The impact of weight loss and low BMI on mortality of nursing home residents - Results from the nutritionDay in nursing homes.

BACKGROUND: Weight loss and low body-mass-index (BMI) are well-known risk factors for mortality among older persons. Both items represent a reduced nutritional state but their nature is different. It is, however, unclear which of these factors is more important for prognosis and if there is interference or interaction between them. OBJECTIVE: To measure the prevalence of low BMI and weight loss in nursing home residents and to analyze their impact on mortality. METHODS: The nutritionDay in nursing homes is an international annual one-day cross sectional survey evaluating malnutrition and 6-months mortality. The data collected from 2007 to 2012 were analyzed. The mortality risk due to a BMI <20 kg/m(2) and weight loss >5 kg was calculated by logistic regression analysis with adjustment for confounding factors. RESULTS: In total, 10,298 residents with a mean age of 85 years (78% female) from 191 nursing homes in 13 countries were included in the analysis. Eighteen percent (17.7%) had a low BMI < 20 kg/m(2), and 11.3% lost > 5 kg of body weight in the previous year. Low BMI <20 kg/m(2) and weight loss >5 kg were both independent and significant risk factors for 6-months mortality (OR 1.7 and 1.5; p < 0.001 in the adjusted model). In comparison to the effect size of low BMI and weight loss alone, the interaction of both factors was substantial (OR = 1.4; p = 0.056). The average 6-months mortality was 13.8%. Subjects with BMI ≥20 kg/m(2) without weight loss >5 kg presented the lowest mortality of 11.2%. In subjects with one of the two features, weight loss >5 kg or low BMI <20 kg/m(2), mortality was significantly increased to 17.4% and 19.8%, respectively. However, if both features were present simultaneously the mortality increased disproportionally to 35.7% (OR 3.5; p < 0.001). In addition, this study presents an overlap and a strong dose-effect relationship of both items with regard to the 6-month mortality. CONCLUSION: A BMI <20 kg/m(2) and weight loss >5 kg in one year are both independent and equally relevant risk factors for the 6-months mortality of nursing home residents aged 65 years or older. For this reason weight loss should be avoided and residents with a low BMI and weight loss should receive particular attention and nutritional care.

Prevalence of sarcopenia in geriatric hospitalized patients.

OBJECTIVES: Sarcopenia, a common syndrome in older individuals, is characterized by a progressive loss of muscle mass and muscle strength. Although data exist on the prevalence of sarcopenia in community-dwelling older individuals and nursing home residents, there has been no systematic research in hospitalized older patients according to newly developed criteria. DESIGN: Cross-sectional study design. SETTING: Acute geriatric ward of a general hospital. PARTICIPANTS: Geriatric inpatients. MEASUREMENTS: Hand grip strength was measured with the Jamar dynamometer, skeletal muscle index was calculated from raw data obtained from the bioelectrical impedance analysis, and physical function was assessed with the Short Physical Performance Battery. Sarcopenia was defined according to the criteria of the European Working Group on Sarcopenia in Older People (EWGSOP). RESULTS: This study involved 198 patients from a geriatric acute ward. Mean age was 82.8 ± 5.9 years and 70.2% (n = 139) of the study participants were women. Thirteen patients (6.6%) were defined as sarcopenic and 37 (18.7%) were defined as severely sarcopenic. In a group comparison, patients with sarcopenia had a poorer nutritional status. In a binary logistic regression analysis, only body mass index was associated with sarcopenia, whereas gender, age, length of stay, cognitive function, and self-care capacity were not. CONCLUSION: The prevalence of sarcopenia in geriatric hospitalized patients is high and does not differ from those of other older individuals. Nutritional status is associated with sarcopenia. The predictive value of sarcopenia regarding outcome for older individuals still requires evaluation.

Guideline clinical nutrition in patients with stroke.

Stroke is regularly accompanied by dysphagia and other factors associated with decreased nutritional intake. Dysphagia with aspiration pneumonia and insufficient nutritional intake lead to worse outcome after stroke.This guideline is the first chapter of the guideline "Clinical Nutrition in Neurology" of the German Society for Clinical Nutrition (DGEM) which itself is one part of a comprehensive guideline about all areas of Clinical Nutrition. The thirty-one recommendations of the guideline are based on a systematic literature search and review, last updated December 31, 2011. All recommendations were discussed and consented at several consensus conferences with the entire DGEM guideline group. The recommendations underline the importance of an early screening and assessment of dysphagia and give advice for an evidence based and comprehensive nutritional management to avoid aspiration, malnutrition and dehydration.

Olfactory function and malnutrition in geriatric patients.

BACKGROUND: Impaired olfaction is considered to be a risk factor for malnutrition in older adults; however, there is little research on this association. The aim of this study was to investigate whether olfactory deficits are associated with an impaired nutritional status in older patients. METHODS: Study participants were recruited from a geriatric day hospital. Nutritional status was assessed with body mass index and Mini-Nutritional Assessment. Olfactory function was evaluated with the Sniffin' Sticks test (SST) and subjectively rated by the patient. Self-caring capacity was rated with the Barthel Index and cognitive status with the Mini-Mental State Examination. RESULTS: One hundred ninety-one patients, 71.7% female, were included with a mean age of 79.6 ± 6.3 years. Prevalence of hyposmia was 39.3%, and 31.9% of patients were functionally anosmic. Malnourished patients did not have a significantly lower Sniffin' Sticks test score than patients at nutritional risk or malnourished patients. In linear regression analysis, nutritional status was only influenced by Barthel Index, age, and number of drugs but not by olfactory function. CONCLUSION: In this sample, olfactory function was not associated with nutritional status.

Basic geriatric assessment does not predict in-hospital mortality after PEG placement.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is an established procedure for long-term nutrition. However, studies have underlined the importance of proper patient selection as mortality has been shown to be relatively high in acute illness and certain patient groups, amongst others geriatric patients. Objective of the study was to gather information about geriatric patients receiving PEG and to identify risk factors associated with in-hospital mortality after PEG placement. METHODS: All patients from the GEMIDAS database undergoing percutaneous endoscopic gastrostomy in acute geriatric wards from 2006 to 2010 were included in a retrospective database analysis. Data on age, gender, main diagnosis leading to hospital admission, death in hospital, care level, and legal incapacitation were extracted from the main database of the Geriatric Minimum Data Set. Self-care capacity was assessed by the Barthel index, and cognitive status was rated with the Mini Mental State Examination or subjectively judged by the clinician. Descriptive statistics and group comparisons were chosen according to data distribution and scale of measurement, logistic regression analysis was performed to examine influence of various factors on hospital mortality. RESULTS: A total of 1232 patients (60.4% women) with a median age of 82 years (range 60 to 99 years) were included. The mean Barthel index at admission was 9.5 ± 14.0 points. Assessment of cognitive status was available in about half of the patients (n = 664), with 20% being mildly impaired and almost 70% being moderately to severely impaired. Stroke was the most common main diagnosis (55.2%). In-hospital mortality was 12.8%. In a logistic regression analysis, old age (odds ratio (OR) 1.030, 95% confidence interval (CI) 1.003-1.056), male sex (OR 1.741, 95% CI 1.216-2.493), and pneumonia (OR 2.641, 95% CI 1.457-4.792) or the diagnosis group 'miscellaneous disease' (OR 1.864, 95% CI 1.224-2.839) were identified as statistical risk factors for in-hospital death. Cognitive status did not have an influence on mortality (OR 0.447, CI 95% 0.248-1.650). CONCLUSION: In a nationwide geriatric database, no component of the basic geriatric assessment emerged as a significant risk factor for mortality after PEG placement, emphasizing individual decision-making.

Complications and mortality after percutaneous endoscopic gastrostomy in geriatrics: a prospective multicenter observational trial.

BACKGROUND: Generally, the high short-term mortality after percutaneous endoscopic gastrostomy (PEG) in geriatric patients is attributed to the severity of their underlying diseases. However, the procedure-related mortality in this group is unknown. METHODS: This prospective multicenter observational study gathered information about 197 geriatric patients treated with PEG insertion, including the indication for PEG insertion and the prevalence of postprocedure complications and analyzed how these factors related to mortality. RESULTS: Dysphagia (64%) and insufficient food intake (76%) were the most frequent indications for PEG insertion. Severe complications after PEG insertion occurred in 9.6% of patients. Mortality was 9.6% in hospital, as well as 18.4% at 1 month. Six months after PEG placement, with 81 patients lost to follow-up, mortality was 51.9%. Hospital mortality was significantly higher in patients with severe complications caused by PEG insertion (47.4% vs 5.6%; P < .001). A regression analysis that corrected for confounding factors revealed that severe complications in general (HR 6.9; 95% CI: 2.6-18.1; P < .001), peritonitis (HR 33.1; 95% CI: 3.7-293.2; P = .002), and severe wound infections (HR 6.9; 95% CI: 1.9-24.9; P = .003) were each independently associated with hospital mortality. Considering the prevalence of procedure-related complications and their association with early mortality after PEG insertion, the procedure-related mortality rate in geriatric patients was at least 2% in this study. CONCLUSION: Although the prevalence of complications after PEG in this study of multimorbid geriatric patients is within the expected range, the procedure-related mortality is higher than expected.

Care problems and nursing interventions related to oral intake in German nursing homes and hospitals: a descriptive mulitcentre study.

BACKGROUND: Reduced nutritional intake in care-dependent patients is a risk factor for malnutrition. The prevalence of malnutrition has been extensively reported, but there is little empirical data on the prevalence of the underlying causes of reduced oral intake and the extent of nursing interventions that address malnutrition. OBJECTIVES: To report the prevalence of problems that potentially led to decreased nutritional intake. To investigate the association between these problems and body mass index (BMI). To investigate the association between increased care dependency and BMI. To document nutrition-related interventions. DESIGN: Cross-sectional multicentre study. SETTING: A total of 15 hospitals (H) and 76 nursing homes (NH) in Germany were included. PARTICIPANTS: A total of 2930 hospital patients and 5521 nursing home residents were included in the study. The mean age was 66.6 ± 16.7 years (in H) and 84.9 ± 9.8 years (in NH); 14.7% (in H) and 50.4% (in NH) were almost or completely care dependent. A BMI ≤ 20kg/m² was found in 8.5% (in H) and 16.7% (in NH). RESULTS: Most hospital patients were eating and drinking independently (72.2%), whereas 58.4% of the nursing home residents needed assistance. Major problems in hospitals were polypharmacy (18.6%), loss of appetite (14.6%) and pain (7.8%); in nursing home common problems were functional problems of the upper extremities (17%), loss of appetite (15.5%) and polypharmacy (15.5%). Patients with a high level of care dependency had higher rates of BMI ≤ 20kg/m². In both settings (H and NH), BMI ≤ 20kg/m² was significantly associated with loss of appetite (odds ratio (OR) 2.6, 95%CI 1.9-3.5 and OR 7.0, 95%CI 5.9-8.3), nausea (OR 2.1, 95%CI 1.3-3.3 and OR 2.8, 95%CI 1.9-4.1), chewing problems (OR 2.1, 95%CI 1.2-3.4 and OR 2.5, 95%CI 2.1-3.1) and swallowing problems (OR 2.3, 95%CI 1.4-3.6 and OR 2.3, 95%CI 1.9-2.8). Nutrition-related nursing interventions were employed more frequently in nursing homes than in hospitals. CONCLUSION: A high care dependency in general and in terms of eating and drinking should be addressed in daily care to ensure sufficient nutritional intake. Additional problems, such as loss of appetite, should also be addressed with suitable interventions to prevent malnutrition. Nutrition-related interventions need to be increased in German health care facilities.

Cutoff percentiles of bioelectrical phase angle predict functionality, quality of life, and mortality in patients with cancer.

BACKGROUND: The bioelectrical phase angle has shown predictive potential in various diseases, but general cutoffs are lacking in the clinical setting. OBJECTIVES: This study evaluated the prognostic value of the fifth percentile of sex-, age-, and body mass index-stratified phase angle reference values in patients with cancer with respect to nutritional and functional status, quality of life, and 6-mo mortality. In a second step, we also studied the effect of the standardized phase angle (with a z score to determine individual deviations from the population average) on these variables. DESIGN: A total of 399 patients with cancer were studied. Phase angle was obtained with bioelectrical impedance analysis; muscle function was assessed by handgrip strength and peak expiratory flow. Quality of life was determined by the European Organization for Research and Treatment of Cancer questionnaire. Nutritional status was assessed by using Subjective Global Assessment. Survival of patients was documented after 6 mo. RESULTS: Patients with a phase angle of less than the fifth reference percentile had significantly lower nutritional and functional status, impaired quality of life (P lt 0.0001), and increased mortality (P lt 0.001). The standardized phase angle emerged as a significant predictor for malnutrition and impaired functional status in generalized linear model regression analyses. It was also a stronger indicator of 6-mo survival than were malnutrition and disease severity in the Cox regression model (P lt 0.0001) and according to the receiver operating characteristic curve. CONCLUSIONS: The standardized phase angle is an independent predictor for impaired nutritional and functional status and survival. The fifth phase angle reference percentile is a simple and prognostically relevant cutoff for detection of patients with cancer at risk for these factors.

Determinants of hand grip strength, knee extension strength and functional status in cancer patients.

BACKGROUND & AIMS: Decreased functionality and muscle weakness are prominent features in cancer patients. We investigated determinants of muscle function assessed by hand grip and knee extension strength as well as functional status in cancer patients. METHODS: 189 consecutively admitted cancer patients (age 60.8 ± 12.7 years, 96 male) were recruited. Muscle function was assessed by hand grip and knee extension strength, and percentage of anticipated peak expiratory flow (%PEF). Functional status was determined by the EORTC questionnaire of quality of life. Nutritional status was assessed with Subjective Global Assessment (SGA). Age, gender, SGA, body mass index, clinical variables such as cancer location, presence of distant metastases, tumour burden according to TNM stage, UICC stage, number of drugs per day, number of comorbidities, type of treatment and depression were investigated as potential risk factors for muscle weakness and impaired functional status in a multiple regression analysis. RESULTS: 80 patients (39 male) were classified moderately or severely malnourished. Malnutrition also emerged as an independent determinant for hand grip (estimated effect size 11%, p < 0.01), knee extension strength (estimated effect size 12%, p < 0.001), and peak expiratory flow (estimated effect size 30%, p < 0.008) and functional status (estimated effect size 19.4%, p < 0.001) next to age and gender, which were the strongest predictors. Among the disease parameters, only amount of daily medication exhibited a significant influence on knee extension strength. CONCLUSIONS: Malnutrition is a disease independent risk factor for reduced muscle strength and functional status in cancer patients. Treatment of malnutrition might therefore also restore muscle strength.

Malnutrition and depression in the institutionalised elderly.

Malnutrition and depression are highly prevalent in the institutionalised elderly and can lead to unfavourable outcomes. The aim of the present study was to assess associations between nutritional status and depressive symptoms and to explore their impact on self-caring capacity and quality of life (QoL) in elderly nursing-home residents (NHR). We conducted a cross-sectional study with 114 NHR (eighty-six female) with a mean age of 84.6 (sd 9.1) years. Nutritional status was assessed with the Mini Nutritional Assessment (MNA). Depressive symptoms were rated with the Geriatric Depression Scale (GDS). Self-caring capacity was measured with the Barthel index (BI) and QoL was assessed with the short-form thirty-six-item (SF-36) questionnaire. Of the NHR, twenty-six (22.8 %) were malnourished according to the MNA and sixty-six (57.9 %) were at nutritional risk. Of the residents, seventy-five could be assessed with the GDS, whereof sixteen (21.3 %) had major and twenty-six (34.7 %) had minor depressive symptoms. GDS scores tended to be higher in patients with impaired nutritional status (5.4 (sd 3.6) in well-nourished subjects and 6.9 (sd 3.2) in residents with malnutrition or at risk of malnutrition). The MNA correlated significantly with the GDS (r - 0.313; P = 0.006) and the GDS emerged as the only independent risk factor for malnutrition in a multiple regression analysis, whereas age, sex, care level, number of prescriptions and self-caring capacity had no influence. The BI was not reduced in patients with a high GDS. QoL was affected in malnourished residents as well as in study participants with depressive symptoms. The results of the present study point towards an association between malnutrition and depressive symptoms. However, the relationship is complex and it remains unclear whether depression in NHR is the cause or consequence of impaired nutritional status. Further studies are needed to identify the direction of this relationship and to assess the effect of depression treatment on nutritional and functional status as well as on QoL.

Effects of food fortification on nutritional and functional status in frail elderly nursing home residents at risk of malnutrition.

OBJECTIVE: Malnutrition is a frequent problem in the elderly and is associated with an impaired functional status and higher morbidity and mortality. In this study we evaluated the effect of a 12-wk nutritional intervention with fortified food on nutritional and functional status in nursing home residents at risk of malnutrition. METHODS: Nutritional status was assessed with the Mini Nutritional Assessment. Body composition was measured with bioelectrical impedance analysis. Functional status was assessed with handgrip strength, peak flow, the Barthel Index, and the Physical Functioning component of the Short Form 36 questionnaire. The residents were assigned to a group receiving the standard food of the nursing home or a group with a protein- and energy-enriched diet and snacks. RESULTS: Sixty-five nursing home residents were included; 62 were at nutritional risk and 3 were severely malnourished according to the Mini Nutritional Assessment. Protein intake was significantly higher in the group on the enriched diet, whereas energy intake did not differ from the group on the standard diet. Both groups significantly improved most nutritional and body composition parameters during the intervention period. We did not observe convincing improvements in muscle function. Furthermore, the Barthel Index and the Physical Functioning component of the Short Form 36 questionnaire declined in all participants. CONCLUSION: Standard food in this nursing home provided sufficient energy and macronutrients. Provision of snacks was not effective in increasing energy intake. Although nutritional status improved, functional status did not increase as a consequence. Functional frailty in this study population seems to be influenced more by age-related morbidity and immobilization than by nutritional intake.

Disease-related malnutrition but not underweight by BMI is reflected by disturbed electric tissue properties in the bioelectrical impedance vector analysis.

The calculation of body composition using bioelectrical impedance analysis in sick and hospitalized patients is hampered due to altered hydration state. We wanted to investigate how disease-related malnutrition assessed by the Subjective Global Assessment (SGA) is reflected in the bioelectrical impedance vector analysis. Patients with benign gastrointestinal disease (n 242) were entered in the study. Nutritional status was assessed by SGA. Arm muscle and fat area were estimated by anthropometry, muscle function was determined by hand grip strength. Whole body impedance measurements were made at 50 kHz. Ninety-eight patients were considered well nourished (SGA A), ninety-four were classified moderately malnourished (SGA B) and fifty patients were classified severely malnourished (SGA C) according to the SGA. The mean vector was significantly displaced between SGA C and SGA A and B, showing comparable resistance with a significantly reduced reactance, indicating comparable hydration but loss of dielectrical mass of soft tissues. This distinctive vector migration was not seen when studying the patients grouped according to BMI. In conclusion, disease-related malnutrition as assessed by the SGA is associated with a distinctive bioelectrical vector migration, implying that abnormal tissue structure and not reduced body mass only occurs in disease-related malnutrition. These disturbances are not seen in underweight according to BMI. Bioelectrical impedance vector analysis appears to be an attractive tool to identify disease-related malnutrition and to monitor nutritional intervention.

Is bioelectrical impedance vector analysis of value in the elderly with malnutrition and impaired functionality?

OBJECTIVE: The calculation of body composition using bioelectrical impedance analysis is difficult in the elderly because most equations have been found to be inadequate, especially in the malnourished elderly. We therefore evaluated the use of bioelectrical impedance vector analysis in elderly nursing home residents. METHODS: One hundred twelve nursing home residents were included in the study (34 men, 78 women, age 85.1 y, age range 79.1-91.4 y). Nutritional status was determined by the Mini Nutritional Assessment (MNA), functional status was assessed by handgrip strength, knee extension strength, and Barthel's index, and bioelectrical impedance analysis was performed using Nutriguard M (Data Input, Darmstadt, Germany). RESULTS: Twenty-two nursing home residents were classified as well nourished (MNA I), 80 were considered to be at nutritional risk (MNA II), and 10 were classified as malnourished (MNA III). Handgrip strength, knee extension strength, and Barthel's index were lower in MNA II and MNA III than in MNA I. Phase angle also decreased significantly with the MNA (4.0, 3.8-4.7 degrees; 3.7, 3.3-4.3 degrees; and 2.9, 2.6-3.5 degrees). There was a significant displacement of the mean vector in MNA II and MNA III compared with MNA I. CONCLUSION: The bioelectrical impedance vector analysis resistance/reactance graph could represent a valuable tool to assess changes in body cell mass and hydration status in elderly nursing home residents.