Three-Year Mortality of Older Hospitalized Patients with Osteosarcopenia: Data from the OsteoSys Study.

Osteosarcopenia, the concurrent presence of sarcopenia and osteopenia/osteoporosis, poses a significant health risk to older adults, yet its impact on clinical outcomes is not fully understood. The aim of this prospective, longitudinal multicentre study was to examine the impact of osteosarcopenia on 3-year mortality and unplanned hospitalizations among 572 older hospitalized patients (mean age 75.1 ± 10.8 years, 78% female). Sarcopenia and low bone mineral density (BMD) were evaluated using Dual Energy X-ray Absorptiometry and the European Working Group on Sarcopenia in Older People (EWGSOP2) and WHO criteria, respectively. Among participants, 76% had low BMD, 9% were sarcopenic, and 8% had osteosarcopenia. Individuals with osteosarcopenia experienced a significantly higher rate of mortality (46%, p < 001) and unplanned hospitalization (86%, p < 001) compared to those without this condition. Moreover, "healthy" subjects-those without sarcopenia or low BMD-showed markedly lower 3-year mortality (9%, p < 001) and less unplanned hospitalization (53%, p < 001). The presence of osteosarcopenia (p = 0.009) increased the 3-year mortality risk by 30% over sarcopenia alone and by 8% over low BMD alone, underscoring the severe health implications of concurrent muscle and bone deterioration. This study highlights the substantial impact of osteosarcopenia on mortality among older adults, emphasizing the need for targeted diagnostic and therapeutic strategies.

Is There an Association Between Inflammation and Serum-Vitamin D? - Results of a Retrospective Analysis of Hospitalized Geriatric Patients.

Purpose: Vitamin D deficiency is a common finding in geriatric patients. The ESPEN micronutrient guideline states that vitamin D serum levels significantly decrease in the presence of inflammation and should be interpreted with caution. This is of great interest for hospital care and would imply a significant change to the current approach to hospitalized patients with suspected vitamin D deficiency. Patients and methods: To evaluate the association of vitamin D and inflammation, we reanalyzed the data set of serum 25(OH)D-Levels of 687 consecutive geriatric hospitalized patients of a previously published study. Results: We found that vitamin D deficiency (<20 ng/dl) was prevalent in 78.0% and vitamin D insufficiency (20-30 ng/dl) in 9.9% of patients. Sperman's correlation showed a significant but very weak correlation (R = -0.100, P < 0.01) of serum vitamin D and C-reactive protein. However, linear regression with the inclusion of age and gender revealed no significant association (beta-coefficient -0.070; p=0.067). Conclusion: In this study, we could not confirm a significant and clinically relevant association between serum vitamin D levels and inflammation, contrasting with a previous study. However, longitudinal studies need to be performed to draw a final conclusion.

Prevalence and determinants of micronutrient deficiencies in malnourished older hospitalized patients.

BACKGROUND AND OBJECTIVE: Malnutrition and micronutrient deficiencies represent significant concerns in geriatric care, leading to adverse health outcomes in older adults. The study aimed to investigate the prevalence and determinants of micronutrient deficiencies in malnourished older hospitalized patients. DESIGN AND SETTING: This prospective, observational study was conducted in a geriatric acute care unit. PARTICIPANTS: The study included 156 malnourished older adults. MEASUREMENTS: Malnutrition was identified using the Mini Nutritional Assessment-Short Form. Micronutrient status was assessed through serum analysis of vitamins (A, B1, B6, B12, C, D, E, H, K, folic acid) and minerals (iron, zinc, copper, selenium) within 24 h post-admission. RESULTS: The average patient age was 82.3 ± 7.5 years, with 69% female. The results revealed a high prevalence of micronutrient deficiencies, with 90% of patients exhibiting deficiencies in three or more micronutrients. Notably, every patient presented at least one micronutrient deficiency. Common deficiencies were found in vitamins C (75%), D (65%), H (61%), and K (45%), as well as folic acid (37%), iron (31%), zinc (36%) and selenium (35%). In binary regression analysis, the amount of previous weight loss was significantly associated with a higher prevalence of multiple (>2) micronutrient deficiencies (P = 0.045). Other variables such age (P = 0.449), gender (P = 0.252), BMI (P = 0.265) and MNA-SF score (P = 0.200) did not show any significant association with the prevalence multiple micronutrient deficiencies. CONCLUSION: The high prevalence of micronutrient deficiencies in malnourished older hospitalized patients underscore the urgent need for targeted interventions to address micronutrient deficiencies in this population, promoting their health status.

Optimized Refeeding vs. Standard Care in Malnourished Older Hospitalized Patients: A Prospective, Non-Randomized Cluster-Controlled Study in Geriatric Acute Care.

Malnutrition is a prevalent geriatric syndrome with adverse health outcomes. This study aimed to assess the effectiveness of an optimized protocol for treatment of malnutrition in older hospitalized patients. We conducted a prospective, non-randomized cluster-controlled study with 156 malnourished patients in the intervention and 73 in the control group, determined using the Mini Nutritional Assessment-Short-Form. The intervention group received individualized nutritional care, including electrolyte and micronutrients monitoring, while the control received standard care. We primarily focused on complications such as infections, falls, unplanned hospital readmissions, and mortality, and secondarily focused on functional status and mobility improvements. Post-discharge follow-ups occurred at 3 and 6 months. Our findings demonstrated that the intervention group (age 82.3 ± 7.5 y, 69% female), exhibited greater previous weight loss (11.5 kg vs. 4.7 kg), more cognitive impairment and a longer hospital stay (19 days vs. 15 days). Binary logistic regression showed no difference in primary endpoint outcomes between groups during hospitalization. At 3- and 6-month follow-ups, the control group exhibited fewer adverse outcomes, particularly falls and readmissions. Both groups showed in-hospital functional improvements, but only controls maintained post-discharge mobility gains. The study concludes that the nutritional intervention did not outperform standard care, potentially due to study limitations and high-quality standard care in control group geriatric departments.

Refeeding Syndrome in Older Hospitalized Patients: Incidence, Management, and Outcomes.

Refeeding syndrome (RFS) is a serious metabolic disturbance that manifests after reintroducing nutrition to severely malnourished individuals. Especially susceptible are older patients, due to higher malnutrition rates, although the incidence remains uncertain. Our study aimed to assess the occurrence and management of RFS in malnourished older hospitalized patients. This prospective study included 156 malnourished older patients, with malnutrition identified using the Mini Nutritional Assessment-Short Form. We evaluated critical biochemical parameters at admission and for ten days after starting nutritional therapy. Using the consensus evidence-based approach, we managed and evaluated RFS. We also tracked mortality and unexpected hospital readmissions for six months after discharge. The average patient age was 82.3 ± 7.5 years, with 69% female. Patients showed hypophosphatemia (23%), hypomagnesemia (31%), and hypokalemia (6%) on admission. Prior to nutritional replenishment, patients were classified as being at low (64%), high (30%), or very high risk (6%) for RFS. After nutritional therapy, 14% and 5% developed imminent and manifest RFS, respectively. There were no significant differences in six-month post-discharge mortality rates or unexpected hospital readmissions between patients with or without RFS. Despite adherence to guideline-recommended management, RFS can persist. No elevated mortality was noted in RFS patients, potentially due to early diagnosis and treatment.

Severity of Inflammation Is Associated with Food Intake in Hospitalized Geriatric Patients-A Merged Data Analysis.

The extent to which inflammation impacts food intake remains unclear, serving as a key risk factor for malnutrition as defined by the Global Leadership Initiative on Malnutrition (GLIM). To address this, we analyzed a large, merged dataset of geriatric hospitalized patients across Europe. The study included 1650 consecutive patients aged ≥65 year from Germany, Italy, Finland, Denmark, and Poland. Nutritional intake was assessed using the first item of the Mini Nutritional Assessment Short Form; C-reactive protein (CRP) levels were measured using standard procedures. In total (age 79.6 ± 7.4 year, 1047 females), 23% exhibited moderate to severe inflammation, and 12% showed severe inflammation; 35% showed moderate reductions in food intake, and 28% were considered malnourished. Median CRP levels differed significantly between patients with severe, moderate, and no decrease in food intake. Among patients with a CRP level of 3.0-4.99 mg/dL, 19% experienced a severe decrease in food intake, while 66% experienced moderate to severe decreases. Regression analysis revealed that inflammation was the most prominent risk factor for low food intake and malnutrition, surpassing other factors such as age, gender, infection, and comorbidity. A CRP level of ≥3.0 mg/dL is associated with reduced food intake during last 3 months in two thirds of hospitalized geriatric patients and therefore indicative for a high risk of malnutrition.

Acute disease induced cognitive dysfunction in older patients - an unrecognized syndrome.

BACKGROUND: It is unknown, how many older hospitalized patients experience cognitive changes independently from delirium. METHODS: In this retrospective study, cognitive function was assessed with the Montreal Cognitive Assessment on admission and discharge in 103 acute care geriatric hospital patients. RESULTS: Mean age was 80.8 ± 7.3 years. The total MoCA score on admission was 17.8 (±4.5) and at discharge 17.7 (±4.4). The mean difference of the total MoCA score was - 0.1 (±3.5). 12 (11.7%) patients suffered from delirium. 46 (44.7%) patients experienced significant changes of cognitive function <- 2 or > 2 MoCA points without delirium. There was no significant association between delirium during hospital stay and the prevalence and magnitude of changes in total MoCA score. CONCLUSION: Cognitive changes frequently occur during acute disease of geriatric patients independently from delirium. We propose the term "acute disease induced cognitive dysfunction" (ADICD) for this entity. TRIAL REGISTRATION: German Clinical trial register (DRKS-ID: DRKS00025157 on 28.04.2021).

Interrater reliability of routine screening for risk of malnutrition with the Mini Nutritional Assessment Short-Form in hospital.

BACKGROUND/OBJECTIVES: The Mini Nutritional Assessment Short-Form (MNA-SF) is the recommended screening tool for older persons. Data on interrater reliability in clinical routine are rare. Thus, we wanted to quantify the interrater reliability of the MNA-SF in hospital. SUBJECTS/METHODS: This observational cross-sectional study was undertaken retrospectively. The study population comprised 105 participants. Risk of malnutrition was measured twice with the routine MNA-SF performed by nurses (within 24 h after admission) and a dedicated dietician (one to three days after the first MNA-SF). The MNA-SF score was analyzed for interrater reliability between nurse and dietician. RESULTS: Participants' mean age was 82.4 (±7.1) years and 71 (68%) were women. The mean total MNA-SF score was 7.4 (±2.4) assessed by dietician and 7.8 (±2.3) assessed by nurse. The intra-class correlation coefficient between the total MNA-SF scores was 0.74 (0.61; 0.82), indicating moderate reliability. For the MNA-SF nutritional status, Cohens Kappa was 0.37 (p < 0.05) showing a fair agreement. CONCLUSION: Multiple misclassifications were observed between malnutrition and risk of malnutrition. Because mean scores were near the border between malnutrition and risk of malnutrition, we recommend to consider the total MNA-SF score in addition to the three risk groups to assess nutritional risk in geriatric hospital patients.

Inflammation as a diagnostic criterion in the GLIM definition of malnutrition-what CRP-threshold relates to reduced food intake in older patients with acute disease?

BACKGROUND/OBJECTIVES: In the recently introduced GLIM diagnosis of malnutrition (Global Leadership Initiative on Malnutrition), details of how to classify inflammation as an etiologic criterion are lacking. This study aimed to determine at what level of serum C-reactive protein (CRP) the risk of low food intake increases in acutely ill older hospitalized patients. SUBJECTS/METHODS: A total of 377 patients, who were consecutively admitted to a geriatric acute care ward, were analyzed. Nutritional intake was determined using the food intake item of Nutritional Risk Screening and the plate diagram method and patients were grouped into three categories as >75%, 50-75% and ≤50% of requirements. CRP was analyzed according to standard procedures and patients were classified into different CRP groups as follows: 0.0-0.99 mg/dl, 1.0-1.99 mg/dl, 2.0-2.99 mg/dl, 3.0-4.99 mg/dl, 5.0-9.99 mg/dl and ≥10.0 mg/dl. RESULTS: Of the total population (mean age of 82.2 ± 6.6 years; 241 females), 82 (22%) had intake <50% of requirements and 126 (33%) demonstrated moderate to severe inflammation. Patients with food intake <50% of requirements had a significantly higher median CRP level compared to patients with food intake >75% of requirements (P < 0.001). The group with serum-CRP levels above 3.0 mg/dl had a markedly higher proportion of patients with low food intake; i.e., <50% and <75% of the requirements. CONCLUSION: A serum-CRP of 3.0 mg/dl appears to be a reasonable threshold of acute inflammation leading to reduced food intake to serve as an orientation with regard to the inflammation criterion of the GLIM diagnosis in acutely ill older patients.

Osteosarcopenia, an Asymmetrical Overlap of Two Connected Syndromes: Data from the OsteoSys Study.

Osteoporosis and sarcopenia are two chronic conditions, which widely affect older people and share common risk factors. We investigated the prevalence of low bone mineral density (BMD) and sarcopenia, including the overlap of both conditions (osteosarcopenia) in 572 older hospitalized patients (mean age 75.1 ± 10.8 years, 78% women) with known or suspected osteoporosis in this prospective observational multicenter study. Sarcopenia was assessed according to the revised definition of the European Working Group on Sarcopenia in Older People (EWGSOP2). Low BMD was defined according to the World Health Organization (WHO) recommendations as a T-score < -1.0. Osteosarcopenia was diagnosed when both low BMD and sarcopenia were present. Low BMD was prevalent in 76% and the prevalence of sarcopenia was 9%, with 90% of the sarcopenic patients showing the overlap of osteosarcopenia (8% of the entire population). Conversely, only few patients with low BMD demonstrated sarcopenia (11%). Osteosarcopenic patients were older and frailer and had lower BMI, fat, and muscle mass, handgrip strength, and T-score compared to nonosteosarcopenic patients. We conclude that osteosarcopenia is extremely common in sarcopenic subjects. Considering the increased risk of falls in patients with sarcopenia, they should always be evaluated for osteoporosis.

Longitudinal Changes of Cytokines and Appetite in Older Hospitalized Patients.

There are few data on the longitudinal association of cytokine and appetite among older hospitalized patients. We aimed to investigate the impact of the changes of inflammatory cytokines on appetite in older hospitalized patients. A total of 191 patients (mean age 81.3 ± 6.6 years, 64% women) participated in this prospective longitudinal observational study. Appetite was evaluated using the Edmonton Symptom Assessment System on admission and after seven days. Serum cytokines such as IL-1ß, IL-6, IL-8, IL-10, IL-12p70, IL-17, IL-18, IL-23 and IL-33, IFN-α2, IFN-γ, TNF-α and MCP-1 were measured both times. No significant differences in the mean serum levels of all the cytokines could be detected overtime in relation to appetite changes, except for IL-18. Appetite significantly deteriorated overtime in patients with increasing IL-18 levels and improved in those without significant changes in IL-18 levels. In a stepwise regression analysis, changes of IL-18 levels were the major independent predictor for the changes of patients' appetite and explained 4% of the variance, whereas other cytokines and variables, such as age, sex, infection and disease, did not show any impact on appetite changes. We conclude that IL-18 seems to exert a significant impact on appetite in acutely ill older hospitalized patients and should, therefore, be considered as a potential target in the diagnosis, prevention and treatment of malnutrition.

Inflammatory cytokines and appetite in older hospitalized patients.

It has already been confirmed that the decline in appetite during disease is a common issue and the biologic players of inflammation such as cytokines may serve as mediators of this effect. This study aimed to investigate the association of appetite with individual cytokines that could be involved in the inflammation-associated loss of appetite in acutely ill older hospitalized patients. 191 patients (mean age 81.3 ± 6.6 years, 64% women) participated in this prospective observational study. Risk of malnutrition and patient's appetite were evaluated using the Mini Nutritional Assessment Short Form and the Simplified Nutritional Appetite Questionnaire on admission, respectively. Serum C-reactive protein (CRP) and serum cytokines such as Interleukin 1 beta (IL-1ß), IL-6, IL-8, IL-10, IL-12p70, IL-17, IL-18, IL-23 and IL-33, interferon alpha-2, interferon gamma, tumor necrosis factor alpha and monocyte chemoattractant protein-1 (MCP-1) were measured. Of total population, 30% had CRP>3.0 (mg/dL), 31% were malnourished and 31% demonstrated poor and very poor appetite. There were significant differences in the mean concentrations of a number of cytokines including IL-1ß, MCP-1, IL-6, IL-10, IL-12p70, IL-18 and IL-23 across the appetite scores. In a regression analysis, an increased IL-18 level (P = 0.049) was the most prominent biomarker for poor appetite. No other significant associations between appetite and circulating levels of other cytokines were found in the regression analysis, except for IL-6 and IL-33, which were only significantly associated in the unadjusted model. The association of IL-18 with decreased appetite was independent from the severity of CRP-level and infections. In this study, certain cytokines, in particular IL-18 were associated with poor appetite in acutely diseased patients and should therefore be considered as a potential target of the prevention and treatment of malnutrition.

Iron deficiency, fatigue and muscle strength and function in older hospitalized patients.

BACKGROUND/OBJECTIVES: Iron deficiency is common in older patients. We investigated whether iron deficiency is an independent risk factor for functional impairment, low muscle function, fatigue, and rehabilitation progress in older hospitalized patients. SUBJECTS/METHODS: Two hundred twenty-four patients (age range 65-95 years; 67% females) who were consecutively admitted to a geriatric acute care ward participated in this prospective longitudinal observational study. Ferritin, iron, transferrin in serum, and blood hemoglobin were measured and current iron supplementation was recorded. Fatigue and comorbidity were measured using the fatigue severity scale and Charlson Comorbidity Index, respectively. Barthel Index, handgrip strength, and isometric knee extension strength were conducted at the time of hospital admission and before discharge. RESULTS: Ninety-one (41%) patients had iron deficiency in which the majority had functional iron deficiency (78/91, 86%). Absolute iron deficiency with and without anemia was diagnosed in 12 (13%) and one patients, respectively. Barthel Index and handgrip and knee extension strength significantly improved during hospitalization in iron deficiency and non-iron deficiency groups. Knee extension strength showed better improvement in iron-deficient patients receiving iron supplementation and iron supplementation during hospital stay was the main predictor for improvement in knee extension strength. Comorbidity, iron deficiency, and changes in handgrip strength were the major independent risk factors for poor improvement in Barthel Index during hospitalization. There were significant associations between patients' fatigue and iron deficiency, comorbidity, and female gender. CONCLUSION: Iron deficiency is an independent risk factor for fatigue and poor functional recovery among older hospitalized patients. Iron supplementation seems to be capable of improving functional performance.

Low Self-Perception of Malnutrition in Older Hospitalized Patients.

BACKGROUND: Studies focusing on self-perception of nutritional status in older hospitalized patients are lacking. We aimed to examine the self-perception of body weight and nutritional status among older hospitalized patients compared to their actual body weight and nutritional status based on medical assessment. MATERIALS AND METHODS: This observational cross-sectional study investigated 197 older participants (mean age 82.2±6.8 years, 61% women) who were consecutively admitted to the geriatric acute care ward. Body weight status and nutritional status were assessed using WHO-BMI classification and Mini Nutritional Assessment-Short Form (MNA-SF), respectively. Self-perceived body weight status and nutritional status were assessed with a standardized questionnaire. A follow-up was performed with a short telephone interview after three months. RESULTS: According to MNA-SF, 49% and 35% were at risk of malnutrition and malnourished, respectively. There was no agreement between self-perceived nutritional status and objective nutritional status according to MNA-SF (Kappa: 0.06). A slight agreement was found between subjective body weight status and objective body weight status according to WHO-BMI classification (Kappa: 0.19). A total of 184 patients completed the 3 months follow-up and additional 9 patients died during this time, of which 7 and 2 were malnourished and at risk of malnutrition according to MNA-SF, respectively. Of those who were malnourished and at risk of malnutrition based on MNA-SF and died during follow-up, 67.7% did not realize their malnutrition. Compared to the patients with normal nutritional status during hospitalization, malnourished patients based on MNA-SF had higher rates of unplanned hospital readmission and further weight loss and more often reported health deterioration and experienced death within three months after discharge. CONCLUSION: No agreement between self-perceived nutritional status and objective nutritional status among older hospitalized patients was found. Our study highlights the need to raise knowledge about the issue of malnutrition and increase awareness of health risks associated with malnutrition among older hospitalized patients.

The impact of disease-related immobilization on thigh muscle mass and strength in older hospitalized patients.

BACKGROUND: We assessed the quantitative changes in muscle mass and strength during 2 weeks of hospitalization in immobile and mobile acutely ill hospitalized older adults. METHODS: Forty-one patients (82.4 ± 6.6 years, 73.0% females) participated in this prospective longitudinal observational study. Mobility status was defined according to walking ability as described in the Barthel-Index. Functional status, including handgrip strength and isometric knee-extension strength, and mid-thigh magnetic resonance imaging (MRI) measurements of cross-sectional area (CSA) were conducted on admission and at discharge. RESULTS: Twenty-two participants (54%) were immobile and 19 (46%) mobile. In all, 54.0 and 12.0% were at risk of malnutrition and malnourished, respectively. The median time between baseline and follow-up for MRI scans were 13 days in mobile and immobile participants (P = 0.072). Mid-thigh muscle and subcutaneous fat CSA significantly decreased by 3.9cm2 (5.0%, P = 0.002) and 5.3cm2 (5.7%, P = 0.036) during hospitalization whereas intermuscular fat remained unchanged in immobile subjects. No significant changes were observed in mobile patients. In a regression analysis, mobility was the major independent risk factor for changes in mid-thigh muscle CSA as a percentage of initial muscle area (P = 0.022) whereas other variables such as age (P = 0.584), BMI (P = 0.879), nutritional status (P = 0.835) and inflammation (P = 0.291) were not associated with muscle mass changes. There was a significant decrease in isometric knee extension strength (P = 0.002) and no change in handgrip strength (P = 0.167) in immobile patients whereas both parameters increased significantly over time in mobile patients (P = 0.048 and P = 0.012, respectively). CONCLUSIONS: Two weeks of disease-related immobilization result in a significant loss of thigh muscle mass and muscle strength in older patients with impaired mobility. Concomitantly, there was a significant reduction of subcutaneous adipose tissue in immobile older hospitalized patients whereas no changes were observed in intermuscular fat among these patients. These data highlight the importance of mobility support in maintaining muscle mass and function in older hospitalized patients.

The impact of acute changes of inflammation on appetite and food intake among older hospitalised patients.

The present study aimed to investigate the effect of acute changes in serum C-reactive protein (CRP) on appetite and food intake among older hospitalised patients. A total of 200 patients (age range 65-94 years, 62·5 % women) participated in this prospective longitudinal observational study. Risk of malnutrition was measured according to the Mini Nutritional Assessment Short Form. The Simplified Nutritional Appetite Questionnaire (SNAQ) and Edmonton Symptom Assessment System (ESAS) were used to evaluate patients' appetite at the time of hospital admission (baseline) and after 7 d (follow-up). Food intake was measured according to the plate diagram and serum CRP was analysed at baseline and follow-up. At baseline, 30·5 % of the patients had moderate to severe inflammation, 31·0 % were malnourished and 48·0 % had food intake <75 % of the meals offered. Also, 32·5 and 23·5 % reported poor and very poor appetite or severe loss of appetite according to the SNAQ and ESAS, respectively. Of the patients, 40 % displayed a pronounced reduction in median CRP levels by -1·2 mg/dl and 19 % demonstrated an increase in median CRP levels by +1·2 mg/dl. Appetite significantly improved (P = 0·006) in patients with a decrease in CRP level and deteriorated in those with an increase in CRP level (P = 0·032). Changes in CRP levels did not show any significant impact on food intake. In a regression analysis, changes of inflammation were the major independent predictor for changes of patients' appetite. We conclude that inflammation has a significant impact on appetite and should therefore be considered in the diagnosis and treatment of malnutrition.

Measured and Predicted Resting Energy Expenditure in Malnourished Older Hospitalized Patients: A Cross-Sectional and Longitudinal Comparison.

A number of equations have been proposed to predict resting energy expenditure (REE). The role of nutritional status in the accuracy and validity of the REE predicted in older patients has been paid less attention. We aimed to compare REE measured by indirect calorimetry (IC) and REE predicted by the Harris-Benedict formula in malnourished older hospitalized patients. Twenty-three malnourished older patients (age range 67-93 years, 65% women) participated in this prospective longitudinal observational study. Malnutrition was defined as Mini Nutritional Assessment Long Form (MNA-SF) score of less than 17. REE was measured (REEmeasured) and predicted (REEpredicted) on admission and at discharge. REEpredicted within ±10% of the REEmeasured was considered as accuracy. Nutritional support was provided to all malnourished patients during hospitalization. All patients were malnourished with a median MNA-LF score of 14. REEmeasured and REEpredicted increased significantly during 2-week nutritional therapy (+212.6 kcal and +19.5 kcal, respectively). Mean REEpredicted (1190.4 kcal) was significantly higher than REEmeasured (967.5 kcal) on admission (p < 0.001). This difference disappeared at discharge (p = 0.713). The average REEpredicted exceeded the REEmeasured on admission and at discharge by 29% and 11%, respectively. The magnitude of difference between REEmeasured and REEpredicted increased along with the degree of malnutrition (r = 0.42, p = 0.042) as deviations ranged from -582 to +310 kcal/day in severe to mildly malnourished patients, respectively. REEpredicted by the Harris-Benedict formula is not accurate in malnourished older hospitalized patients. REE measured by IC is considered precise, but it may not represent the true energy requirements to recover from malnutrition. Therefore, the effect of malnutrition on measured REE must be taken into account when estimating energy needs in these patients.

The Impact of Malnutrition on Acute Muscle Wasting in Frail Older Hospitalized Patients.

Very little is known about the effect of malnutrition on short-term changes of body composition, particularly muscle, among older hospitalized patients. We sought to investigate the association of malnutrition as assessed by the Global Leadership Initiative on Malnutrition (GLIM) criteria with changes of thigh muscle mass and muscle strength among older patients during hospitalization. Forty-one patients (age range 66-97 years, 73% female) participated in this prospective longitudinal observational study. Nutritional status was evaluated using the GLIM criteria on admission and at discharge. Functional status and mid-thigh magnetic resonance imaging (MRI) measurements of cross-sectional area (CSA) were conducted on admission and before discharge. In all, 17% were malnourished and 83% had no malnutrition. Mean mid-thigh muscle CSA declined by 7.0 cm2 (-9%) in malnourished patients during hospitalization (p = 0.008) and remained unchanged among non-malnourished patients (-1%, p = 0.390). Mean mid-thigh CSA of subcutaneous and intermuscular fat did not change significantly during hospitalization in both groups. Malnourished subjects lost 10% of handgrip strength (-1.8 kg) and 12% of knee extension strength (-1.5 kg) during hospitalization. However, the magnitude of both changes did not differ between groups. In a stepwise multiple regression analysis, malnutrition and changes in body weight during hospitalization were the major independent risk factors for the reduction of muscle CSA. Malnutrition according to the GLIM criteria was significantly and independently associated with acute muscle wasting in frail older patients during 2-week hospitalization.

[The refeeding-syndrome in older patients]. / Das Refeeding-Syndrom beim älteren Patienten.

The refeeding-syndrome is a potentially life-threatening metabolic complication that may occur after the initiation of a nutritional therapy in malnourished patients. The syndrome is not well known and probably frequently unrecognized and untreated. The pathophysiology is characterized by a progressive depletion in potassium, sodium and phosphate, despite mostly normal serum levels. This occult intracellular depletion is aggravated by the reintroduction of energy intake and thus compensated by a rapid transcellular shift from the extra- to the intracellular space. At that stage, suddenly decreasing serum levels occur and are responsible for the respective symptoms. Malnutrition, weight loss, chemotherapy, diuretics and alcoholism are the most important risk factors. Accordingly, due to the high prevalence of malnutrition in older persons, the refeeding-syndrome frequently occurs in this patient group. However, prevalence data are scarce. About 8 % of older hospitalized patients develop the refeeding syndrome if a nutritional therapy is introduced. The symptoms of the refeeding syndrome are various and unspecific. In geriatric patients, it frequently occurs in the form of a delirium. Particularly specific is the time course. The refeeding-syndrome typically develops within a few days after the start of a nutritional therapy. If serum-electrolytes, including magnesium and phosphate are monitored and supplemented tightly, the syndrome can be prevented or treated at an early stage. In addition, the measurement and supplementation of thiamine and the particularly slow increase of energy intake are fundamental for the prevention and treatment of the syndrome.

Inflammation, Appetite and Food Intake in Older Hospitalized Patients.

The effect of inflammation on appetite and food intake has been rarely studied in humans. In this study, we examined the association of C-reactive protein (CRP), as an inflammatory marker, with appetite and food intake among older hospitalized patients. A total of 200 older individuals, who were consecutively admitted to a geriatric acute care ward, participated in this prospective observational study. Appetite was evaluated using the Edmonton Symptom Assessment System (ESAS) and the Simplified Nutritional Appetite Questionnaire (SNAQ), respectively. Food intake was measured according to plate diagram method and participants were categorized as having food intake <75% and ≥75% of meals served. Nutritional status was evaluated using the Mini Nutritional Assessment Short Form (MNA-SF). In addition, serum CRP was analyzed and the levels >3.0 (mg/dL) were considered as moderate to severe inflammation. Of total population with mean age 81.4 ± 6.6 years (62.5% females), 51 (25.5%) had no inflammation and 88 (44.0%) and 61 (30.5%) had mild and moderate to severe inflammation, respectively. According to MNA-SF, 9.0% and 60.0% had normal nutritional status or a risk of malnutrition, respectively, whereas 31.0% were malnourished. Based on the SNAQ-appetite-question, 32.5% of the patients demonstrated poor and very poor appetite whereas 23.5% reported severe loss of appetite according to ESAS. Ninety-five (48.0%) of the participants had food intake <75% of the meals offered. Significant associations between SNAQ-appetite (p = 0.003) and ESAS-appetite (p = 0.013) scores and CRP levels were observed. In addition, significant differences were observed in CRP levels between intake ≥75% and <75% of meals served (p < 0.001). Furthermore, there were significant associations between appetite and nutritional status whereas malnourished older patients demonstrated a decreased appetite compared to those with normal nutritional status (p = 0.011). In a regression analysis, inflammation was the major independent risk factor for patients' appetite (p = 0.003) and food intake (p = 0.011) whereas other variables such as infection (p = 0.960), chronic inflammatory diseases (p = 0.371), age (p = 0.679) and gender (p = 0.447) do not show any impact on appetite. Our findings confirm that poor appetite and low food intake are associated with inflammation in older hospitalized patients, suggesting that inflammation may contribute an important aspect to the development of malnutrition in these patients.