Results of High-Protein, High-Calorie Oral Nutritional Supplementation in Malnourished Older People in Nursing Homes: An Observational, Multicenter, Prospective, Pragmatic Study (PROT-e-GER).

OBJECTIVES: To assess if the impact of oral nutritional supplements (ONS) on nutritional and functional status in malnourished older persons living in nursing homes shown by clinical trials are also found outside a trial setting. DESIGN: Observational, multicenter, prospective, pragmatic study. SETTING AND PARTICIPANTS: This study was carried out in 38 nursing homes throughout Spain. Nursing home physicians recruited consecutive residents, older than 65 years, with a diagnosis of malnutrition, when a clinical decision to start ONS had been taken after unsuccessful initial management with dietary interventions. INTERVENTION: The participants received daily 2 bottles of an energy-rich, high-protein commercial ONS for 3 months. MEASURES: Primary outcomes were changes in nutritional status [body weight, body mass index (BMI), and Mini Nutritional Assessment-Short Form (MNA-SF)]; secondary outcomes were functional changes [Functional Ambulation Classification, Barthel index, handgrip strength, and Short Physical Performance Battery (SPPB)], as well as safety and adherence after 12 weeks of follow-up. RESULTS: A total of 282 residents (median age 86 years, 67% women) were included, and 244 (86.5%) completed the follow-up. At baseline, 77.3% of the participants were malnourished (BMI 19.7 kg/m2, interquartile range 18.3-21.8). After 12 weeks of follow-up, participants experienced significant increases in body weight (2.6 ± 3.1 kg, 5.2 ± 5.9%), BMI (1.0 ± 1.2 kg/m2) and MNA-SF (4.0 ± 2.5 points). There were also significant improvements in functional status measured by the Barthel index, handgrip strength, SPPB, and gait speed. Good adherence was registered in 94.6% of the participants. No relevant side effects were found. CONCLUSIONS AND IMPLICATIONS: Improvements in nutritional and functional status can be found when using a high-protein, high-calorie ONS in older undernourished people living in nursing homes.

Effects of high-protein, high-calorie oral nutritional supplementation in malnourished older people in nursing homes: An observational, multi-center, prospective study (PROT-e-GER). Protocol and baseline population characteristics.

INTRODUCTION: Malnutrition is common among older people living in nursing homes. Poor nutritional status is associated with functional loss and with worse health. Oral nutritional supplementation (ONS) can be an effective means to counteract weight loss, improve nutritional status and reduce complications in malnourished older people living in nursing homes. The main objective of this study was to assess whether ONS over 12 weeks improved the nutritional status and physical function of malnourished older people living in nursing homes. METHODS: This was a multi-center, prospective, observational study carried out in 53 nursing homes in Spain. Participants were aged 65 or over. They were prescribed a high-calorie, high-protein ONS to treat well documented malnutrition. Subjects who received enteral nutrition, had special nutritional requirements, or receiving end-of-life care were excluded. Anthropometric data were recorded (weight, height and BMI) as well as scores on nutritional and functional scales (MNA-SF, Barthel index, SPPB, grip strength and Functional Ambulation Categories, FAC) at the beginning of the study and after 12 weeks. Cognitive status, comorbidities and depressive symptoms were also assessed. Frailty status was assessed using the FRAIL scale. RESULTS: 320 participants were included, of whom 253 completed the study (mean age 84.2 ± 7.1 years). Baseline BMI was 20.2 ± 2.8. A high prevalence of functional impairment (Barthel Index median 45, range 15-75; median SPPB 4, range 1-6) and cognitive impairment (MMSE median 12, 7-20) was found. DISCUSSION: This study identified a population with malnutrition and a high degree of physical and mental disability that mirrors the typical population of many nursing homes. Analysis of the results of this study will help to determine the factors associated with malnutrition and the effect of nutritional intervention in practice.

[Prevalence of sarcopenia in Spanish nursing homes: Comparison of the results of the ELLI study with other populations]. / La prevalencia de sarcopenia en residencias de España: comparación de los resultados del estudio multicéntrico ELLI con otras poblaciones.

INTRODUCTION: The main aim of this study is to assess the prevalence of sarcopenia, according to the criteria of the European Working Group on Sarcopenia in Older People, in men and women living in Spanish nursing homes. METHODS: Multi-centre study was conducted on ambulatory persons over 69 years old living in nursing homes. Body composition was assessed using bioimpedance analysis, grip strength with a Jamar dynamometer, and gait speed using the 4 metre walk test. Sarcopenia was assessed using the European Working Group on Sarcopenia in Older People criteria (gait speed<0.8m/s; grip strength<30kg in men or 20kg in women, and muscle mass index <8.31kg/m(2) in men or<6.68kg/m(2) in women). RESULTS: The study included 276 subjects with a median age 87.2 years, and with 69% women. Sarcopenia was demonstrated in 37% (15% men, 46% women), 37% had low muscle mass, 86% low gait speed, and 95% low grip strength. Prevalence of sarcopenia increased with advancing age. Both weakness and low gait speed was observed in 90% of individuals with sarcopenia, with 39% of the total having low gait speed, and 38% with weakness. CONCLUSION: Sarcopenia is a frequent condition in older persons living in nursing homes, especially among women. Most of the cases are severe, with both low muscle strength and physical performance. Although muscle function is altered in 9 out 10 participants, most of them have preserved muscle mass.

Prevalence of sarcopenia in patients attending outpatient geriatric clinics: the ELLI study.

OBJECTIVES: the aim of this study is to know the prevalence of sarcopenia in geriatric outpatient clinics using the EGWSOP (European Working Group on Sarcopenia in Older People) diagnostic criteria that include muscle mass, muscle strength and physical performance. METHODS: subjects over 69 years old, able to walk without help and who attended five geriatric outpatient clinics were recruited. Body composition was assessed using bioimpedance analysis (BIA), grip strength using a JAMAR dynamometer and physical performance by the 4 m gait speed. Sarcopenia was diagnosed using the EGWSOP criteria (gait speed <0.8 m/s; grip strength <30 kg in men or <20 kg in women, and muscle mass index (MMI) <8.31 kg/m(2) in men or <6.68 kg/m(2) in women). RESULTS: two hundred and ninety-eight subjects were included (median age 83.2 years, 63.1% women). 19.1% had sarcopenia (12.7% men, 22.9% women); 20.1% had low muscle mass; 68.8% had low gait speed and 81.2% low grip strength. Only 21.9% of the subjects with low grip strength and 19.5% of those with low gait speed had sarcopenia. No correlations between muscle mass and either muscle strength or gait speed were detected. CONCLUSIONS: sarcopenia is present in one out of five subjects attending geriatric outpatient clinics.

[Prevalence of sarcopenia in geriatric outpatients and nursing homes. The ELLI study]. / Prevalencia de sarcopenia en consultas de geriatría y residencias. Estudio ELLI.

BACKGROUND: There are few systematic studies on the prevalence of sarcopenia using the new diagnostic criteria in different geriatric care settings. OBJECTIVE: To estimate the prevalence of sarcopenia, using the European Working Group on Sarcopenia in Older People (EWGSOP) criteria in older subjects living in nursing homes and in those who attend geriatric outpatient clinics. MATERIAL AND METHODS: A single country multicentre study in two samples of older subjects: patients cared for in outpatient geriatric clinics, and individuals living in nursing homes. Data collected will include demographic variables, medical history, medication, geriatric syndromes, functional status (assessment of basic and instrumental activities of daily living), mobility, cognitive status, comorbidity, quality of life, nutritional status, and laboratory parameters. For the diagnosis of sarcopenia, 4m walking speed, handgrip strength, and body composition measured by bioelectrical impedance analysis will be assessed. RESULTS: Using the EWGSOP algorithm, the prevalence of sarcopenia in an elderly Spanish population will be estimated. In addition, concordance and correlation between the three parameters included in the definition (muscle mass, muscle strength, and physical performance) will be analysed, using the different existing cut-off points, and examining the diagnostic accuracy of each. Finally, demographic, anthropometric and functional data that define subjects with sarcopenia will be investigated. CONCLUSIONS: The ELLI study should improve knowledge on the prevalence and characteristics of sarcopenia in older people in our population.

Functional status and quality of life 12 months after discharge from a medical ICU in healthy elderly patients: a prospective observational study.

INTRODUCTION: Long-term outcomes of elderly patients after medical ICU care are little known. The aim of the study was to evaluate functional status and quality of life of elderly patients 12 months after discharge from a medical ICU. METHODS: We prospectively studied 112/230 healthy elderly patients (≥ 65 years surviving at least 12 months after ICU discharge) with full functional autonomy without cognitive impairment prior to ICU entry. The main diagnoses at admission using the Acute Physiology and Chronic Health Evaluation III (APACHE III) classification diagnosis and length of ICU stay and ICU scores (APACHE II, Sepsis-related Organ Failure Assessment (SOFA) and OMEGA) at admission and discharge were collected. Comprehensive geriatric assessment included the presence of the main geriatric syndromes and the application of Lawton, Barthel, and Charlson Indexes and Informant Questionnaire on Cognitive Decline to evaluate functionality, comorbidity and cognitive status, respectively. The EuroQol-5D assessed quality of life. Data were collected at baseline, during ICU and ward stay and 3, 6 and 12 months after hospital discharge. Paired or unpaired T-tests compared differences between groups (continuous variables), whereas the chi-square and Fisher exact tests were used for comparing dichotomous variables. For variables significant (P ≤ 0.1) on univariate analysis, a forward multiple regression analysis was performed. RESULTS: Only 48.9% of patients (mean age: 73.4 ± 5.5 years) were alive 12 months after discharge showing a significant decrease in functional autonomy (Lawton and Barthel Indexes) and quality of life (EuroQol-5D) compared to baseline status (P < 0.001, all). Multivariate analysis showed a higher Barthel Index and EQ-5D vas at hospital discharge to be associated factors of full functional recovery (P < 0.01, both). Thus, in patients with a Barthel Index ≥ 60 or EQ-5D vas ≥ 40 at discharge the hazard ratio for full functional recovery was 4.04 (95% CI: 1.58 to 10.33; P = 0.005) and 6.1 (95% CI: 1.9 to 19.9; P < 0.01), respectively. Geriatric syndromes increased after ICU stay and remained significantly increased during follow-up (P < 0.001). CONCLUSIONS: The survival rate of elderly medical patients 12 months after discharge from the ICU is low (49%), although functional status and quality of life remained similar to baseline in most of the survivors. However, there was a two-fold increase in the prevalence of geriatric syndromes.

[The emergent role of sarcopenia: Preliminary Report of the Observatory of Sarcopenia of the Spanish Society of Geriatrics and Gerontology]. / La eclosión de la sarcopenia: Informe preliminar del Observatorio de la Sarcopenia de la Sociedad Española de Geriatría y Gerontología.

Sarcopenia is a common and prominent geriatric syndrome, of major interest for daily clinical practice of professionals working with older people. The number of affected individuals and its relation with disability, frailty, many chronic diseases, lifestyle and adverse outcomes are extremely relevant for geriatric care. Moreover, biological changes that lead to the loss of muscle mass and strength are intrinsically related to the mechanisms of aging. It is not therefore surprising that research in this field is growing exponentially in recent years, and sarcopenia has been placed in recent years in the forefront of research in geriatric medicine and gerontology. The Spanish Society of Geriatrics and Gerontology has recently created an Observatory of Sarcopenia, which aims to promote educational and research activities in this field. The first activity of the Observatory has been to offer the Spanish speaking scientific community a review of the current status of sarcopenia, that may allow unifying concepts and fostering interest in this promising field of geriatrics.

Inhibition of circulating immune cell activation: a molecular antiinflammatory effect of the Mediterranean diet.

BACKGROUND: Adherence to the Mediterranean diet (Med-Diet) is associated with a reduced risk of cardiovascular disease (CVD). However, the molecular mechanisms involved are not fully understood. OBJECTIVE: The objective was to compare the effects of 2 Med-Diets with those of a low-fat diet on immune cell activation and soluble inflammatory biomarkers related to atherogenesis in subjects at high risk of CVD. DESIGN: In a controlled study, we randomly assigned 112 older subjects with diabetes or > or =3 CVD risk factors to 3 dietary intervention groups: Med-Diet with supplemental virgin olive oil (VOO), Med-Diet with supplemental nuts, and low-fat diet. Changes from baseline in cellular and serum inflammatory biomarkers were assessed at 3 mo. RESULTS: One hundred six participants (43% women; average age: 68 y) completed the study. At 3 mo, monocyte expression of CD49d, an adhesion molecule crucial for leukocyte homing, and of CD40, a proinflammatory ligand, decreased (P < 0.05) after both Med-Diets but not after the low-fat diet. Serum interleukin-6 and soluble intercellular adhesion molecule-1, inflammatory mediators crucial in firm adhesion of leukocytes to endothelial surfaces, decreased (P < 0.05) in both Med-Diet groups. Soluble vascular cellular adhesion molecule-1 and C-reactive protein decreased only after the Med-Diet with VOO (P < 0.05), whereas interleukin-6, soluble vascular cellular adhesion molecule-1, and soluble intercellular adhesion molecule-1 increased (P < 0.05) after the low-fat diet. CONCLUSIONS: Med-Diets supplemented with VOO or nuts down-regulate cellular and circulating inflammatory biomarkers related to atherogenesis in subjects at high risk of CVD. The results support the recommendation of the Med-Diet as a useful tool against CVD.

Mortality in healthy elderly patients after ICU admission.

PURPOSE: The aim of this study was to assess mortality in healthy elderly patients after non-elective medical ICU admission and to identify predictive factors of mortality in these patients. METHODS: Patients >or=65 years living at home and with full-autonomy (Barthel index, BI > 60), without cognitive impairment, and non-electively admitted to a medical ICU were prospectively recruited. A full comprehensive geriatric assessment was made with validated scales. RESULTS: A total of 230 patients were included, 110 (48%) between 65 and 74 years and 120 (52%) >or=75 years. No significant differences were observed between the two groups in premorbid functional and cognitive status, main diagnosis at ICU admission, APACHE II and SOFA scores, use of mechanical ventilation or haemodialysis or length of ICU stay. Over a mean follow-up of 522 days (range 20-1,170 days) the cumulative mortality of the whole group was 55%, being significantly higher in older subjects (62 vs. 47%; P = 0.024). On multivariate analysis, only parameters related to quality of life (QOL) and functional status were independent predictors of cumulated mortality (P < 0.01, both). Thus, in patients with EQ-5D(vas) (<70) or baseline Lawton index (LI) (<5) the hazard ratio for cumulated mortality was 2.45 (95% CI: 1.15-5.25; P = 0.03) and 4.10 (95% CI: 1.53-10.99; P = 0.006), respectively, compared to those with better scores. CONCLUSIONS: Healthy elderly non-elective medical patients admitted to the ICU have a high mortality rate related to premorbid QOL. The LI and/or EQ-5D(vas) may be useful tools to identify patients with the best chance of survival.

Influence of acute exacerbation of chronic obstructive pulmonary disease or congestive heart failure on functional decline after hospitalization in nonagenarian patients.

BACKGROUND: The functional decline that follows hospitalization may be especially important in frail populations such as nonagenarians. The present study examined the functional decline among nonagenarians admitted because of exacerbations of chronic obstructive pulmonary disease (COPD) or congestive heart failure (CHF). METHODS: A prospective cohort study was performed on two groups of patients who were distinguished by diagnosis in two tertiary academic medical hospitals. Sixty nonagenarian patients, admitted because of exacerbation of COPD (n=30) or CHF (n=30), were evaluated at admission, upon discharge, and 3 months post-hospitalization. The Barthel Index (BI) was used to assess functionality. The outcome we were interested in was functional decline 3 months after hospital discharge. RESULTS: The inpatient mortality rate was 10%. Overall functional status at discharge, as compared with that before admission, declined in all 54 surviving patients (p<0.001). At the 3-month follow-up, 37 patients were evaluated; a decline in their BI persisted in 60% of them. We did not find significant differences, either upon discharge or at 3 months post-hospitalization, in the decrease in BI rate between COPD patients and CHF patients. CONCLUSIONS: The fact that the underlying disease does not induce differences in the functional outcome of nonagenarians reinforces the importance of using a comprehensive approach at admission and after discharge for all frail patients.

Skeletal muscle mitochondrial function is preserved in young patients with chronic renal failure.

Patients with chronic renal failure (CRF) show limited exercise tolerance, classically attributed to anemia. However, persistence of abnormally low peak oxygen consumption, even after restoration of hemoglobin concentration with recombinant erythropoietin therapy and studies of muscle bioenergetics, suggests that the problem is located beyond hemoglobin oxygen transport. The present study is designed to assess mitochondrial respiratory chain (MRC) function from skeletal muscle of patients with CRF to determine whether there is impairment in mitochondrial oxidative capacity. We studied six young patients with CRF on regular hemodialysis and erythropoietin therapy and six healthy controls matched by age, sex, anthropometric characteristics, and physical activity. Muscle biopsy of the quadriceps was performed, and mitochondria were isolated. Mitochondrial content was estimated by means of mitochondrial yield and citrate synthase activity. Maximal capacity for oxygen consumption was measured polarographically using complex I, II, III, and IV substrates of the MRC. Individual enzyme activities of MRC complexes I to V were determined spectrophotometrically. Membrane lipid peroxidation was estimated by cis-parinaric fluorescence. Compared with controls, patients with CRF showed preserved mitochondrial content, conserved respiratory activity, intact enzyme activity of MRC complexes, and no increase in lipid peroxidation. We therefore conclude that mitochondrial function is preserved in young patients with CRF.