in weight was found in men 18 months after retirement. Retired individuals reported taking more time for breakfast. 45.5% of retired individuals, compared to 25.5% before retirement, took more than 30 minutes for lunch than before retirement. The amount of dietary nutrients consumed remained the same before and after retirement. However, retired individuals ate out more often, and had guests more frequently. Nutrients' distribution is similar before and after retirement. Given a life expectancy of more than 20 years after retirement, it is necessary to initiate nutritional intervention.

Assessment of the effectiveness of drug therapies on nutritional status in the elderly: "concerning a randomised, double-blind clinical study of the activity of pancreatic extracts and a placebo during the renutrition of elderly subjects suffering from protein caloric undernutrition".

AIMS: to study, versus placebo, the value of administering pancreatic extracts in elderly subjects suffering from denutrition. METHODS: 52 subjects over 70 years of age, living in the Toulouse region of France, were included in this study. Each subject was required to present with an impaired nutritional status of their food intake, anthropometric and laboratory markers. RESULTS: among the 52 patients included in the study, 26 received the placebo and 26 received a pancreatic extract (Créon 12,000). 88% of these patients were women and 12% were men, the mean age of patients was 87+/-6 years. The groups were comparable at entry into the study. Nutritional intake increased in the two groups. There was a non-significant increase in body weight in the treated group when compared with the placebo group. DISCUSSION: we think that in the future, it would be preferable to conduct studies in convalescent subjects, reducing the frequency of nutritional assessments (food intake on D0 and D90, to reduce interference with the patient's habits.

Nutrition and successful aging: a study of 520 elderly persons from the Toulouse and New-Mexico Aging Process Study.

Epidemiological studies of aging are usually confronted with the presence of numerous pathologies or environmental factors which make it difficult to identify the effects of aging individually. One way of reducing the variability among individuals is to use well defined criteria to select the study population. This is the choice that was made for the New Mexico and Toulouse Aging Process Studies, which were particularly turned towards successful aging. In this study we have sought to explain the diversity of states of health of the subjects of these two studies by means of an aging classification exploring the medical history, balance and walking, and the cognitive functions. This reveals that the poorer health of certain subjects (about 10% and 30% of the populations of Toulouse and Albuquerque respectively) is slightly associated with changes in eating behaviour relative to subjects who age successfully. We have, however observed a decrease in vitamin E intake in Toulouse associated with a reduction of lipids in the food. But the poorer state of health is predominantly explained by advancing age and the occurrence of pathological states. This study confirms that aging was generally successful in the two populations studied.