BUN as an Independent Predictor of Post-Hospital-Discharge Mortality among Older Veterans.

BACKGROUND/OBJECTIVES: An elevated blood urea nitrogen (BUN) in known to be an important prognostic indicator in patients with end-stage heart or kidney disease or certain other life-threatening illnesses. However, it is less certain as to whether an elevated BUN is an independent predictor of long-term mortality risk in less seriously ill patients. To address this issue, we examined the relationship between BUN and long-term mortality after adjusting for potential confounders and other indicators of health status/disease severity, in a select population of older medically stable Veterans. DESIGN: Long-term prospective cohort study. SETTING: Outpatient follow-up of patients discharged from a recuperative care and rehabilitation unit (RCRU) of a Department of Veterans Affairs Community Living Center. PARTICIPANTS: 383 older Veterans (mean age = 78.6±7.6 years, 98% male, and 87% white) discharged alive and in stable medical condition. MEASUREMENTS: At discharge, each subject completed a comprehensive assessment and was then monitored as an outpatient for up to 9.3 years. Associations between blood urea nitrogen at RCRU discharge and mortality were identified utilizing Cox proportional hazards (PH) regression analyses adjusting for conditions known to confound this relationship. RESULTS: Within the follow-up period, 255 subjects (67%) died. In the unadjusted Cox PH model, a BUN ≥ 30 mg/dL was associated with a nearly 2-fold increased risk of mortality (hazard ratio 1.90, 95%CI 1.41 - 2.56). The association between BUN and long-term mortality remained highly significant after adjusting for potential confounders (hazard ratio 1.78, 95%CI 1.29 - 2.44). CONCLUSION: Our findings support BUN levels as an independent predictor of long-term mortality in older, medically stable Veterans. An elevated BUN may be reflective of global health status rather than solely an indicator of the severity of acute illness or unstable chronic disease.

Single-Arm Resistance Training Study to Determine the Relationship between Training Outcomes and Muscle Growth Factor mRNAs in Older Adults Consuming Numerous Medications and Supplements.

OBJECTIVES: Determine if the muscle mRNA levels of three growth factors (insulin-like growth factor-1 [IGF1], ciliary neurotropic factor [CNTF], and vascular endothelial growth factor-D [VEGFD]) are correlated with muscle size and strength gains from resistance exercise while piloting a training program in older adults taking medications and supplements for age-associated problems. DESIGN: Single-arm prospective study. SETTING: US Veterans Affairs hospital. PARTICIPANTS: Older (70±6 yrs) male Veterans (N=14) of US military service. INTERVENTION: Thirty-five sessions of high-intensity (80% one-rep max) resistance training including leg press, knee curl, and knee extension to target the thigh muscles. MEASUREMENTS: Vastus lateralis biopsies were collected and body composition (DEXA) was determined pre- and post-training. Simple Pearson correlations were used to compare training outcomes to growth factor mRNA levels and other independent variables such as medication and supplement use. RESULTS: Average strength increase for the group was ≥ 25% for each exercise. Subjects averaged taking numerous medications (N=5±3) and supplements (N=2±2). Of the growth factors, a significant correlation (R>0.7, P≤0.003) was only found between pre-training VEGFD and gains in lean thigh mass and extension strength. Mass and strength gains were also correlated with use of α-1 antagonists (R=0.55, P=0.04) and pre-training lean mass (R=0.56, P=0.04), respectively. CONCLUSIONS: Muscle VEGFD, muscle mass, and use of α-1 antagonists may be predisposing factors that influence the response to training in this population of older adults but additional investigation is required to determine if these relationships are due to muscle angiogenesis and blood supply.

The Interrelationships among albumin, nutrient intake, and inflammation in elderly recuperative care patients.

OBJECTIVES: To examine the interrelationships among low serum albumin, nutritional depletion, and ongoing inflammation in older patients recovering from illness. DESIGN: A prospective cohort study. SETTING: A transitional care unit (TCU) within a Department of Veterans Affairs hospital nursing home care unit. PARTICIPANTS: 275 older veterans (mean age=78.9 ± 7.5y, 99% male) admitted for recuperative care and rehabilitation. MEASUREMENTS: At admission and discharge (median LOS 24d, IQR 16 to 44d), each subject completed a comprehensive standardized evaluation including a nutritional assessment and measurement of serum albumin, C-reactive protein (CRP), interleukin-6 (IL-6) and its soluble receptor, and tumor necrosis factor-alpha (TNF-α) and its soluble receptors (sTNF-RI and II). Complete nutrient intake assessments (calorie counts) were performed daily. RESULTS: Both the discharge albumin and the change in albumin (discharge minus admission) were strongly and inversely correlated with various indicators of inflammation, particularly CRP and IL-6. Change in CRP was the strongest correlate of change in albumin (R2 = 0.21, P<.001) and discharge IL-6 the strongest correlate of discharge albumin (R2 = 0.21, P<.001). Nutrient intake also correlated with albumin and its change, but entered the multivariable models after inflammatory indicators and explained a smaller portion of the variance. Although there were significant interactions between time and both nutrient intake and inflammation, the relative importance of inflammation as a potential determinant of the serum albumin concentration appeared to remain unchanged with longer periods of observation. CONCLUSIONS: Among elderly patients admitted to a TCU, inflammation appears to be a more powerful determinant of albumin and its change during the hospitalization than is nutrient intake. Further study is needed to prove causality and to determine whether the relative importance of inflammation on the albumin concentration diminishes with more prolonged periods of observation.

The GAIN (Geriatric Anorexia Nutrition) registry: the impact of appetite and weight on mortality in a long-term care population.

PURPOSE: To investigate nursing home residents at high nutritional risk to determine: 1) which baseline nutrition or health status indicators correlated with subsequent weight gain or appetite improvement; and, 2) whether a continued weight loss correlated with higher mortality. METHODS: At study entry, nutritional, health status, and demographic data were extracted from the nursing home chart or the MDS. Each subject was tracked for 6 months with survival, weight gain of 5%, and appetite improvement the primary outcome measures. RESULTS: During the 6-month study, younger age was the strongest correlate of appetite improvement. The odds of gaining weight were negatively correlated with BMI, age, and feeding dependency. Subjects who were receiving appetite stimulants (orexigenics) at study entry had a 70% greater probability of gaining weight than those who were not. A weight loss during the 6-month period was associated with a nearly two-fold increase in the likelihood of dying (adjusted RR: 1.95, 95% CI 1.43 to 2.66). CONCLUSION: The course of nutritional problems within nursing homes is highly variable. Continued weight loss, however, appears to have ominous implications for mortality. Younger residents who are not dependent on others for feeding assistance, and who receive orexigenics tend to experience weight gain.

Progressive resistance muscle strength training of hospitalized frail elderly.

OBJECTIVE: To determine whether frail elderly patients recuperating from acute illnesses could safely participate in and gain appreciable improvement in muscle strength from progressive resistance muscle strength training. DESIGN: Muscle strength (one repetition maximum), functional abilities (sit-to-stand maneuver and 20-sec maximal safe gait speed), and body composition were measured before and at the conclusion of a 10-wk program of lower limb progressive resistance muscle strength training. The nonrandomized study was conducted in a 30-bed geriatric rehabilitation unit of a university-affiliated Veterans Affairs hospital and a 28-bed transitional care unit of a community nursing home. Participants included 19 recuperating elderly subjects (14 male, 5 female; 13 ambulatory, 6 nonambulatory) >64 yr (mean age, 82.8+/-7.9 yr). RESULTS: The one repetition maximum increased an average of 74%+/-49% (median, 70%; interquartile range, 38%-95%, and an average of 20+/-13 kg (P = 0.0001). Sit-to-stand maneuver times improved in 15 of 19 cases (79%). Maximum safe gait speeds improved in 10 of 19 cases (53%). Four of the six nonambulatory subjects progressed to ambulatory status. No subject experienced a complication. CONCLUSIONS: A carefully monitored program of progressive resistance muscle strength training to regain muscle strength is a safe and possibly effective method for frail elderly recuperating from acute illnesses. A randomized control study is needed to examine the degree to which progressive resistance muscle strength training offers advantages, if any, over routine posthospital care that includes traditional low-intensity physical therapy.

Influence of sibutramine on energy expenditure in African American women.

OBJECTIVE: African American women have a high prevalence of obesity, which partially may be explained by their lower rates of resting energy expenditure (REE). The aim of this study was to examine the influence of acute sibutramine administration on REE and post-exercise energy expenditure in African American women. RESEARCH METHODS AND PROCEDURES: A total of 15 premenopausal, African American women (age, 29 +/- 5 years; body fat, 38 +/- 7%) completed a randomized, double-blind cross-over design with a 30-mg ingestion of sibutramine or a placebo. Each trial was completed a month apart in the follicular phase and included a 30-minute measurement of REE 2.5 hours after sibutramine or placebo administration. This was followed by 40 minutes of cycling at approximately 70% of peak aerobic capacity and a subsequent 2-hour measurement of post-cycling energy expenditure. RESULTS: There was no difference (p > 0.05) in REE (23.70 +/- 2.81 vs. 23.69 +/- 2.95 kcal/30 min), exercise oxygen consumption (1.22 +/- 0.15 vs. 1.25 +/- 0.15 liter/min), and post-cycling energy expenditure (104.2 +/- 12.7 vs. 104.9 +/- 11.4 kcal/120 min) between the sibutramine and placebo trials, respectively. Cycling heart rate was significantly higher (p = 0.01) during the sibutramine (158 +/- 14 beats/min) vs. placebo (150 +/- 12 beats/min) trials. DISCUSSION: These data demonstrate that acute sibutramine ingestion does not increase REE or post-exercise energy expenditures but does increase exercising heart rate in overweight African American women. Sibutramine may, therefore, impact weight loss through energy intake and not energy expenditure mechanisms.

Placement of nasoenteral feeding tubes using magnetic guidance: retesting a new technique.

OBJECTIVE: To study a new technique of intubating the small bowel using a newly developed nasoenteral feeding tube fitted with a magnet in its tip and guided for placement with an external magnet. METHODS: The study was performed in medical and surgical wards of a university-affiliated Department of Veterans Affairs hospital on 42 patients referred by their attending physicians for tube placement. The newly designed feeding tube was inserted per nares into the stomach using traditional technique. As the tube was advanced, movement of the hand-held steering magnet was designed to guide the tip of the magnetic nasoenteral tube along the lesser curvature of the stomach, through the pyloric sphincter, and into the duodenum. Portable abdominal radiography confirmed the anatomic location of the tube tip. RESULTS: Fifty-one intubations were performed on 42 subjects. In 45 intubations (88%), tubes passed into the duodenum. Twenty-seven (53%) met criteria for optimal placement in the second portion of the duodenum or distally. Six of 11 tubes (55%) that were not optimally placed were advanced to the distal duodenum on repositioning. Median procedure time for the initial intubations was 30 minutes (interquartile range 15-40). Median procedure time for last 10 intubations improved to 13 minutes (interquartile range 5-20). No complications were related to the procedure. CONCLUSIONS: Enteral feeding tube placement using external magnetic guidance is a promising, novel technique which is deserving of further study.

Protein-energy undernutrition among elderly hospitalized patients: a prospective study.

CONTEXT: Numerous studies have identified strong correlations between the severity of nutritional deficits and an increased risk of subsequent morbid events among the hospitalized elderly, but whether inadequate nutrient intake during hospitalization contributes to such nutritional deficits or the risk of adverse outcomes is not known. OBJECTIVES: To identify the distribution of average daily nutrient intake among the nonterminally ill hospitalized elderly, ascertain what factors contribute to persistently low intakes, and determine whether the adequacy of nutrient intake correlates with the risk of mortality. DESIGN: Prospective cohort study conducted from 1994 to 1997. SETTING: University-affiliated Department of Veterans Affairs hospital. PATIENTS: A total of 497 patients 65 years or older (mean [SD] age, 74 [6] years; 97% male; 86% white) with a length of stay of 4 days or more. MAIN OUTCOME MEASURES: Daily in-hospital nutrient intake, in-hospital mortality, and 90-day mortality. RESULTS: A total of 102 patients (21%) had an average daily in-hospital nutrient intake of less than 50% of their calculated maintenance energy requirements. Admission illness severity, average length of stay, and admission albumin and prealbumin levels for this low nutrient group did not differ significantly from those of the remaining patients. However, the low nutrient group had lower mean (SD) discharge serum total cholesterol (154 [44] mg/dL [4 [1.1] mmol/L] vs 173 [42] mg/dL [4.5 [1.1] mmol/L]; P=.001), albumin (29.1 [6.7] vs 33.2 [6.1] g/L, P=.001), and prealbumin (162 [69] vs 205 [68] mg/L; P=.001) concentrations and a higher rate of in-hospital mortality (relative risk, 8.0; 95% confidence interval, 2.8-22.6) and 90-day mortality (relative risk, 2.9; 95% confidence interval, 1.4-6.1). Contributing to the problem of inadequate nutrient intake, patients were frequently ordered to have nothing by mouth and were not fed by another route. Neither canned supplements nor nutritional support were used effectively. CONCLUSIONS: Throughout their hospitalization, many elderly patients were maintained on nutrient intakes far less than their estimated maintenance energy requirements, which may contribute to an increased risk of mortality. Given the difficulties reversing established nutritional deficits in the elderly, greater efforts should be made to prevent the development of such deficits during hospitalization.

Protein-energy undernutrition and the risk of mortality within six years of hospital discharge.

OBJECTIVE: The primary objective was to determine whether protein-energy undernutrition among elderly patients discharged from the hospital remains a significant risk factor for mortality beyond 1 year. DESIGN: Prospective Survey (cohort study). SETTING: Outpatient follow-up of patients discharged from a Geriatric Rehabilitation Unit (GRU) of a Veterans Administration hospital. PARTICIPANTS: Of 350 randomly selected admissions to the GRU, 322 were discharged alive from the hospital. These 322 patients represented the study population of whom 99% were male, and 75% were white. The average age of the study patients was 76 (range 58 to 102) years. MEASUREMENTS: At admission and again at discharge, each patient completed a comprehensive medical, functional, neuro-psychological, socioeconomic, and nutritional assessment. Subsequent to discharge, each subject was tracked for an average of 6 years. In addition to including serum albumin and other putative nutrition indicators in the data set, a "nutrition-risk" indicator variable was created. Subjects were stratified into the nutrition "high-risk" group if their albumin was less than 30 g/L or BMI was less than 19; and, "low-risk" group if albumin was equal to or greater than 35 g/L and BMI equal to or greater than 22. All others represented the "moderate-risk" group. RESULTS: Within the 6-year post-hospital-discharge follow-up period, 237 study subjects (74%) died. Based on the Cox proportional hazards survival model, the variable most strongly associated with mortality was discharge "nutrition-risk" followed by the Katz Index of ADL Score, diagnosis of congestive heart failure, discharge location (home vs. institution), age, and marital status. Within the first 4.5 years of follow-up, the relationship between "nutrition-risk" and mortality remained constant. After 4.5 years, the strength of the correlation began to diminish. CONCLUSIONS: Among the elderly, protein-energy undernutrition present at hospital discharge appears to be a strong independent risk factor for mortality during the subsequent 4.5 years or longer.

Side effects resulting from the use of growth hormone and insulin-like growth factor-I as combined therapy to frail elderly patients.

BACKGROUND: The objective of this study was to examine the relationship between serum IGF-I concentration and the incidence of side effects of therapy with recombinant human growth hormone (rhGH) and recombinant human insulin-like growth factor-I (rhIGF-I). METHODS: Thirteen high-risk, undernourished elderly males were started on a 15-day course of rhGH and rhIGF-I by subcutaneous injection. The dose of rhGH was held constant at .0125 mg/kg/day, whereas the dose of rhIGF-I was increased in a stepwise fashion from 10 micrograms/kg to the targeted dose of 40 micrograms/kg twice a day. RESULTS: Nine subjects completed the protocol and reached the full target dose of both hormones. Fluid retention, gynecomastia, and orthostatic hypotension were the most common complications. The hormone injections increased the serum concentration of IGF-I (from 72.7 +/- 40.9 to 483.7 +/- 251.4 eta g/ml, p = .001) and IGFBP-3 (from 1.82 +/- 0.66 to 2.72 +/- 1.18 mg/L, p = .012), and decreased serum albumin (from 34.3 +/- 5.5 to 31.4 +/- 4.6 g/L, p = .009). The magnitude of the initial increase in the serum IGF-I concentration was a powerful risk factor for severe orthostatic hypotension, diffuse myalgias, and drug-induced hepatitis. There was no association between the serum IGF-I concentration and fluid retention or gynecomastia. CONCLUSIONS: Treatment of the undernourished frail elderly with the anabolic agents rhGH and rhIGF-I at the specified dosages may produce undesirable side effects including fluid retention, gynecomastia, and orthostatic hypotension. Although these agents hold therapeutic promise, they must be used with caution in this high-risk population.

Nightly enteral nutrition support of elderly hip fracture patients: a phase I trial.

OBJECTIVE: This non-blinded randomized controlled trial was the first phase of a planned series of investigations designed to test the efficacy of aggressive post-operative enteral nutrition support to decrease the rate of post-operative complications or improve long-term outcomes in specifically defined subgroups of elderly patients who have sustained a hip fracture requiring surgery. METHODS: Eighteen patients (17 males) were randomized to the treatment (eight male subjects) or control groups. The control group (mean age 76.5+/-6.1 years) received standard post-operative care. Subjects in the treatment group (mean age 74.5+/-2.1 years) received 125 cc/hour of nasoenteral tube feedings over 11 hours each night in addition to standard post-operative nutritional care. RESULTS: Both the treatment and control groups had reduced volitional nutrient intakes for the first 7 post-operative days (3,966+/-2,238 vs. 4,263+/-2,916 kJ/day [948+/-535 vs. 1019+/-697 kcal/day], p=0.815), but the treatment subjects had a greater total nutrient intake (7,719+/-2,109 vs. 4,301+/-2,858 kJ/day [1845+/-504 vs. 1028+/-683 kcal], p=0.012). On average, treatment subjects were tube fed for 15.8+/-16.4 days. There was no difference between the groups (treatment vs. controls) in the rate of post-operative life-threatening complications (25 vs. 30%, p=1.00) or in-hospital mortality (0 vs. 30%, p=0.216). Mortality within 6 months subsequent to surgery was lower in the treatment group compared to the controls (0 vs. 50%, p=0.036). DISCUSSION: We conclude that nightly enteral feedings are a safe and effective means of supplementing nutrient intake. The greatest impact of nutrition support may be to reduce mortality.

Group II: collaboration in caring for enterally tube-fed patients.

Collaboration among each NST discipline and with other health care workers is the basis for much of the success and advances we have seen in the field of nutrition support. These interdisciplinary efforts often show us how much we gain from sharing our expertise and developing new associations. In many cases, the progress achieved far exceeds expectations.

The change in serum protein concentration in response to the stress of total joint surgery: a comparison of older versus younger patients.

OBJECTIVE: To investigate whether the physiological response to surgery-induced stress, as measured by changes in serum secretory proteins, is more profound on older than in younger total joint arthroplasty patients. DESIGN: Retrospective study. SETTING: A 267-bed teaching hospital. PARTICIPANTS: A total of 220 ambulatory patients with normal admission serum albumin levels, of whom 106 were 65 years of age or older (mean age 73.3 +/- 6.2 years) and 114 less than age 65 (mean age 48.8 +/- 12.2 years). METHODS: Serum albumin and transferrin levels obtained at admission an on the fifth and tenth postoperative days were compared in the two age groups. RESULTS: In both age groups, admission serum albumins were significantly higher than on the corresponding postoperative Day 5 levels (40.4 +/- 3.7 g/L vs 25.0 +/- 3.3 g/L, P < .0001 and 39.5 +/- 2.5 g/L vs 23.9 +/- 3.1 g/L, P < .001 in older and younger patients, respectively). The drop in the serum concentration of albumin by postoperative Day 5 in the older patients was not significantly different from that of the younger patients (a drop of 15.6 +/- 3.3 g/L in older vs 15.4 +/- 4.4 g/L for the younger, P = .740). Among the 64 patients who remained in the hospital 10 days subsequent to surgery, the average postoperative Day 10 serum albumin concentration was significantly lower in the older patients when compared with the younger (26.2 vs 29.1 g/L P = .016). Similar results were obtained for serum transferrin. CONCLUSIONS: Subsequent to elective arthroplasty, the magnitude of change in serum albumin and transferrin concentrations is similar in older compared with younger, patients, suggesting that this stress response to surgery is nor age dependent. In contrast, the rate of recovery of the serum protein concentrations to preoperative levels may be slower in the older patients. However, this issue needs to be investigated further.

The role of nutrition in increased morbidity and mortality.

Up to 65% of the hospitalized elderly are protein-energy undernourished at admission or develop serious nutritional deficits while hospitalized. These undernourished patients are at an increased risk of developing serious in-hospital complications, the likelihood of developing a complication increasing in relation to the severity of the nutritional deficits. Several studies suggest that aggressive nutritional support targeted to these undernourished patients may be beneficial both in terms of rectifying their nutritional deficits and improving their clinical outcomes; however, these findings have not been confirmed. There must be a greater understanding of the nutritional needs in the hospitalized elderly to guarantee optimal care.

Protein-energy undernutrition and the risk of mortality within one year of hospital discharge: a follow-up study.

OBJECTIVE: The primary objective of this study was to confirm the results of a previous study that demonstrated a strong independent correlation between the severity of protein-energy undernutrition and the risk of 1-year postdischarge mortality in a population of older rehabilitation patients. DESIGN: Prospective survey (cohort study). SETTING: The Geriatric Rehabilitation Unit (GRU) of a Veterans Administration hospital. PARTICIPANTS: Of 350 randomly selected admissions to the GRU, 322 were discharged alive from the hospital. These 322 patients represented the study population, of whom 99% were male, and 75% were white. The average age of the study patients was 76 years. MEASUREMENTS: At admission and again at discharge, each patient completed a comprehensive medical, functional, neuropsychological, socioeconomic, and nutritional assessment. After discharge, each subject was tracked for 1 year. MAIN RESULTS: Within the 1-year posthospital discharge follow-up period, 64 study subjects (20%) died. This included 17% of the patients discharged home and 34% of the patients discharged to a nursing home (P < .01). Based on the Cox Proportional Hazards survival model, the variable most strongly associated with mortality was the discharge serum albumin, followed by discharge weight expressed as a percentage of ideal, self-dressing ability, and a discharge diagnosis of cardiac arrhythmia (usually atrial fibrillation). When all four of these variables were included in the analysis, the model was able to differentiate the survivors from those who died by years end with a sensitivity of 69%, a specificity of 69%, and an overall predictive accuracy of 69%. When tested using the data from the previous study, the model differentiated the patients who died from those who had not at a sensitivity of 62%, a specificity of 68%, and an overall predictive accuracy of 64%. CONCLUSIONS: Protein-energy undernutrition appears to be a strong independent risk factor for 1-year postdischarge mortality.

The risk of life-threatening complications in a select population of geriatric patients: the impact of nutritional status.

OBJECTIVE: The primary objective of this study was to assess the interrelationship between protein-energy nutritional status, disease severity, and life-threatening complications in a population of elderly rehabilitation patients. METHODS: Three-hundred and fifty randomly selected admissions to Geriatric Rehabilitation Unit of a Veterans Administration hospital were prospectively studied. The average age of the study subjects was 76 years, nearly all (99%) were male, and 75% were white. At admission, each patient completed a comprehensive medical, functional, neuropsychological, socioeconomic, and nutritional assessment. While remaining in the hospital, each subject was monitored on a daily basis for the development of complications. RESULTS: Of the 96 variables evaluated, the best predictors of developing at least one life-threatening complication were serum albumin, body mass index, the presence of renal disease (i.e. blood urea nitrogen > 30 mg/L), the Katz Index of Activities of Daily Living score, and the amount of weight loss in the year prior to admission. When all of these variables were included in the logistic regression analysis, the final model was highly significant by the -2Log Likelihood Chi-square goodness-of-fit criterion (Chi-square of 64.1 with 5 d.f., p < 0.0001) with a sensitivity of 77%, a specificity of 77% and an overall predictive accuracy of 77%. When the predictive accuracy of the logistic model was tested using a second sample of 110 patients, the model differentiated those who developed a life-threatening complication from those who had not with a sensitivity of 88%, a specificity of 61%, and an overall predictive accuracy of 65%. As indicated by the Chi-square test, these results were significant (p < 0.0001). CONCLUSIONS: Protein-energy undernutrition appears to be a strong independent risk factor for life-threatening morbidity during hospitalization.

Impact of nutritional status on morbidity in a population of geriatric rehabilitation patients.

OBJECTIVE: The primary objective was to confirm the results of a prior study that demonstrated a strong independent correlation between the severity of protein-energy undernutrition and the risk of subsequent morbidity in a population of elderly rehabilitation patients. A second objective was to determine whether inadequate in-hospital nutrient intake is a co-contributor to the risk of subsequent morbidity. DESIGN: Cohort study. SETTING: Geriatric Rehabilitation Unit (GRU) of a Veterans Administration hospital. PATIENTS: Three hundred fifty randomly selected admissions to the GRU, of whom 99% were male, and 75% were white. The average age of the study patients was 76 years. MEASUREMENTS: At admission, each patient completed a comprehensive medical, functional, neuro-psychological, socio-economic, and nutritional assessment. While remaining in the hospital, each subject was monitored on a daily basis for the development of complications. Complete calorie counts were obtained at least every other day, and the average pre-complication daily nutrient intake was expressed as a percent of predicted requirements as determined using the Harris-Benedict equation. RESULTS: Of the 96 variables evaluated, the strongest predictor of subsequent complications was the Katz Index of ADL score, followed by serum albumin, usual weight percent, number of prescription medications, presence of renal disease, individual income, the presence of decubiti, dysphagia, and mid-arm muscle circumference. When all nine of these variables were included in the logistic regression analysis, the final model had a sensitivity of 70%, a specificity of 71%, and an overall predictive accuracy of 71%. When tested using the data from the previous study, the model differentiated the patients who developed a complication from those who had not a sensitivity of 76.7, a specificity of 76.1, and an overall predictive accuracy of 76.3. There was no difference in the pre-complication average daily nutrient intake between the complication and the no-complication groups (79% vs 75% of predicted requirements, P > 0.2). CONCLUSIONS: Protein-energy undernutrition appears to be a strong independent risk factor for in-hospital morbidity. However, in-hospital nutrient intake may not be a significant determinant of risk.