Four-week administration of an energy and protein dense oral nutritional supplement improves micronutrient concentrations but does not completely correct deficiencies in institutionalized malnourished older adults.

Introduction: Poor food intake is common among elderly living in nursing homes, leading to micronutrient deficiency (MD). There are no recommendations for the management of MD in malnourished older adults. Methods: We conducted a single arm, open-label, multicenter interventional study in institutionalized malnourished older adults to describe the effect of a 4-week daily energy and protein dense oral nutritional supplementation (ONS, 600 kcal, 30 g protein per unit) containing 50% of the recommended daily micronutrient intake on micronutrient status. Plasma concentrations of vitamins (A, B9, B12, C, E), magnesium (Mg), selenium (Se) and zinc (Zn), and erythrocyte vitamin B9 were measured at baseline and after 4 weeks. Results: Forty-six participants completed the study (age 87.4 ± 6.6). At baseline, the most frequent MD were Se (48%), Zn (35%), Mg (24%) and vitamin C (24%). Plasma concentrations of vitamins B9, B12, C and E, Mg, Se and Zn significantly increased and the proportion of subjects with at least one MD decreased (p = 0.006). However, after 4 weeks, 40% of subjects still had at least one MD. Discussion: ONS consumption improved micronutrient status but did not correct MD in all participants. Our data suggest that the prescription of vitamin, mineral and trace element supplementation should be considered in institutionalized malnourished older adults in addition to high energy and high protein ONS.

Hypnosis for pain and anxiety management in cognitively impaired older adults undergoing scheduled lumbar punctures: a randomized controlled pilot study.

BACKGROUND: Core cerebrospinal fluid (CSF) amyloid and tau biomarker assessment has been recommended to refine the diagnostic accuracy of Alzheimer's disease. Lumbar punctures (LP) are invasive procedures that might induce anxiety and pain. The use of non-pharmacological techniques must be considered to reduce the patient's discomfort, in this setting. The objective of this study was to examine the efficacy of hypnosis on anxiety and pain associated with LP. METHODS: A monocentric interventional randomized-controlled pilot study is conducted in a university geriatric day hospital. Cognitively impaired patients aged over 70 were referred for scheduled LP for the diagnostic purpose (CSF biomarkers). The participants were randomly assigned either to a hypnosis intervention group or usual care. Pain and anxiety were both self-assessed by the patient and hetero-evaluated by the operator. RESULTS: We included 50 cognitively impaired elderly outpatients (women 54%, mean age 77.2 ± 5.0, mean Mini-Mental State Examination score 23.2 ± 3.5). Hypnosis was significantly associated with reduced self-assessed (p < 0.05) and hetero-assessed anxiety (p < 0.01). Hetero-evaluated pain was significantly lower in the hypnosis group (p < 0.05). The overall perception of hypnosis was safe, well-accepted, and feasible in all the participants of the intervention group with 68% perceiving the procedure as better or much better than expected. CONCLUSIONS: This pilot study suggested that hypnosis was feasible and may be used to reduce the symptoms of discomfort due to invasive procedures in older cognitively impaired patients. Our results also confirmed the overall good acceptance of LP in this population, despite the usual negative perception. TRIAL REGISTRATION: ClinicalTrials.gov NCT04368572. Registered on April 30, 2020.

[Protein supplementation to prevent loss in muscle mass and strength in frail older patients: a review]. / Quels bénéfices attendre de la supplémentation en protéines pour limiter la perte de masse et de fonction musculaire chez le sujet âgé fragile ?

Minimum levels of protein intake are essential for the preservation of muscle mass and function, which is a major preventive issue of successful aging. Epidemiological studies suggest strong associations between protein intake and the different elements of sarcopenia, namely maintenance of lean mass and muscle strength. Most often, protein intakes among older patients are below requirements, independently from situations of under nutrition. This opens the path for nutritional interventions to prevent the consequences of sarcopenia in older patients. Isolated amino-acids such as leucine have shown positive effects in the short term only. The positive effects of protein supplementations on muscle strength and function are currently not established in the absence of concomitant exercise training. The highest level of evidence supports interventions combining exercise and nutrition.

Impact of 3-week citrulline supplementation on postprandial protein metabolism in malnourished older patients: The Ciproage randomized controlled trial.

BACKGROUND: Citrulline (CIT), is not extracted by the splanchnic area, can stimulate muscle protein synthesis and could potentially find clinical applications in conditions involving low amino acid (AA) intake, such as in malnourished older subjects. OBJECTIVE: Our purpose was to research the effects of CIT supplementation on protein metabolism in particular on non-oxidative leucine disposal (NOLD, primary endpoint), and splanchnic extraction of amino acids in malnourished older patients. DESIGN: This prospective randomized multicenter study determined whole-body and liver protein synthesis, splanchnic protein metabolism and appendicular skeletal muscle mass (ASMM) in 24 malnourished older patients [80-92 years; 18 women and 6 men] in inpatient rehabilitation units. All received an oral dose of 10 g of CIT or an equimolar mixture of six non-essential amino acids (NEAAs), as isonitrogenous placebo, for 3 weeks. RESULTS: NOLD and albumin fractional synthesis rates were not different between the NEAA and CIT groups. Splanchnic extraction of dietary amino acid tended to decrease (p = 0.09) in the CIT group (45.2%) compared with the NEAA group (60.3%). Total differences in AA and NEAA area under the curves between fed-state and postabsorptive-state were significantly higher in the CIT than in the NEAA group. There were no significant differences for body mass index, fat mass (FM), lean mass (LM) or ASMM in the whole population except for a tendential decrease in FM for the citrulline group (p = 0.089). Compared with Day 1, lean mass and ASMM significantly increased (respectively p = 0.016 and p = 0.018) at Day 20 in CIT-treated women (mean respective increase of 1.7 kg and 1.1 kg), and fat mass significantly decreased (p = 0.001) at Day 20 in CIT-group women (mean decrease of 1.3 kg). CONCLUSIONS: Our results demonstrate that CIT supplementation has no effect on whole-body protein synthesis or liver protein synthesis in malnourished older subjects. However, CIT supplementation was associated with a higher systemic AA availability. In the subgroup of women, CIT supplementation increased LM and ASMM, and decreased FM.

Citrulline Supplementation Induces Changes in Body Composition and Limits Age-Related Metabolic Changes in Healthy Male Rats.

BACKGROUND: Aging is associated with profound metabolic disturbances, and citrulline may be of use to limit them. OBJECTIVE: The aim of this work was to evaluate the long-term effect of citrulline supplementation on metabolism in healthy aged rats. METHODS: Twenty-month-old male rats were randomly assigned to be fed (ad libitum) for 12 wk with either a citrulline-enriched diet (1 g ⋅ kg(-1) ⋅ d(-1)) or a standard diet [rendered isonitrogenous by addition of nonessential amino acids (NEAAs)]. Motor activity and muscle strength were measured, body composition was assessed, and muscle metabolism (protein structure, mitochondrial exploration, and transductional factors) and lipid metabolism (lipoprotein composition and sensitivity to oxidative stress) were explored. RESULTS: Compared with the NEAA-treated group, citrulline supplementation was associated with lower mortality (0% vs. 20%; P = 0.05), 9% higher lean body mass (P < 0.05), and 13% lower fat mass (P < 0.05). Compared with the NEAA-treated group, citrulline-treated rats had greater muscle mass (+14-48% depending on type of muscle; P < 0.05 for tibialis, gastrocnemius, and plantaris). Susceptibility to oxidation of lipoproteins, as measured by the maximal concentration of 7-ketocholesterol after copper-induced VLDL and LDL oxidation, was lower in citrulline-treated rats than in NEAA-treated rats (187 ± 8 µmol/L vs. 243 ± 7 µmol/L; P = 0.0005). CONCLUSIONS: Citrulline treatment in male aged rats favorably modulates body composition and protects against lipid oxidation and, thus, emerges as an interesting candidate to help prevent the aging process.

Leucine and citrulline modulate muscle function in malnourished aged rats.

Protein energy malnutrition in the elderly causes preferential loss of muscle mass which is associated with poor functional states. Leucine and citrulline are able to stimulate muscle protein synthesis in aged rats but no study has been undertaken to evaluate their effect on muscle function. Sprague-Dawley male rats aged 23 months were used in the experiment. Part of them were subjected to a dietary restriction for 12 weeks and then assigned to four groups: a group was euthanized (restricted group), and the others were refed for 1 week with either a leucine-, a citrulline-supplemented diet, or a standard diet. The other rats were fed ad libitum. Muscle mass and motor activity significantly increased during the refeeding with either leucine or citrulline (respectively, +51 and +37% for muscle mass, P < 0.05). The improvement of muscle mass and of motor activity induced by leucine and citrulline was highly associated with that of maximal tetanic isometric force (r = 0.769, P < 0.0001; r = 0.389, P < 0.05, respectively) but only leucine improved maximal tetanic isometric force (+101%, P < 0.05). In conclusion, this is the first study to demonstrate the ability of two amino acids (leucine and citrulline) to modulate muscle function.

Clinical practice guidelines from the French Health High Authority: nutritional support strategy in protein-energy malnutrition in the elderly.

These guidelines were produced at the request of the General Directorate of Health within the scope of the French Nutrition and Health Program (PNNS). They concern the management of malnutrition in elderly persons living at home, in institutional care, or in hospital. They belong to a recent series of studies published by ANAES(1) or HAS. Preceding studies concerned the "Diagnostic assessment of protein-energy malnutrition in hospitalized adults" (ANAES, September 2003) and the work conducted by the Committee for the Assessment of Devices and Health Technologies (CEPP) on "Reimbursement procedures for dietary foods for special medical purposes for nutritional supplementation and home enteral nutrition" (HAS, September 2006). The objective of these guidelines is to develop a tool for identifying and managing elderly subjects who are malnourished or at risk of malnutrition.

[Pressure sores in geriatric medicine: the role of nutrition]. / Escarres en gériatrie: place de la prise en charge nutritionnelle.

Malnutrition is frequent in geriatric patients: it affects 30 to 60% of elderly residents of institutions and 30 to 70% of patients admitted for short-term hospitalization. Malnutrition is a risk factor for developing pressure sores, and patients with them are more often and more severely malnourished than patients without them. In elderly subjects, multiple and interlinked factors may trigger or aggravate malnutrition; they may be physical, psychological or social and may be worsened by drugs and some diets. Malnutrition has been recognized as a risk factor for the onset and perpetuation of pressure sores. Of the dietary factors, protein intake seems most important. A low body mass index (BMI), low serum albumin, and weight loss are associated with an increased risk of pressure sores. A physician observing pressure sores must conduct a nutritional assessment, using clinical and laboratory screening tools. The criteria for malnutrition in elderly subjects are weight loss > or =5% in 3 months or > or =10% in 6 months, BMI<21 kg/m(2), serum albumin<35 g/L or a MNA (Mini Nutritional Assessment) score<17. Any one of these criteria is a sufficient basis for a diagnosis of malnutrition. Nutritional management is part of the prevention and treatment of pressure sores in geriatric medicine. It must be adapted for each patient. The recommended calorie intake in malnourished patients at risk of or with pressure sores is 30-40 kcal/kg/d, with 1.2-1.5 g of proteins/kg/d.