High-Dose Monthly Vitamin D for Prevention of Acute Respiratory Infection in Older Long-Term Care Residents: A Randomized Clinical Trial.

OBJECTIVES: To determine the efficacy and safety of high-dose vitamin D supplementation for prevention of acute respiratory infection (ARI) in older long-term care residents. DESIGN: Randomized controlled trial investigating high-dose vs standard-dose vitamin D from 2010 to 2014. SETTING: Colorado long-term care facilities. PARTICIPANTS: Long-term care residents aged 60 and older (n = 107). INTERVENTION: The high-dose group received monthly supplement of vitamin D3 100,000 IU, the standard-dose group received a monthly placebo (for participants taking 400-1,000 IU/d as part of usual care) or a monthly supplement of 12,000 IU of vitamin D3 (for participants taking <400 IU/d as part of usual care). MEASUREMENTS: The primary outcome was incidence of ARI during the 12-month intervention. Secondary outcomes were falls and fractures, 25-hydroxyvitamin D levels, hypercalcemia, and kidney stones. RESULTS: Participants (55 high dose, 52 standard dose) were randomized and included in the final analysis. The high-dose group had 0.67 ARIs per person-year and the standard-dose group had 1.11 (incidence rate ratio (IRR) = 0.60, 95% confidence interval (CI) = 0.38-0.94, P = .02). Falls were more common in the high-dose group (1.47 per person-year vs 0.63 in standard-dose group; IRR = 2.33, 95% CI = 1.49-3.63, P < .001). Fractures were uncommon and similar in both groups (high dose 0.10 vs standard dose 0.19 per person-year; P = .31). Mean trough 25-hydroxyvitamin D levels during the trial were 32. ng/mL in the high-dose group and 25.1 ng/mL in the standard-dose group. There was no hypercalcemia or kidney stones in either group. CONCLUSION: Monthly high-dose vitamin D3 supplementation reduced the incidence of ARI in older long-term care residents but was associated with a higher rate of falls without an increase in fractures.

Accumulated frailty characteristics predict postoperative discharge institutionalization in the geriatric patient.

BACKGROUND: Frailty is a state of increased vulnerability to health-related stressors and can be measured by summing the number of frailty characteristics present in an individual. Discharge institutionalization (rather than discharge to home) represents disease burden and functional dependence after hospitalization. Our aim was to determine the relationship between frailty and need for postoperative discharge institutionalization. STUDY DESIGN: Subjects ≥ 65 years undergoing major elective operations requiring postoperative ICU admission were enrolled. Discharge institutionalization was defined as need for institutionalized care at hospital discharge. Fourteen preoperative frailty characteristics were measured in 6 domains: comorbidity burden, function, nutrition, cognition, geriatric syndromes, and extrinsic frailty. RESULTS: A total of 223 subjects (mean age 73 ± 6 years) were studied. Discharge institutionalization occurred in 30% (n = 66). Frailty characteristics related to need for postoperative discharge institutionalization included: older age, Charlson index ≥ 3, hematocrit <35%, any functional dependence, up-and-go ≥ 15 seconds, albumin <3.4 mg/dL, Mini-Cog score ≤ 3, and having fallen within 6 months (p < 0.0001 for all comparisons). Multivariate logistic regression retained prolonged timed up-and-go (p < 0.0001) and any functional dependence (p < 0.0001) as the variables most closely related to need for discharge institutionalization. An increased number of frailty characteristics present in any one subject resulted in increased rate of discharge institutionalization. CONCLUSIONS: Nearly 1 in 3 geriatric patients required discharge to an institutional care facility after major surgery. The frailty characteristics of prolonged up-and-go and any functional dependence were most closely related to the need for discharge institutionalization. Accumulation of a higher number of frailty characteristics in any one geriatric patient increased their risk of discharge institutionalization.

Postoperative falls in the acute hospital setting: characteristics, risk factors, and outcomes in males.

BACKGROUND: Hospital falls are an important cause of morbidity in older surgical patients. The objectives of this study were to describe the characteristics, risk factors, and outcomes for postoperative falls. METHODS: A retrospective study was performed on patients who were admitted to the hospital for more than 23 hours after surgery. Patients who fell within 30 days of their surgery were considered to have experienced a postoperative fall. RESULTS: Over 5 years and 9,625 inpatient surgical procedures, 154 patients experienced 190 falls. Injuries resulting from postoperative falls included major injury (hip fracture), less than 1%; injury requiring intervention, 2%; injury not requiring intervention, 27%; and no injury, 70%. Variables associated with postoperative falls included older age, functional dependence, lower albumin level, and higher American Society of Anesthesia score. CONCLUSIONS: One or more postoperative falls occurred in 1.6% of surgical inpatients and can lead to significant morbidity. Recognition of fall risk factors will help design postoperative fall prevention programs by identifying patients at highest risk for postoperative falls.

Redefining geriatric preoperative assessment using frailty, disability and co-morbidity.

OBJECTIVES: (1) Determine the relationship of geriatric assessment markers to 6-month postoperative mortality in elderly patients. (2) Create a clinical prediction rule using geriatric markers from preoperative assessment. BACKGROUND: Geriatric surgery patients have unique physiologic vulnerability requiring preoperative assessment beyond the traditional evaluation of older adults. The constellation of frailty, disability and comorbidity predict poor outcomes in elderly hospitalized patients. METHODS: Prospectively, subjects > or =65 years undergoing a major operation requiring postoperative intensive care unit admission were enrolled. Preoperative geriatric assessments included: Mini-Cog Test (cognition), albumin, having fallen in the past 6-months, hematocrit, Katz Score (function), and Charlson Index (comorbidities). Outcome measures included 6-month mortality (primary) and postdischarge institutionalization (secondary). RESULTS: One hundred ten subjects (age 74 +/- 6 years) were studied. Six-month mortality was 15% (16/110). Preoperative markers related to 6-month mortality included: impaired cognition (P < 0.01), recent falls (P < 0.01), lower albumin (P < 0.01), greater anemia (P < 0.01), functional dependence (P < 0.01), and increased comorbidities (P < 0.01). Similar statistical relationships were found for all 6 markers and postdischarge institutionalization. Logistic regression identified any functional dependence (odds ratio 13.9) as the strongest predictor of 6-month mortality. Four or more markers in any one patient predicted 6-month mortality with a sensitivity of 81% (13/16) and specificity of 86% (81/94). CONCLUSIONS: Geriatric assessment markers for frailty, disability and comorbidity predict 6-month postoperative mortality and postdischarge institutionalization. The preoperative presence of > or =4 geriatric-specific markers has high sensitivity and specificity for 6-month mortality. Preoperative assessment using geriatric-specific markers is a substantial paradigm shift from the traditional preoperative evaluation of older adults.

Tumor necrosis factor-alpha and involuntary weight loss in elderly, community-dwelling adults.

STUDY OBJECTIVE: To evaluate the association between involuntary weight loss and serum concentrations of tumor necrosis factor (TNF)-alpha in elderly, community-dwelling adults. DESIGN: Cross-sectional, single-time point investigation. SETTING: Two primary care ambulatory clinics. SUBJECTS: Ambulatory adults aged 70 years or older with involuntary weight loss of 2.27 kg (5 lbs) or more, or with stable weight (+/-0.91 kg [2 lbs]) for the 3 months before enrollment. MEASUREMENTS AND MAIN RESULTS: Ten subjects with weight loss (mean+/-SD-4.9+/-2.6 kg) and 25 subjects with stable weight (+0.06+/-0.55 kg) were enrolled. The latter group was recruited to serve as a comparison group to the weight-loss group. Subjects donated a venous blood sample and were administered the Mini Nutritional Assessment at a single clinic visit. Serum concentrations of TNF-alpha were measured by using enzyme-linked immunosorbent assay. The TNF-alpha concentrations were significantly higher in subjects with weight loss (mean+/-SD 19.3+/-24.9 pg/ml) than in subjects with stable weight (mean+/-SD 1.1+/-2.0 pg/ml, p<0.01). No relationship was found between the TNF-alpha concentration and the degree of weight loss expressed as a percentage of total body weight. CONCLUSION: Older adults with involuntary weight loss had increased circulating concentrations of TNF-alpha. Whether TNF-alpha plays a causal role in involuntary weight loss among older adults is unclear; however, this finding is consistent with those in other disease states associated with cachexia. Further research is necessary to clarify this relationship and to determine if pharmacotherapeutic interventions targeted at TNF-alpha can prevent or reverse involuntary weight loss and its associated morbidity and mortality.

Response of elevated methylmalonic acid to three dose levels of oral cobalamin in older adults.

OBJECTIVES: Because the effects of lower-dose oral cobalamin (Cbl) supplements on older people with cobalamin deficiency are not known, we determined whether oral Cbl supplements at three different dose levels would normalize elevated serum methylmalonic acid (MMA) and total homocysteine (tHcy) concentrations. DESIGN: Sequential nonrandomized intervention study of three dose levels. SETTINGS: Two university-based senior care clinics. PARTICIPANTS: Twenty-three older adults (aged >/=65) with serum Cbl levels of 221 pmol/L (300 pg/mL) or lower and serum MMA greater than 271 nmol/L who had been enrolled in a previous screening study for Cbl deficiency (mean age 79 +/- 9; 17 male, 6 female; 17 white, 6 other). INTERVENTION: Sequential daily treatment with 25 microg oral cobalamin, followed by 100 microg and 1,000 microg cobalamin each for a 6-week period. MEASUREMENTS: Serum MMA, tHcy, and other metabolites at baseline and after each 6-week dosing interval. RESULTS: Treatment with 25 microg and 100 microg lowered but did not normalize MMA levels in most subjects. A dose of 1,000 microg/day proved to be the most effective in lowering MMA levels to within normal limits. Serum tHcy was normalized in six of 11 subjects who had elevated tHcy pretreatment with oral Cbl alone and in one subject in combination with a multivitamin. CONCLUSIONS: Most Cbl-deficient older people require more than 100 microg of oral Cbl to normalize serum MMA, which is a larger dose than is available in most standard multivitamins and Cbl supplements.

Epidemiology of weight loss in humans with special reference to wasting in the elderly.

Unintentional weight loss in older adults is a problem that occurs frequently in clinical practice. Although slight declines in weight have been observed with aging alone, clinically important weight loss (decrements of 5% or more of usual body weight) is almost always the result of disease, disuse, and/or psychosocial factors. Adverse health outcomes associated with weight loss include decreased functional abilities and increased morbidity and mortality. Case series and prospective studies have helped to identify the most common causes of weight loss in older adults, and are reviewed herein. Knowledge of these frequent underlying etiologies can help guide an appropriate and cost-effective evaluation of patients presenting with weight loss. In many cases the causes are remediable and weight loss may slow or reverse with appropriate intervention. In some cases no clear etiology can be identified but the patient may still respond to nutritional support therapies that include hypercaloric feeding and appetite stimulants. Increasing caloric intake alone, however, is usually not sufficient to mitigate against losses in body mass (especially muscle mass) that are the result of chronic inflammatory or other severe disease states (cachexia). Potential strategies to help reduce losses in lean body mass and the functional decline that often accompanies weight loss include anabolic agents, exercise/physical activity, and cytokine inhibition. This article reviews the epidemiology of weight loss in older adults with special attention to the problem of cachexia. Diagnostic and treatment algorithms are provided to help guide clinical evaluation of, and therapeutic interventions for, older adults presenting with weight loss.

Screening for cobalamin deficiency in geriatric outpatients: prevalence and influence of synthetic cobalamin intake.

OBJECTIVES: To describe the prevalence of cobalamin (Cbl) deficiency in older adult outpatients and to determine whether regular intake of a synthetic source of cobalamin confers protection against Cbl deficiency. DESIGN: Cross-sectional study. SETTING: Two university-affiliated geriatric medicine outpatient clinics. PARTICIPANTS: Three hundred fifteen older adults (age range 65-100) without a history of previously diagnosed or treated Cbl deficiency, severe anemia, or a life-threatening illness. MEASUREMENTS: Detailed information on total synthetic Cbl intake (from vitamins, fortified cereal, and supplemental nutritional formula sources) and laboratory measures of serum Cbl, metabolite panel (serum methylmalonic acid, homocysteine, cystathionine, and 2-methylcitric acid), complete blood count, and serum creatinine levels. RESULTS: Cbl deficiency (serum Cbl < or =300 pg/mL and methylmalonic acid (MMA)>271 nmol/L) was found in 13% of screened patients. Forty-six percent of screened patients reported regularly taking a source of synthetic Cbl. Serum Cbl correlated with synthetic Cbl intake, and patients regularly taking synthetic Cbl were significantly less likely to be Cbl deficient than persons not taking supplemental Cbl (8% vs 17%, P =.02). CONCLUSION: Regular use of a multivitamin/synthetic Cbl source confers some degree of protection against Cbl deficiency in older adults. The relatively high prevalence rates and benefit of synthetic Cbl intake in this study reinforce recommendations that older adults should be screened for Cbl deficiency and should incorporate synthetic sources of Cbl as part of a balanced diet. Appropriate screening intervals and the optimal dose of supplemental Cbl to prevent Cbl deficiency remains to be determined.