Obese very old women have low relative hangrip strength, poor physical function, and difficulties in daily living.

OBJECTIVES: To investigate whether anthropometric and body composition variables and handgrip strength (HS) were associated with physical function and independent daily living in 88-year-old Swedish women. PARTICIPANTS: A cross-sectional analysis of 83 community-dwelling women aged 88 years who were of normal weight (n=30), overweight (n=29), and obese (n=24) was performed. MEASUREMENTS: Body weight (Wt), height, waist circumference (WC), and arm circumference were assessed using an electronic scale and a measuring tape. Tricep skinfold thickness was measured using a skinfold calliper. Fat mass (FM) and fat-free mass (FFM) were measured using bioelectrical impedance analysis, and HS was recorded with an electronic grip force instrument. Linear regression was used to determine the contributions of parameters as a single predictor or as a ratio of HS to physical function (Short Form-36, SF-36PF) and instrumental activities of daily living (IADL). RESULTS: Obese women had greater absolute FM and FFM and lower HS corrected for FFM and HS-based ratios (i.e., HS/Wt, HS/body mass index [BMI]) than their normal weight and overweight counterparts. After adjusting for physical activity levels and the number of chronic diseases, HS-based ratios explained more variance in SF-36PF scoring (R2, 0.52-0.54) than single anthropometric and body composition variables (R2, 0.45-0.51). WC, HS, and HS-based ratios (HS/Wt and HS/FFM) were also associated with independence in IADL. CONCLUSION: Obese very old women have a high WC but their HS is relatively low in relation to their Wt and FFM. These parameters are better than BMI for predicting physical function and independent daily living.

Symptom burden in stable COPD patients with moderate or severe airflow limitation.

OBJECTIVES: To describe a multidimensional symptom profile in patients with stable chronic obstructive pulmonary disease (COPD) and determine whether symptom experience differed between patients with moderate or severe airflow limitations. BACKGROUND: Patients with severe airflow limitation experience numerous symptoms, but little is known regarding patients with moderate airflow limitation. METHODS: A multidimensional symptom profile (Memorial Symptom Assessment Scale) was assessed in 42 outpatients with moderate and 49 with severe airflow limitations. RESULTS: The mean number of symptoms in the total sample was 7.9 (±4.3) with no difference between patients with moderate and severe airflow limitations. The most prevalent symptoms with the highest MSAS symptom burden scores were shortness of breath, dry mouth, cough, sleep problems, and lack of energy in both groups. CONCLUSIONS: Patients with moderate or severe airflow limitations experience multiple symptoms with high severity and distress. An assessment of their multidimensional symptom profile might contribute to better symptom management.

Food habits and intake of nutrients in elderly patients with Parkinson's disease.

BACKGROUND: Weight loss is reported frequently in patients with Parkinson s disease also early during the disease. OBJECTIVE: To investigate food habits and nutrient intake in elderly Parkinson s disease patients compared with matched controls, as well as to compare PD patients with and without weight loss. METHODS: Twenty-six elderly free-living patients with PD, and 26 sex- and age-matched healthy controls, were assessed twice with one year interval between. All food consumed was recorded over 3 consecutive days. Food habits were assessed with the Food Based Concept for Classification of Eating Episodes and intakes of energy and nutrients were calculated. PD symptoms, olfaction, swallowing function, daily activities and serum concentration of different nutrients were investigated. RESULTS: After 1 year, the PD patients decreased their intakes of daily high quality snacks from 0.5 +/- 0.7 to 0.3 +/- 0.3 (p < 0.05) and their prepared complete meals from 0.8 +/- 0.3 to 0.6 +/- 0.3 (p < 0.05), while their daily number of prepared incomplete meals increased from 0.2 +/- 0.2 to 0.3 +/- 0.3 (p < 0.01). PD patients with weight loss increased their daily intakes of fat by 12 +/- 34 g and their energy intake per kg body weight increased by 21 +/- 31 kJ (p < 0.05), respectively, and this was higher than in those without weight loss (p < 0.01). PD patients required more help with buying and cooking food compared with the controls. CONCLUSIONS: PD patients' food habits changed so that they consumed a lower number of prepared complete meals. PD patients with weight loss had a higher intake of fat and energy than those without weight loss, although this was obviously not sufficient to prevent weight loss. Impaired absorption of fat in PD should be discussed.

Smaller but energy and protein-enriched meals improve energy and nutrient intakes in elderly patients.

UNLABELLED: The purpose of the present study was to investigate if smaller but energy and protein enriched meals could improve energy and nutrient intakes in elderly geriatric patients. Ten patients, between 77 and 87 years of age were included in the study, performed at a Geriatric rehabilitation ward. The first week after inclusion, the patients were offered a three days' standard hospital menu and the second week, a three days' energy and protein-enriched menu. The consumption of food and the fluid intake were recorded using a pre-coded food record book during both the menus and analysed by the Swedish National Food Administration. The patients' energy requirements were calculated according to the Nordic Nutrition Recommendation for elderly subjects. When the standard hospital menu was offered, six patients had lower energy intake, -67 to -674 kcal/day, than the calculated energy requirements. The daily energy intake increased by 37 %, with the energy and protein-enriched menu compared with the standard hospital menu. Furthermore, the daily intake of protein, fat, carbohydrate, certain vitamins and minerals was significantly higher with the energy and protein-enriched menu compared with the standard hospital menu. CONCLUSION: This study showed that the intake of energy and nutrients increased with the energy and protein-enriched menu in elderly patients on a geriatric rehabilitation ward.

Stress reduction and analgesia in patients exposed to calming music postoperatively: a randomized controlled trial.

BACKGROUND AND OBJECTIVES: This randomized controlled trial was designed to evaluate, first, whether intra- or postoperative music therapy could influence stress and immune response during and after general anaesthesia and second, if there was a different response between patients exposed to music intra- or postoperatively. METHOD: Seventy-five patients undergoing open hernia repair as day care surgery were randomly allocated to three groups: intraoperative music, postoperative music and silence (control group). Anaesthesia and postoperative analgesia were standardized and the same surgeon performed all the operations. Stress response was assessed during and after surgery by determining the plasma cortisol and blood glucose levels. Immune function was evaluated by studying immunoglobulin A (IgA) levels. Patients' postoperative pain, anxiety, blood pressure (BP), heart rate (HR) and oxygen saturation were also studied as stress markers. RESULTS: There was a significantly greater decrease in the level of cortisol in the postoperative music group vs. the control group (206 and 72 mmol L(-1) decreases, respectively) after 2 h in the post anaesthesia care unit. The postoperative music group had less anxiety and pain and required less morphine after 1 h compared with the control group. In the postoperative music group the total requirement of morphine was significantly lower than in the control group. The intraoperative music group reported less pain after 1 h in the post anaesthesia care unit. There was no difference in IgA, blood glucose, BP, HR and oxygen saturation between the groups. CONCLUSION: This study suggests that intraoperative music may decrease postoperative pain, and that postoperative music therapy may reduce anxiety, pain and morphine consumption.

Does L-dopa treatment contribute to reduction in body weight in elderly patients with Parkinson's disease?

OBJECTIVE: Many patients with Parkinson's disease (PD) lose weight also early during the disease. The objective of the study was to investigate possible causative factors for this loss. MATERIALS AND METHODS: In this report, 28 PD patients and 28 age- and sex-matched controls were repeatedly assessed with the focus on body weight, body fat mass, dysphagia, olfaction, physical activity, PD symptomatology and drug treatment. RESULTS: Weight loss was seen in PD patients both before and during L-dopa treatment. CONCLUSION: The underlying disease could play a role, but our results also suggest that L-dopa per se could contribute to the weight loss.

Factors of importance for weight loss in elderly patients with Parkinson's disease.

OBJECTIVE: Weight loss is reported frequently in patients with Parkinson's disease (PD). The objective of this study was to find the underlying factors of this phenomenon. PARTICIPANTS AND METHODS: Twenty-six L-dopa-treated patients with PD and 26 age- and sex-matched healthy controls were assessed twice within a 1-year interval. Body weight, body fat mass, resting energy expenditure, physical activity, energy intake, thyroid hormones and cognitive function were investigated. RESULTS: Nineteen (73%) of the PD patients lost body weight, although energy intake and the time for rest increased. Weight loss was most marked in patients with more severe PD symptoms and in whom cognitive function had decreased. Multiple regression analyses showed that determinants for weight loss were female gender, age and low physical activity. CONCLUSION: Weight loss was common in PD patients, in spite of the increased energy intake and was most obvious in patients with increased PD symptoms and decreased cognitive function.

Type of anaesthesia and patient acceptance in groin hernia repair: a multicentre randomised trial.

BACKGROUND: Groin hernia repair can be performed under general (GA), regional (RA), or local (LA) anaesthesia. This multicentre randomised trial evaluates patient acceptance, satisfaction, and quality of life with these three anaesthetic alternatives in hernia surgery. METHODS: One hundred and thirty-eight patients at three hospitals were randomised to one of three groups, GA, RA, or LA. Upon discharge, they were asked to complete a specially designed questionnaire with items focusing on pain, discomfort, recovery, and overall satisfaction with the anaesthetic method used. The global quality-of-life instrument EuroQol was used for estimation of health perceived. RESULTS: Significantly more patients in the LA group than in the RA group felt pain during surgery ( P<0.001). This pain was characterised as light or moderate and for the majority of LA patients was felt during infiltration of the anaesthetic agent. Postoperatively, patients in the LA group first felt pain significantly later than patients in the other two groups ( P=0.012) and significantly fewer LA patients consumed analgesics more than three times during the first postoperative day ( P=0.002). The results concerning nausea, vomiting, and time to first meal all favour LA. No difference was found among the three groups concerning overall satisfaction and quality of life. CONCLUSION: In a general surgical setting, we found LA to be well tolerated and associated with significant advantages compared to GA and RA.

Oral health problems in elderly rehabilitation patients.

A combination of poor oral hygiene and dry mouth may be hazardous to the oral health status. However, systematic assessments in order to detect oral health problems are seldom performed in the nursing care of the elderly. The aims of this study were to investigate the occurrence of oral health problems measured using the Revised Oral Assessment Guide (ROAG) and to analyse associations between oral health problems and age, gender, living conditions, cohabitation, reason for admission, number of drugs, and functional and nutritional status. One registered nurse performed oral health assessments using ROAG in 161 newly admitted elderly patients in rehabilitation care. Oral health problems were found in 71% of the patients. Thirty per cent of these patients had between four and eight problems. Low saliva flow and problems related to lips were the most frequent oral health problems. Problems in oral health status were significantly associated with presence of respiratory diseases (problems with gums, lips, alterations on the tongue and mucous membranes), living in special accommodation (low saliva flow, problems with teeth/dentures and alterations on the tongue), being undernourished (alterations on the tongue and low saliva flow) and being a woman (low saliva flow). The highest Odds ratio (OR) was found in problems with gums in relation with prevalence of respiratory diseases (OR 8.9; confidence interval (CI) 2.8-27.8; P < 0.0005). This study indicates the importance of standardised oral health assessments in order to detect oral health problems which can otherwise be hidden when the patients are admitted to the hospital ward.

A comparison of intra-operative or postoperative exposure to music--a controlled trial of the effects on postoperative pain.

The effect of intra-operative compared to postoperative music on postoperative pain was evaluated in a controlled trial. In all, 151 patients undergoing day case surgery for inguinal hernia repair or varicose vein surgery under general anaesthesia were randomly allocated to three groups: group 1 listened to music intra-operatively, group 2 listened to music postoperatively and group 3, the control group, listened to 'white noise'. The anaesthetic and postoperative analgesic techniques were standardised. Pain was assessed using a numeric rating scale (0-10) and patients requirements for postoperative morphine, paracetamol and ibuprofen was recorded. The effect of music on nausea, fatigue and anxiety was also investigated. The results showed that patients exposed to music intra-operatively or postoperatively reported significantly lower pain intensity at 1 and 2 h postoperatively and patients in the postoperative music group required less morphine at 1 h compared to the control group. No differences were noted in the other variables. This study demonstrates that there is a short-term pain-reducing effect of music therapy however, the beneficial effects do not differ if the patient is exposed to music intra-operatively or postoperatively.

Analgesia following music and therapeutic suggestions in the PACU in ambulatory surgery; a randomized controlled trial.

BACKGROUND: This study was designed to determine whether music (M), or music in combination with therapeutic suggestions (M/TS) could improve the postoperative recovery in the immediate postoperative in daycare surgery. METHODS: One-hundred and eighty-two unpremedicated patients who underwent varicose vein or open inguinal hernia repair surgery under general anaesthesia were randomly assigned to (a). listening to music (b). music in combination with therapeutic suggestions or (c). blank tape in the immediate postoperative period. The surgical technique, anaesthesia and postoperative analgesia were standardized. Analgesia, the total requirement of morphine, nausea, fatigue, well-being, anxiety, headache, urinary problems, heart rate and oxygen saturation were studied as outcome variables. RESULTS: Pain intensity (VAS) was significantly lower (P = 0.002) in the M (2.1), and the M/TS (1.9) group compared with the control group (2.9) and a higher oxygen saturation in M (99.2%) and M/TS (99.2%) group compared with the control (98.0%), P < 0.001, were found. No differences were noted in the other outcome variables. CONCLUSION: This controlled study has demonstrated that music with or without therapeutic suggestions in the early postoperative period has a beneficial effect on patients' experience of analgesia. Although statistically significant, the improvement in analgesia is modest in this group of patients with low overall pain levels.

Patient and nurse assessment of quality of care in postoperative pain management.

OBJECTIVE: To describe and compare patient and nurse assessments of the quality of care in postoperative pain management, to investigate differences between subgroups of patients, and to compare patient assessments in different departments. DESIGN: Patient and nurse questionnaires. SETTING: Five surgical wards in general surgery, orthopaedics, and gynaecology in a central county hospital in Sweden. SAMPLE: Two hundred and nine inpatients and 64 registered nurses. The response rates were 96% for the patients and 99% for the nurses; there were 196 paired patient-nurse assessments. METHOD: The Strategic and Clinical Quality Indicators in Postoperative Pain Management patient questionnaire was used which comprises 14 items in four subscales (communication, action, trust, and environment). The items were scored on a 5 point scale with higher values indicating a higher quality of care. Five complementary questions on levels of pain intensity and overall satisfaction with pain relief were scored on an 11 point scale. Twelve of the 14 items in the patient questionnaire and two of the complementary questions were adjusted for use in the nurse questionnaire. RESULTS: The patients' mean (SD) score on the total scale (scale range 14-70) was 58.6 (8.9) and the nurses' mean (SD) score (scale range 12-60) was 48.1 (6.2). The percentage of patients who scored 1 or 2 for an individual item (disagreement) ranged from 0.5% to 52.0%, while for nurses the percentage ranged from 0.0% to 34.8%. Forty two patients (24%) reported more pain than they expected; these patients assessed the quality of care lower. There were differences between patient and nurse assessments concerning the environment subscale, the question on overall satisfaction, and patients' experience of worst possible pain intensity. CONCLUSION: The results provided valuable baseline data and identified important areas for quality improvement in postoperative pain management.

Evaluation of nutritional assessment techniques in elderly people newly admitted to municipal care.

OBJECTIVES: To evaluate the Subjective Global Assessment (SGA) and the Mini Nutritional Assessment (MNA) with regard to validity using a combination of anthropometric and serum-protein measurements as standard criteria to assess protein-energy malnutrition (PEM). DESIGN: Cross-sectional study with consecutive selection of residents aged >or=65 y. SETTING: A municipality in the south of Sweden. SUBJECTS: During a year, starting in October 1996, 148 females and 113 males, aged >or=65-104 y of age, newly admitted to special types of housing for the elderly, were included in the study. RESULTS: According to SGA, 53% were assessed as malnourished or moderately malnourished on admission. The corresponding figure from MNA was 79% malnourished or at risk of malnutrition. Both tools indicated that anthropometric values and serum proteins were significantly lower in residents classified as being malnourished (P<0.05). Sensitivity in detecting PEM was in SGA 0.93 and in MNA 0.96 and specificity was 0.61 and 0.26, respectively. Using regression analysis, weight index and serum albumin were the best objective nutritional parameters in predicting the SGA- and MNA classifications. Item 'muscle wasting' in SGA and 'self-experienced health status' in MNA showed most predictive power concerning the odds of being assessed as malnourished. CONCLUSIONS: SGA was shown to be the more useful tool in detecting residents with established malnutrition and MNA in detecting residents who need preventive nutritional measures.

Life situation and function in elderly people with and without leg ulcers.

The majority of elderly patients with leg ulcers live at home and receive treatment for their ulcers within the primary health care system. Little is known about the patients' ability or behaviour in the life situation and how well they manage their daily life at home. The Philadelphia Geriatric Center Multilevel Assessment Instrument (PGC MAI) was used to assess and compare the life situation in 70 patients (mean age 79 +/- 6.5 years) with leg ulcers and in 74 elderly persons (mean age 80 +/- 5.7 years) without leg ulcers. The patients with leg ulcers had significantly lower mean values in the domains of physical health, activity of daily living (ADL), cognition, time use and social behaviour, personal adjustment and environmental quality than those without ulcers. Sixty-three percent of the patients reported ulcer-related pain, and all of them were dependent on health care personnel for dressing changes. This may indicate that the life situation among elderly persons with leg ulcers is not so good as compared with that of elderly persons without ulcers and that patients with leg ulcers are more vulnerable than elderly people of the same age.

Can individualised nutritional support improve healing in therapy-resistant leg ulcers?

OBJECTIVE: This study investigated whether an individually designed programme of nutritional support can improve healing in otherwise therapy-resistant venous leg ulcers. METHOD: Six primary health-care patients, aged between 79 and 93 years, with venous ulcers that had been open for one year or more (range: 1.5-8 years) were recruited into the study. The patients were asked to follow an individualised diet plan which included the use of liquid dietary supplements. Ulcer area, anthropometric and biochemical variables, and energy and nutrient intake were assessed before intervention and then regularly for nine months. RESULTS: At nine months ulcer healing had occurred in two patients, of whom one had had ulcers on both legs. In a third patient the ulceration on one leg had healed and that on the other leg had almost healed. In a fourth patient, the ulcer area reduced by approximately 90%. CONCLUSION: The use of nutritional support might have assisted the wound healing in these patients. Although the relationship between nutritional supplementation and wound healing is not well defined, an appropriate nutritional plan is recommended if undernourishment is suspected and leg ulcers are not healing.

Improved recovery after music and therapeutic suggestions during general anaesthesia: a double-blind randomised controlled trial.

PURPOSE: This study was designed to determine whether music or music in combination with therapeutic suggestions in the intra-operative period under general anaesthesia could improve the recovery of hysterectomy patients. METHODS: In a double-blind randomised clinical investigation, 90 patients who underwent hysterectomy under general anaesthesia were intra-operatively exposed to music, music in combination with therapeutic suggestion or operation room sounds. The anaesthesia was standardised. Postoperative analgesia was provided by a patient-controlled analgesia (PCA). The pain scores were recorded by means of a visual analogue scale. Nausea, emesis, bowel function, fatigue, well-being and duration of hospital stay were studied as outcome variables. RESULTS: On the day of surgery, patients exposed to music in combination with therapeutic suggestions required less rescue analgesic compared with the controls. Patients in the music group experienced more effective analgesia the first day after surgery and could be mobilised earlier after the operation. At discharge from the hospital patients in the music and music combined with therapeutic suggestion group were less fatigued compared to the controls. No differences were noted in nausea, emesis, bowel function, well-being or length of hospital stay between the groups. CONCLUSION: This double-blind study has demonstrated that intra-operative music and music in combination with therapeutic suggestions may have some beneficial effects on postoperative recovery after hysterectomy. Further controlled studies are necessary to confirm our results.

Assessment of nutritional status using biochemical and anthropometric variables in a nutritional intervention study of women with hip fracture.

BACKGROUND & AIMS: The aim of this study of women with hip fracture was to describe nutritional status with biochemical markers and anthropometric variables, and to evaluate the effect of nutritional intervention with the intention of increasing protein and energy intake. METHODS: The first consecutive 44 women were included, and used as controls. The next 44 were matched for age, fracture and mental state. Anthropometric variables, IGF-I, hormones and serum albumin were collected 4--6 days (baseline), 1 and 3 months after surgery. Twenty-four women filled out a 7-day food record. RESULTS: At baseline, one fourth had BMI <20 kg/m(2)and subnormal triceps skinfold thickness. Baseline serum albumin, IGF-I and growth hormone levels were low, probably as an acute response to trauma. Women with BMI <20 kg/m(2)had lower IGF-I levels compared to those with higher BMI. At 3 months, one-third of both groups were protein and energy malnourished. The intervention group obtained higher daily energy percentage from fat but none of the groups reached their calculated energy need. CONCLUSIONS: Using biochemical markers in the acute postoperative situation to assess nutritional status is not recommended. The intervention had no impact on anthropometric or biochemical variables.

A follow-up study of ulcer healing, nutrition, and life-situation in elderly patients with leg ulcers.

This study was undertaken in order to follow up ulcer healing, ulcer recurrence, nutritional status and life-situation in elderly patients with leg ulcers. Of 70 patients assessed previously in 1996, 43 (61%) were still alive in 2000 and, of these, 38 (88%) participated in the follow-up. Rate of healing, recurrence and amputation were obtained from medical records and interviews with the patients. The Mini Nutritional Assessment (MNA) was used to assess their nutritional status and the Philadelphia Geriatric Center Multilevel Assessment Instrument was used for assessment of their life-situation. Nineteen patients (50%), mean age 82+/-4.6 years, had healed ulcers. Two (5%) patients, mean age 86+/-2.8, had required amputation and had no ulceration after surgery. Seventeen patients (45%), mean age 80.3+/-6 years, had open ulcers, six had their original ulcers still unhealed, and 11 had open recurrent ulcers. Decreased mean MNA scores, as well as decreased mean scores in ADL and mobility, were seen over time in patients with open ulcers but not in those who were healed. Patients with healed ulcers had significantly higher mean scores in social interaction than those with open ulcers and significantly increased mean scores in environmental quality over time. The results indicate that nutrition and the life-situation might be related to leg ulcer healing. The nutritional situation and the whole life-situation should be observed and taken into consideration when care is planned. Additional research is needed to increase the understanding of the relationship between nutrition, life-situation and ulcer healing.

Individually adjusted meals for older people with protein-energy malnutrition: a single-case study.

The objective of this study was to investigate the effect of a 3-month intervention programme consisting of meals based on individual nutritional requirements in residents assessed as protein-energy malnourished on admission to a municipal care Institution. Using a single-case design, 11 malnourished residents were given individual care aimed at fulfilling their personal requirements for energy intake during a period of 12 weeks. The residents were selected from a sample of 261 newly admitted older adults of whom 87 were assessed to be malnourished on admission. Nutritional status, including anthropometric and biochemical variables and functional capacities were assessed before, during, and after the intervention. Energy intake was recorded every day. Body weight, and serum concentration of albumin and transthyretin were measured every other week. During a 3-month period, the mean value of energy intake reached the calculated energy requirement in 10 residents. Eight residents increased in weight, triceps skin-fold thickness, and transthyretin concentration. Nine residents increased in arm muscle circumference, and 10 showed increased serum albumin concentration and functional capacity. We conclude that nursing care based on individual nutritional requirements, resources, and desires improves nutritional status and functional capacity in a group of malnourished residents.