Possible Role of Tauroursodeoxycholic Acid (TUDCA) and Antibiotic Administration in Modulating Human Gut Microbiota in Home Enteral Nutrition Therapy for the Elderly: A Case Report.

Tauroursodeoxycholic acid (TUDCA) increases the influx of primary bile acids into the gut. Results obtained on animal models suggested that Firmicutes and Proteobacteria phyla are more resistant to bile acids in rats. As part of a pilot study investigating the role of probiotics supplementation in elderly people with home enteral nutrition (HEN), a case of a 92-year-old woman with HEN is reported in the present study. She lives in a nursing home and suffers from Alzheimer's disease (AD); the patient had been prescribed TUDCA for lithiasis cholangitis. The aim of this case report is therefore to investigate whether long-term TUDCA administration may play a role in altering the patient's gut microbiota (GM) and the impact of an antibiotic therapy on the diversity of microbial species. Using next generation sequencing (NGS) analysis of the bacterial 16S ribosomal RNA (rRNA) gene a dominant shift toward Firmicutes and a remodeling in Proteobacteria abundance was observed in the woman's gut microbiota. Considering the patient's age, health status and type of diet, we would have expected to find a GM with a prevalence of Bacteroidetes phylum. This represents the first study investigating the possible TUDCA's effect on human GM.

Reliability and validity of the Italian Eating Assessment Tool.

OBJECTIVES: We sought to evaluate the reliability and validity of the Italian EAT-10 (Italian Eating Assessment Tool; I-EAT-10). METHODS: The study consisted of 4 phases: item generation, internal consistency and reliability analysis, normative data generation, and validity analysis. Discussion of the EAT-10 with 30 patients and its back-translation were accomplished. The recruited population included 172 patients (40 with dysphonia and 132 with dysphagia) and 269 asymptomatic subjects for testing of internal consistency, and 94 patients with dysphagia and 158 asymptomatic subjects for test-retest reliability analysis. Normative data were gathered from the 269 subjects. The scores of patients and asymptomatic subjects were compared. The I-EAT-10 and flexible endoscopic evaluation of swallowing (FEES) scores in 94 patients were correlated. The I-EAT-10 scores made before and after successful swallowing rehabilitation in 38 patients were compared. RESULTS: Excellent internal consistency (Cronbach's alpha values of 0.90 and 0.93) and strong test-retest reliability (intraclass correlation coefficients of 0.95 and 0.98) were found in patients and asymptomatic subjects. The I-EAT-10 mean (+/- SD) score of the normal cohort was 0.6 +/- 1.1. The asymptomatic subjects and dysphonic patients scored lower than the dysphagic patients on the Kruskal-Wallis test (p = 0.001). The I-EAT-10 and FEES scores were mildly correlated. The mean I-EAT-10 score improved from 9.8 +/- 10.3 to 5.8 +/- 6.7 after swallowing rehabilitation (p = 0.04). CONCLUSIONS: The I-EAT-10 is a reliable, valid, symptom-specific outcome tool.

Development of Quality Indicators for Geriatric Home Enteral Nutrition (HEN) Services.

The evidence on the safety, efficacy and patient centeredness of Home Enteral Nutrition (HEN) services is scarce. In 2015, we carried out a search of the literature to identify specific indicators for HEN services as tools to be used to assess the quality of INRCA HEN services. No specific indicators for HEN services were found. Through a subsequent search of the literature, we have identified the appropriate methodology to define quality indicators and developed eight (8) specific indicators to track the quality of our HEN service for geriatric patients. Following Donabiedan's classification, we have defined two structure indicators, two process indicators and four outcome indicators that are presented in this manuscript. Though they may be used to make a comparison of HEN services for geriatric patients and to monitor the quality of therapy provided at patients' homes, the definition of quality system indicators for HEN services requires the additional joint efforts of experts in the field of nutrition and the scientific community for their validation.

Multidisciplinary Assessment and Individualized Nutritional Management of Dysphagia in Older Outpatients.

INTRODUCTION: The evidence on the efficacy of nutrition therapy to prevent complications of dysphagia is based on observational studies that used different tools for nutritional and dysphagia assessment, and different scales for the definition of diet textures, rendering their results incomparable and the knowledge on dysphagia management inconclusive. METHODS: This retrospective observational study was performed in 267 older outpatients who were assessed for dysphagia and nutritional status by a multidisciplinary team at the Clinical Nutrition Unit of IRCCS INRCA geriatric research hospital (Ancona, Italy) from 2018 to 2021. GUSS test and ASHA-NOMS measurement systems were used for dysphagia assessment, GLIM criteria for the assessment of nutritional status, and the IDDSI framework to describe the texture-modified diets. Descriptive statistics were used to summarize the characteristics of the subjects evaluated. Sociodemographic, functional and clinical parameters were compared between patients with and without BMI improvement overtime by an unpaired Student's t test, Mann-Whitney U test or Chi square test, as appropriate. RESULTS: Dysphagia was diagnosed in more than 96.0% of subjects; 22.1% (n = 59) of dysphagic subjects were also malnourished. Dysphagia was treated exclusively by nutrition therapy, prevalently by individualized texture-modified diets (77.4%). For the classification of diet texture, the IDDSI framework was used. The follow-up visit was attended by 63.7% (n = 102) of subjects. Aspiration pneumonia was registered only in one patient (less than 1%), and BMI improved in 13 of 19 malnourished subjects (68.4%). The improvement of nutritional status was primarily reached in subjects whose energy intake was increased and texture of solids modified, in younger subjects, and in those taking less drugs and not reporting any weight loss before the first assessment. CONCLUSIONS: The nutritional management of dysphagia must guarantee both an adequate consistency and energy-protein intake. Evaluations and outcomes should be described with universal scales, in order to allow for comparison between studies and contribute to the collection of a critical mass of evidence on the efficacy of texture-modified diets in the management of dysphagia and its complications.

Potential Role of Probiotics for Inflammaging: A Narrative Review.

BACKGROUND AND AIMS: Inflammaging, a chronic, low-grade inflammation (LGI), is one of the mechanisms of adaptation of an organism to aging. Alterations in the composition of gut microbiota and gut permeability are among the main sources of LGI. They may be modulated by supplementation with live microorganisms, i.e. probiotics. This narrative review was performed with the aim to critically examine the current evidence from randomized clinical trials (RCTs) on the effects of probiotics on pro-inflammatory and anti-inflammatory cytokines and C-reactive protein (CRP) in healthy older subjects. METHODOLOGY: RCTs on the effects of probiotics on inflammatory parameters in subjects older than 65 years published in English and Italian from 1990 to October 2020 were searched in PubMed. Studies that were not RCTs, those using probiotics together with prebiotics (synbiotics), and studies performed in subjects with acute or chronic diseases were excluded. The findings of RCTs were reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). RESULTS: A total of nine RCTs met the eligibility criteria and were included in this narrative review. Four articles reported that probiotic supplementation significantly affected inflammatory parameters, respectively, by reducing TGF-ß1 concentrations, IL-8, increasing IL-5 and Il-10, and IFN-γ and IL-12. CONCLUSIONS: Based on this narrative review, probiotic supplementation showed a limited effect on inflammatory markers in healthy individuals older than 65 years. Besides being few, the studies analyzed have methodological limitations, are heterogeneous, and provide results which are incomparable.

Safety and Efficacy of Probiotic Supplementation in Reducing the Incidence of Infections and Modulating Inflammation in the Elderly with Feeding Tubes: A Pilot, Double-Blind, Placebo-Controlled Study, "IntegPRO".

A double-blind, placebo-controlled study was performed in a sample of geriatric patients treated with home enteral nutrition (HEN) to analyze the efficacy of a probiotic supplement Proxian®, which contains Lactiplantibacillus plantarum LP01 (LMG P-21021), Lentilactobacillus buchneri Lb26 (DSM 16341), Bifidobacterium animalis subsp. lactis BS01 (LMG P-21384), and is enriched with zinc (Zn) and selenium (Se), in reducing the incidence of infections and modulating inflammation. Thirty-two subjects were enrolled (mean age 79.7 ± 10.3 years), 16 in the intervention group, 16 controls. They received Proxian® or placebo for 60 days. Patients were assessed at baseline (t0) and 60 (t1) and 90 (t2) days after the beginning. Infections were detected by information regarding their clinical manifestations and the incidence of antibiotic therapy. Levels of C-reactive protein (CRP) were measured to study inflammation. Information on bowel function, nutritional status and testimonials regarding the feasibility of administration of the product were collected. Differences between the two groups in number of infections (25% intervention group vs. 44% controls), antibiotic therapies (12% vs. 37%) and modulation of CRP levels (median CRP moved from 0.95 mg/L (t0), to 0.6 (t1) and 0.7 (t2) in intervention group vs. 0.7 mg/L, 0.5 and 0.7 in controls) did not reach statistical significance. No significant changes in bowel function and nutritional status were found. Caregivers' adherence was 100%. Results of this "IntegPRO" study showed that Proxian® is potentially safe, easy to administer and promising for further studies but it appears not to change the incidence of infections or modulate inflammation in elderly treated with HEN. The utility of Proxian® in reducing the incidence of infections and modulating inflammation in these subjects needs to be investigated by a larger multi-center clinical trial, and by using additional analyses on inflammatory markers and markers of infections.

Dysphagia in Nursing Home Residents: Management and Outcomes.

OBJECTIVES: To define the prevalence of dysphagia and its associated factors and to investigate the influence of dysphagia and nutritional therapies performed in dysphagic subjects on clinical outcomes, including nutritional status, pressure ulcers, hospitalization, and mortality. DESIGN: A prospective observational study. SETTING AND PARTICIPANTS: Thirty-one Italian nursing homes participating in the ULISSE project and 1490 long-stay nursing home residents, older than 65 years, assessed at baseline and reassessed after 6 and 12 months. MEASURES: All participants underwent a standardized comprehensive assessment using the Italian version of the nursing home Minimum Data Set. The activities of daily living Long-Form scale was used to evaluate functional status. Health care professionals assessed dysphagia by means of clinical evaluation. Nutritional status was assessed using the information on weight loss. RESULTS: The prevalence of dysphagia was 12.8%, and 16% of the subjects were treated with artificial nutrition. The mortality rate in subjects with dysphagia was significantly higher compared with that of nondysphagic subjects (27.7% vs 16.8%; P = .0001). The prevalence of weight loss and pressure ulcers was also higher in dysphagic subjects. At variance, dysphagia was not associated with a higher hospitalization risk. CONCLUSION/IMPLICATIONS: Dysphagia is common in nursing home residents, and it is associated with higher mortality. Therefore, early diagnosis and optimal management of dysphagia should become a priority issue in nursing homes.

Malnutrition upon Hospital Admission in Geriatric Patients: Why Assess It?

OBJECTIVE: To assess the prevalence of malnutrition according to the new ESPEN definition in a population of geriatric hospital patients and to determine how malnutrition affects the length of hospital stay (LOS) and hospital mortality. DESIGN: A retrospective analysis of data gathered during nutritional screening surveys carried out three consecutive years, from 2012 to 2014, in an Italian geriatric research hospital (INRCA, Ancona) was performed. On the day of the study, demographic data, data on clinical conditions and the nutritional status of newly admitted patients were collected. Patients were screened for malnutrition risk using the Malnutrition Universal Screening Tool (MUST). Subsequently, malnutrition was diagnosed, for subjects at high risk, following the criteria suggested by the European Association for Clinical Nutrition and Metabolism [body mass index (BMI) < 18.5 kg/m2 or different combinations of unintentional weight loss over time and BMI values]. Sensitivity, specificity, positive and negative predictive value of MUST compared to ESPEN criteria were assessed. The characteristics of patients with a diagnosis of malnutrition were compared to those of non-malnourished patients. The impact of malnutrition on LOS and hospital mortality was investigated through logistic and linear regression models. SETTING: The study was performed in an Italian geriatric research hospital (INRCA, Ancona). SUBJECTS: Two hundred eighty-four newly hospitalized geriatric patients from acute care wards (mean age 82.8 ± 8.7 years), who gave their written consent to participate in the study, were enrolled. RESULTS: According to the MUST, high risk of malnutrition at hospitalization was found in 28.2% of patients. Malnutrition was diagnosed in 24.6% of subjects. The malnutrition was an independent predictor of both the LOS and hospital mortality. The multivariate analyses-linear and logistic regression-were performed considering different potential confounders contemporarily. The results showed that the malnutrition is an independent predictor of LOS and hospital mortality. Malnourished subjects were hospitalized almost 3 days longer compared to non-malnourished patients (p = 0.047; CI 0.04-5.80). The risk of death during hospitalization was 55% higher for malnourished patients (p = 0.037; CI 0.21-0.95). CONCLUSION: A new ESPEN consensus of malnutrition was easily applicable in a population of geriatric hospital patients. Given that the nutritional status of geriatric patients was strongly correlated with the LOS and hospital mortality, the use of this simple and non-time consuming tool is highly recommended in clinical practice.

Utility of video consultation to improve the outcomes of home enteral nutrition in a population of frail older patients.

AIM: To determine whether the outcomes of home enteral nutrition for frail older patients can be improved by video consultation between home visiting staff and a hospital physician, specialized in clinical nutrition, during monthly home visits. METHODS: A randomized prospective study out of patients aged older than 65 years receiving home enteral nutrition from the Department of Clinical Nutrition of an Italian geriatric hospital in 2013 was carried. A total of 100 patients were randomly assigned to receive video consultation in addition to regular monthly home visits, 88 patients only had regular monthly home visits. Therapy outcomes - incidence rates of complications, outpatient hospital visits and hospitalizations - were compared between two groups. A logistic regression analysis was carried out to evaluate the usefulness of the video consultation to improve therapy outcomes. RESULTS: Incidence rates for metabolic and gastrointestinal complications were significantly lower for patients who received a video consultation, respectively: 0.032/year "video consultation" versus 0.055/year "no video consultation" (P = 0.0001) and 0.006/year "video consultation" versus 0.028/year "no video consultation" (P < 0.0001). No differences were found for incidence rates of mechanical complications, outpatient hospital visits and hospitalizations. Logistic regression showed that the video consultation was significantly correlated with a reduction of metabolic complications (OR 2.63, 95% CI 1.00-6.91; P = 0.049 after adjustment for duration of home enteral nutrition and diabetes mellitus 2). CONCLUSION: The present study provides evidence that a video consultation between home visiting staff and hospital physicians specialized in clinical nutrition during monthly home visits is associated with a reduction of metabolic complications in a population of frail older patients. Geriatr Gerontol Int 2015; ●●: ●●-●●.