Nutritional risk, functional status and mortality in newly institutionalised elderly.

Previous studies have reported a close relationship between nutritional and functional domains, but evidence in long-term care residents is still limited. We evaluated the relationship between nutritional risk and functional status and the association of these two domains with mortality in newly institutionalised elderly. In the present multi-centric prospective cohort study, involving 346 long-term care resident elderly, nutritional risk and functional status were determined upon admission by the Geriatric Nutritional Risk Index (GNRI) and the Barthel Index (BI), respectively. The prevalence of high (GNRI <92) and low (GNRI 92­98) nutritional risk were 36·1 and 30·6 %, respectively. At multivariable linear regression, functional status was independently associated with age (P=0·045), arm muscle area (P=0·048), the number of co-morbidities (P=0·027) and mainly with the GNRI (P<0·001). During a median follow-up of 4·7 years (25th­75th percentile 3·7­6·2), 230 (66·5 %) subjects died. In the risk analysis, based on the variables collected at baseline, both high (hazard ratio (HR) 1·86, 95% CI 1·32, 2·63; P<0·001) and low nutritional risk (HR 1·52, 95% CI 1·08, 2·14; P=0·016) were associated with all-cause mortality. Participants at high nutritional risk (GNRI <92) also showed an increased rate of cardiovascular mortality (HR 1·93, 95% CI 1·28, 2·91; P<0·001). No association with outcome was found for the BI. Upon admission, nutritional risk was an independent predictor of functional status and mortality in institutionalised elderly. Present data support the concept that the nutritional domain is more relevant than functional status to the outcome of newly institutionalised elderly.

Alzheimer's disease and mortality in traditional long-term care facilities.

Although there is evidence that different types of dementia share similar pathophysiologic mechanisms, research studies support the concept that dementia of the Alzheimer type (AD) is a distinct clinical entity, which may differ in terms of disease progression and outcome. We assessed whether a diagnosis of probable AD in elderly patients admitted to traditional long-term care facilities results in different mortality rates. We analyzed data belonging to a prospective, multi-center (n=4) cohort study involving 378 long-term care facility residents. In our population the prevalence of dementia (any-type) and AD were 46.3% and 11.9%, respectively. During a median follow-up of 5.7 years [25-75th percentile, 2.6-6.9], 262 (69.3%) elderly died. Compared to other admission diagnoses, AD was characterized by lower mortality rates: all-cause hazard risk (HR), 0.64 [95% CI, 0.41-0.99] (P=0.048); HR for cardiovascular (CV) causes, 0.40 [95% CI, 0.20-0.78] (P=0.008). Pre-specified subgroup analyses restricted to patients with dementia (n=175) provided similar results. HRs for AD were: all-cause, 0.60 [95% CI, 0.35-1.00] (P=0.049); CV, 0.43 [95% CI, 0.20-0.91] (P=0.028). However, any-type dementia did not show any difference in risk when compared to other admission diagnosis. In conclusion, probable AD was associated with reduced mortality risk in traditional long-term care facilities. The reasons for these findings deserve further investigation; peculiar pathophysiological features could not be excluded.

Nutritional screening and mortality in newly institutionalised elderly: a comparison between the geriatric nutritional risk index and the mini nutritional assessment.

BACKGROUND & AIMS: Several tools are available for nutritional screening. We evaluated the risk of mortality associated with the Geriatric Nutritional Risk Index (GNRI) and the Mini Nutritional Assessment (MNA) in newly institutionalised elderly. METHODS: A prospective observational study involving 358 elderly newly admitted to a long-term care setting. Hazard ratios (HR) for mortality among GNRI categories and MNA classes were estimated by multivariable Cox's model. RESULTS: At baseline, 32.4% and 37.4% of the patients were classified as being malnourished (MNA <17) and at severe nutritional risk (GNRI <92), respectively, whereas 57.5% and 35.2%, respectively, were classified as being at risk for malnutrition (MNA 17-23.5) and having low nutritional risk (GNRI 92-98). During a median follow-up of 6.5 years [25th-75th percentile, 5.9-8.6], 297 elderly died. Risk for all-cause mortality was significantly associated with nutritional risk by the GNRI tool (GNRI<92 HR = 1.99 [95%CI, 1.38-2.88]; GNRI 92-98 HR = 1.51 [95%CI, 1.04-2.18]) but not with nutritional status by the MNA. A significant association was also found with cardiovascular mortality (GNRI <92 HR = 1.79 [95%CI, 1.23-2.61]). CONCLUSIONS: Nutritional risk by GNRI but not nutritional status by MNA was associated with higher mortality risk. Present data suggest that in the nutritional screening of newly institutionalised elderly the use of the GNRI should be preferred to that of the MNA.

Body mass index and mortality in institutionalized elderly.

OBJECTIVE: Malnutrition and sarcopenia in institutions are very common and significantly affect the prognosis. Aging is characterized by weight and lean body mass losses. Accordingly, in elderly patients, body mass index (BMI) is considered a marker of protein stores rather than of adiposity. Current guidelines suggest a BMI 21 kg/m(2) or lower as major trigger for nutritional support. We evaluated the association between BMI and mortality in institutionalized elderly. METHODS: This was a multicentric prospective cohort study involving 519 long-term care resident elderly individuals. Risk for mortality across BMI tertiles was estimated by the Cox hazards regression model adjusted for potential confounders recorded at inclusion and collected during the follow-up. RESULTS: During a median follow-up of 5.7 years (25th to 75th percentile, 5.2-8.2], 409 (78.8%) elderly patients died. In primary analyses, based on variables collected at inclusion, patients in the first tertile of BMI (≤ 21 kg/m(2)) were at higher risk for all-cause (hazard ratio [HR] 1.38; 95% confidence interval [CI] 1.04-1.84; P = .025) and cardiovascular mortality (HR = 1.49; 95% CI, 1.00-2.08; P = .045). Increased risk was confirmed even after adjusting for nutritional support during the follow-up (all-cause HR = 1.53; 95% CI, 1.13-2.06; P = .006; cardiovascular HR = 1.62; 95% CI, 1.09-2.40; P = .018), which in turn was associated with a reduced risk (all-cause HR = 0.74; 95% CI, 0.55-0.97; P = .035; cardiovascular HR = 0.62; 95% CI, 0.42-0.91; P = .016). CONCLUSION: BMI is significantly associated with all-cause and cardiovascular mortality in institutionalized elderly patients. A value of 21 kg/m(2) or lower can be considered a useful trigger for nutritional support. These results support intending BMI as nutritional reserve in institutionalized elderly patients.

Disease-specific, versus standard, nutritional support for the treatment of pressure ulcers in institutionalized older adults: a randomized controlled trial.

OBJECTIVES: To investigate whether a disease-specific nutritional approach is more beneficial than a standard dietary approach to the healing of pressure ulcers (PUs) in institutionalized elderly patients. DESIGN: Twelve-week follow-up randomized controlled trial (RCT). SETTING: Four long-term care facilities in the province of Como, Italy. PARTICIPANTS: Twenty-eight elderly subjects with Stage II, III, and IV PUs of recent onset (<1-month history). INTERVENTION: All 28 patients received 30 kcal/kg per day nutritional support; of these, 15 received standard nutrition (hospital diet or standard enteral formula; 16% calories from protein), whereas 13 were administered a disease-specific nutrition treatment consisting of the standard diet plus a 400-mL oral supplement or specific enteral formula enriched with protein (20% of the total calories), arginine, zinc, and vitamin C (P<.001 for all nutrients vs control). MEASUREMENTS: Ulcer healing was evaluated using the Pressure Ulcer Scale for Healing (PUSH; 0=complete healing, 17=greatest severity) tool and area measurement (mm(2) and %). RESULTS: The sampled groups were well matched for age, sex, nutritional status, oral intake, type of feeding, and ulcer severity. After 12 weeks, both groups showed significant improvement (P<.001). The treatment produced a higher rate of healing, the PUSH score revealing a significant difference at Week 12 (-6.1+/-2.7 vs -3.3+/-2.4; P<.05) and the reduction in ulcer surface area significantly higher in the treated patients already by Week 8 (-1,140.9+/-669.2 mm(2) vs -571.7+/-391.3 mm(2); P<.05 and approximately 57% vs approximately 33%; P<.02). CONCLUSION: The rate of PU healing appears to accelerate when a nutrition formula enriched with protein, arginine, zinc, and vitamin C is administered, making such a formula preferable to a standardized one, but the present data require further confirmation by high-quality RCTs conducted on a larger scale.

The ability of the Geriatric Nutritional Risk Index to assess the nutritional status and predict the outcome of home-care resident elderly: a comparison with the Mini Nutritional Assessment.

The Mini Nutritional Assessment (MNA) is recommended for grading nutritional status in the elderly. A new index for predicting the risk of nutrition-related complications, the Geriatric Nutritional Risk Index (GNRI), was recently proposed but little is known about its possible use in the assessment of nutritional status. Thus, we aimed to investigate its ability to assess the nutritional status and predict the outcome when compared with the MNA. Anthropometry and biochemical parameters were determined in 241 institutionalised elderly (ninety-four males and 147 females; aged 80.1 (SD 8.3) years). Nutritional risk and nutritional state were graded by the GNRI and MNA, respectively. At 6 months outcomes were: death; infections; bedsores. According to the GNRI and MNA, the prevalence of high risk (GNRI < 92)/malnutrition (MNA < 17), moderate risk (GNRI 92-98)/malnutrition at-risk (MNA 17-23.5) and no risk (GNRI > 98)/good status (MNA > 24) were 20.7/12.8%, 36.1/39% and 43.2/48.2%, respectively, with poor agreement in scoring the patient (Cohen's kappa test: kappa = 0.29; 95% CI 0.19, 0.39). GNRI categories showed a stronger association (OR) with overall outcomes than MNA classes, although no difference (P>0.05) was found between malnutrition (v. 'good status', OR 6.4; 95% CI 2.1, 71.9) and high nutritional risk (v. 'no risk', OR 9.7; 95% CI 3.0, 130). Multivariate logistic regression revealed the GNRI as an independent predictor of complications. In overall-outcome prediction, a good sensitivity was found only for GNRI < 98 (0.86 (95% CI 0.67, 0.96)). The combination of a GNRI > 98 with an MNA > 24 seemed to exclude adverse outcomes. The GNRI showed poor agreement with the MNA in nutritional assessment, but appeared to better predict outcome. In home-care resident elderly, outcome prediction should be performed by combining the suggestions from both these tools.

The association of Geriatric Nutritional Risk Index and total lymphocyte count with short-term nutrition-related complications in institutionalised elderly.

OBJECTIVE: To investigate how total lymphocyte count (TLC) and the Geriatric Nutritional Risk Index (GNRI) are associated with short-term nutritional-related complications (death, infections, bedsores) in institutionalised elderly. METHODS: 220 home-care resident elderly (age +/- SD; 80.7 +/- 7.9, range: 67-98 years) were studied (anthropometry, biochemistry, food intake) and prospectively followed over a period of 3 months for the occurrence of health complications. Nutritional risk was assessed by GNRI. Patients were categorized according to GNRI (<92, 92-98, >98) and TLC (<900, 900-1499, >or=1500/mm3). RESULTS: GNRI was significantly associated with TLC according to both simple and adjusted correlation models (p < 0.001) and to multiple stepwise regression analysis (p < 0.005). TLC < 900 revealed a higher specificity (87.8%) than sensitivity (30.6%) in identifying "at-risk" patients (GNRI < 92). Adjusted multiple logistic regression revealed a significant association between overall 3-month health outcomes and both TLC and food intake. TLC was the only significant predictor for infections, while death was independently associated with GNRI and food intake. When a GNRI < 92 and a TLC < 900 were considered together, the sensitivity was 0.83 (95% confidence interval, C.I.95%: 0.66-1.0) and 0.89 (C.I.95%: 0.68-1.00) for overall complications (Odds ratio: 22.1; C.I.95%: 5.1-96.1) and infections (Odds ratio: 20.8; C.I.95%: 2.6-168.8), respectively. The association of a GNRI > 98 with a TLC >or= 1500 was able to exclude health complications. CONCLUSIONS: In the institutionalised elderly patients, GNRI confirmed its predictive value even for short-term health complications, particularly when death was considered. However, the use of TLC might improve the evaluation of nutritional risk and the identification of patients at risk of infections. Nutrition study should be considered to confirm possible risk reduction.

Geriatric Nutritional Risk Index and overall-cause mortality prediction in institutionalised elderly: a 3-year survival analysis.

BACKGROUND & AIMS: A new tool, the Geriatric Nutritional Risk Index (GNRI), was recently proposed to predict short-term complications in elderly medical patients but no information is available when long-term follow-up periods are considered. METHODS: A 3-year follow-up study in 245 institutionalised elderly (51 M:194 F; 83.7+/-8.6 years). Nutritional risk was graded by GNRI (severe, <82; moderate, 82 to <92; mild, 92-98; no risk, >98). Main outcome was overall-cause death. RESULTS: After the follow-up 99 (26 M:73 F) events occurred. Nutritional risk prevalence was 5.7%, 24.1%, 34.7% and 35.5% and mortality rates were 71.4%, 48.6% 33.7% and 34.3% with the GNRI<82, 82 to <92, 92-98, and >98, respectively. Kaplan-Meier curves were significantly associated to GNRI (p=0.0068). GNRI<82 was consistently related to death (odds ratio, OR=5.29, [95%CI: 1.43-19.57], p=0.0127) when compared to GNRI>98. Similar results were confirmed by Cox regression (hazard ratio, HR=2.76 [95%CI: 1.89-4.03], p=0.0072). Finally, when "severe" and "moderate" risk were analysed as a single class (GNRI<92) outcome associations were: OR=2.17, [95%CI: 1.10-4.28] (p=0.0245); HR=1.76 [95%CI: 1.34-2.23] (p=0.0315). Survival analysis showed higher mortality rates by GNRI<92 (p=0.0188). CONCLUSIONS: Present data support the use of the GNRI in the evaluation of long-term nutrition-related risk of death. We suggest a GNRI<92 as clinical trigger for nutritional support in institutionalised elderly.

Non-pharmacological control of plasma cholesterol levels.

The importance of non-pharmacological control of plasma cholesterol levels in the population is increasing, along with the number of subjects whose plasma lipid levels are non-optimal, or frankly elevated, according to international guidelines. In this context, a panel of experts, organized and coordinated by the Nutrition Foundation of Italy, has evaluated the nutritional and lifestyle interventions to be adopted in the control of plasma cholesterol levels (and specifically of LDL cholesterol levels). This Consensus document summarizes the view of the panel on this topic, with the aim to provide an updated support to clinicians and other health professionals involved in cardiovascular prevention.

Short dietary assessment improves muscle dysfunction identification by Geriatric Nutritional Risk Index in uncomplicated institutionalised patients over 70 years old.

BACKGROUND & AIMS: To possibly investigate the validity of the Geriatric Nutritional Risk Index (GNRI) in predicting muscle dysfunction among the uncomplicated elderly when coupled and compared with short dietary assessment. METHODS: A total of 130 (61 males and 69 females) stable-weight, over 70-years-old elderly patients were studied according to anthropometry, handgrip strength (HG) and simple dietary assessment, expressed as oral (percentage of food consumed to that delivered) and protein (g/kg/day) intakes. RESULTS: For the overall population, HG and strength for centimetres of arm muscle area (HG/AMA) significantly correlated with age, GNRI and nutrients intake (p<0.001). In gender-separated analyses, these associations were less evident for males than females, which were older (p<0.0001) and presented lower strength and intakes (p<0.0001). Patients in the lowest tertile of oral intake (<68%) were more likely (p<0.0001) to have low HG and HG/AMA than those at severe/moderate nutritional risk (GNRI<92; p<0.01). In multivariate models, being an aged female significantly predicted muscle dysfunction. For the overall population, HG was significantly associated with GNRI (p<0.05) and oral intake (p<0.0001), while HG/AMA was independently associated with GNRI (p<0.001) and protein intake (p<0.0001). CONCLUSIONS: The validity of GNRI in predicting muscle dysfunction is confirmed also in the uncomplicated elderly. Though, oral intake appears an even better predictor. A frequent evaluation of its changes should be considered, particularly when concomitant high risk (GNRI<92) is scored.

Feasible use of estimated height for predicting outcome by the geriatric nutritional risk index in long-term care resident elderly.

BACKGROUND: The Geriatric Nutritional Risk Index (GNRI) is a new index recently introduced for predicting risk of nutritional-related complications in elderly patients. It combines albumin with information about body weight: GNRI = (1.489 x albumin, g/l) + (41.7 x present/ideal body weight), with ideal weight calculated according to the Lorentz formula. Because standing height (SH) is frequently difficult to obtain in older people, in Lorentz equations this parameter has been replaced by estimated height (EH) from knee height. Though, if EH is well accepted as a valid surrogate for SH, the same might not be expected for its use in ideal body weight calculation, with possible consequences in grading nutritional risk correctly. OBJECTIVE: The aim of this study was to investigate whether the use of SH rather than EH for the calculation of ideal body weight predicts similar outcomes by GNRI. METHODS: Body weight, SH and EH were obtained in 231 long-term care resident elderly (88 males and 143 females, mean age +/- SD 80.0 +/- 8.4, range 65-97 years). Blood samples were assessed for albumin concentration. Ideal body weight was derived from the Lorentz formula using both SH and EH. According to both ideal weight estimates, nutritional risk was defined by the GNRI score. RESULTS: The Pearson correlation coefficients were high for both EH (with SH; r = 0.90) and estimates of ideal body weight (r = 0.90) and all were highly significant (p < 0.0001). A statistically significant difference was found between SH and EH (p = 0.0265). Similar and expectable differences in significance have also been observed between ideal body weights (p = 0.0271). However, an accordance of 95.2% has been detected (Kendall's tau test: tau = 0.85, p < 0.0001) in grading nutritional risk by GNRI. CONCLUSION: The use of EH for ideal body weight calculation and nutritional risk assessment by GNRI is feasible. Thus, GNRI seems to have been designed in the best way and its use is really attractive, particularly when considering the low-grade participation demanded of the patient in the assessment. This simple and valid assessment tool should be taken into greater consideration.

The new Geriatric Nutritional Risk Index is a good predictor of muscle dysfunction in institutionalized older patients.

BACKGROUND & AIMS: The validity of Geriatric Nutritional Risk Index (GNRI), in predicting nutrition-related risk of complications in the elderly, has been recently underscored. Malnutrition may results also in muscle function impairment. Thus, the present study aims to investigate if GNRI might be a reliable detector of muscle dysfunction in institutionalized older people. METHODS: In total, 153 institutionalized elderly (71 males, 82 females; mean age+/-SD: 75.2+/-8.4; range: 65-96) were studied in anthropometric parameters, serum albumin concentration and total score on GNRI. Muscle function was assessed by handgrip strength (HG). RESULTS: Women were significantly older than men and presented lower values of HG and arm muscle area (AMA). In overall population, GNRI was significantly correlated with AMA, HG and strength for centimeter of muscle area (HG/AMA); however, in gender-separated analysis, men presented higher degrees of correlation. After dividing patients in four categories according to GNRI, a more significant difference was detected in HG and HG/AMA rather than the other clinical and anthropometric parameters. Moreover, ANOVA analysis between HG quartiles was highly significant for GNRI, AMA and HG/AMA. CONCLUSIONS: GNRI is a good predictor of muscle dysfunction, particularly in men, and useful in identifying patients suitable for nutritional support and physical activity.