Dietary intake of older patients in hospital and at home: the validity of patient kept food diaries.

OBJECTIVE: To investigate the validity of a patient kept food diary in relation to weighted intakes and to measure dietary intakes of older people both in hospital and after discharge at home. DESIGN: A randomly selected cohort of hospitalised elderly patients was recruited. All patients were instructed how to keep a record of all food and drink consumed and any leftovers. Food diaries were kept for up to seven days in hospital and for seven days in the community. In 18 consecutive patients dietary records were compared with weighed intake. SETTING: Associate Teaching Hospital, United Kingdom. RESULTS: A total of 116 patients participated in the study (median age 77 years, range 66-86 yrs; 49 female). We found significant correlations between food diary and weighted macronutrient intakes both in hospital and in the community. Overall the food diary predicted within+/-17% weighted energy intakes in 70% of individuals. Compared with the National Diet and Nutrition Survey for free-living elderly people in the UK (1998), we found more or less similar energy and micronutrient intakes in hospital, but lower intakes at home. CONCLUSION: Patients kept food diaries can be used to identify those at risk of undernutrition and monitor those on nutritional support. It can also be used for nutritional education and for achieving dietary goals.

Antioxidant supplementation enhances antioxidant capacity and mitigates oxidative damage following acute ischaemic stroke.

OBJECTIVE: To test whether supplementary antioxidants immediately following acute ischaemic stroke will enhance antioxidant capacity and mitigate oxidative damage. DESIGN: A randomised controlled trial. SETTING: A university teaching hospital. SUBJECTS: A total of 48 acute ischaemic stroke patients within 12 h of symptom onset. INTERVENTION: Daily oral 800 IU (727 mg) of alpha-tocopherol and 500 mg of vitamin C (n = 24), or no treatment (n = 24) for 14 days. Treatment group and controls were matched for stroke subtype and age. MAIN OUTCOME MEASURES: alpha-Tocopherol, ascorbic acid, total antioxidant capacity (TAOC), plasma malondialdehyde (MDA) and C-reactive protein (CRP) before treatment, at day 7 and day 14 following recruitment. RESULTS: In all, 14 days of vitamin supplementation significantly improved plasma alpha-tocopherol and ascorbic concentrations in the treatment group compared with the decrease seen in the control group (P < 0.005 for difference in cumulative changes). TAOC increased significantly in the treatment group compared with controls (P < 0.003). There was a significant reduction in plasma MDA concentration in the treatment group, in contrast to the increase seen in the control group (P < 0.002). After adjusting for clinical complications CRP concentrations within 90 days postinfarct were significantly lower in the treatment group compared with controls. CONCLUSION: Supplementation with antioxidant vitamins within 12 h of onset of acute ischaemic stroke increased antioxidant capacity, reduced lipid peroxidation products and may have an anti-inflammatory effect. SPONSORSHIP: Sheffield Teaching Hospital NHS Trust.

Influence of nutritional status on clinical outcome after acute stroke.

A cause-and-effect relation between protein-energy malnutrition and poor outcome in acute stroke patients has not been definitively established. To measure the effect of the nutritional status of hospitalized stroke patients on clinical outcome, a prospective, observational study was performed. Acute stroke patients admitted to Leicester General Hospital from June 1994 to October 1995 had their nutritional status assessed with anthropometric, hematologic, and biochemical methods within 48 h of admission and after 2 and 4 wk. Outcome measures including disability, handicap, length of stay, morbidity (infective complications), discharge destination, and mortality were recorded during the hospital stay and at 3 mo. Nutritional status deteriorated significantly during the study period, but only serum albumin concentrations showed a significant association with various outcome measures. Stroke patients with hypoalbuminemia had a greater risk of infective complications (P<0.0001) and poor functional outcome during hospitalization than those with normal or higher serum albumin concentrations. Serum albumin concentrations were good predictors of the degree of disability and handicap during the hospital stay. After prognostic indicators of poor outcome were adjusted for, serum albumin concentration in the hospital was a strong and independent predictor of mortality at 3 mo after acute stroke [hazard ratio 0.91 (95% CI: 0.84, 0.99) for a 1-g/L higher serum albumin concentration]. Whether nutritional supplementation removes or mitigates the hazard of poor outcome associated with undernutrition after acute stroke needs to be determined.

Hypokalemia and potassium excretion in stroke patients.

OBJECTIVES: To determine (1) the prevalence of hypokalemia (plasma potassium < or = 3.4 mmol/L) in a group of stroke patients in comparison with age- and sex-matched groups of patients having sustained a myocardial infarction or having mild hypertension and (2) the association between plasma potassium concentration and stroke outcome. DESIGN: Observational study. PARTICIPANTS: A total of 421 consecutive stroke patients admitted to a teaching hospital, 150 consecutive patients 50 years or older with myocardial infarction admitted to the hospitals Coronary Care Unit, and 161 out-patients 60 years or older with borderline and established hypertension. MEASUREMENTS: All stroke and cardiac patients had plasma urea and electrolytes estimated within 2 hours of hospital admission; in the hypertensive group blood samples were taken in clinic. Stroke patients had blood pressure, stroke severity (Barthel score) and smoking status recorded. A sub-group of 61 stroke patients and all 79 hypertensive patients not taking antihypertensive medication had 24-hour urine electrolyte excretion measured. Outcome (independent, dependent, or dead) at 3 months post-stroke was established in 349 patients. RESULTS: Hypokalemia occurred more frequently in stroke patients than in patients with myocardial infarction (84 (20%) vs 15 (10%), P = .008) or patients with hypertension (84 (20%) vs 13 (8%), P < .001), even when patients taking diuretics were excluded from analysis (56 (19%) vs 12 (9%) of cardiac group, P = .014 and 56 (19%) vs 4 (5%) of hypertensive group, P = .005, respectively). 24-hour urine excretion of potassium and the potassium:creatinine ratio was lower in stroke patients than in hypertensive patients (41 +/- 21 vs 62 +/- 25 mmol/24 hour, P = .001, 5.5 +/- 2.2 vs 7.4 +/- 2.6 mmol/24 hour, P = .001, respectively). On survival analysis, a lower plasma potassium on admission to hospital was associated with an increased chance of death, independent of age, stroke severity, history of hypertension, blood pressure level, or smoking history (hazard ratio 1.73 (95% CI: 1.03-2.9) for a 1 mmol/L lower plasma potassium concentration). CONCLUSIONS: Hypokalemia post stroke is common and may be associated with a poor outcome.

Antioxidant capacity after acute ischaemic stroke.

BACKGROUND: Experimental studies have reported a rapid increase in the production of markers of oxidative damage following acute stroke due to the reperfusion event following ischaemia, and that endogenous antioxidant defences are rapidly depleted, permitting further tissue damage. AIM: To measure changes in antioxidant capacity (individual and total) in stroke disease within a known time period post infarct. DESIGN: Observational cohort study. METHODS: We studied 31 acute ischaemic stroke patients; 26 hospitalized non-stroke patients and 23 community-based healthy controls. Non-fasting venous blood was obtained within 24 h, at 48-72 h and at 7 days after stroke onset (after hospitalization for non-stroke patients) and at baseline for community controls. Vitamins E and C, total plasma glutathione, total antioxidant capacity (TAC), uric acid, thiobarbituric-acid-reactive substances (TBARS), serum albumin, transferrin and C-reactive protein (CRP) were measured. RESULTS: Baseline glutathione concentrations were non-significantly lowest and TBARS significantly highest in ischaemic stroke patients compared with controls. Serum TAC strongly correlated with serum uric acid. Under multivariate analysis, serum uric acid explained most of the variance in TAC during the study period. Despite increased concentrations of uric acid, TAC was reduced in stroke patients compared with controls. Serum vitamin C concentrations deteriorated significantly in stroke patients, and differences between the cumulative changes between strokes and hospital controls were also statistically significant (p=0.013). DISCUSSION: There was some evidence of reduction in TAC, despite increased uric acid concentrations, and deterioration in serum vitamin C levels in ischaemic stroke patients compared with controls.

Malnutrition in hospitalized elderly patients: when does it matter?

BACKGROUND: Identifying the individual effects of acute illness and malnutrition on elderly patient outcome and the timing of nutritional support is still an important challenge for modern medicine. OBJECTIVE: The aims of this study were to assess the practical significance of serum albumin concentrations following acute illness as a measure of nutritional status in ageing patients and also to review recently published studies related to this field. DESIGN: Consecutive stroke patients had their nutritional status assessed from anthropometric, haematological and biochemical data during the hospital stay. Predicted energy needs and daily in-hospital energy intake were also studied in a subgroup of 24 acute stroke patients and 24 age and sex-matched hospitalized non-stroke patients. A multivariate analysis was used to measure the amount of variance in serum albumin concentrations explained by nutritional and non-nutritional clinical variables. RESULTS: Serum albumin concentrations deteriorated steadily during the study period and there was an increase in the amount of variance in the serum albumin explained by nutritional variables between admission and week 4 of the hospital stay. Almost all patients studied were in negative energy balance during hospitalization. Evidence is provided which links low serum albumin concentrations with clinical outcomes during the hospital stay and immediately following discharge. That nutritional supplementation started one week as opposed to immediately following acute illness, and continued during the convalescent period, can improve serum albumin concentrations during the hospital stay. CONCLUSION: Poor nutritional status following acute illness in ageing patients may be of more prognostic significance and amenable to therapy later on during the course of hospitalization.

A randomized, controlled, a single-blind trial of nutritional supplementation after acute stroke.

BACKGROUND: Although stroke patients who do not have difficulty swallowing may be at risk of undernutrition and worsening nutritional status during hospitalization, optimum methods for nutrition intervention in stroke patients have not been established. AIM: To examine the feasibility of enteral sip feeding as an effective nutrition intervention after acute stroke. METHODS: Forty-two acute ischemic stroke inpatients with impaired nutritional status who did not have difficulty swallowing within 1 week after the stroke were entered into a single-blind, randomized, controlled, prospective study of enteral sip feeding. Twenty-one patients were randomized to receive daily oral food supplements for 4 weeks in addition to the hospital food, and 21 patients received only the hospital food for the same period. Main outcome measures were energy and protein intakes during the intervention period, change in nutritional status, disability, infective complications, length of stay, and mortality during hospitalization and at 3 months. RESULTS: Two patients, one from each group, were lost to follow-up immediately after randomization. Twenty patients received oral nutritional supplementation. The energy intake was significantly greater in the supplemented group: 1807 +/- 318 vs 1084 +/- 343 kcal/d (mean +/- SD; p < .0001) (estimated treatment effect, 723 kcal/d; 95% confidence interval [CI], 498 to 947), as was protein intake: 65.1 +/- 13.8 vs 44.1 +/- 12.8 g/d (p < .001) (estimated treatment effect, 21.0 g/d; 95% CI, 11.7 to 30.3). There also were significant differences between the two groups in the changes in serum albumin and serum iron concentrations between randomization and at follow-up. There was a trend to lower mortality at 3 months in the supplemented group with two deaths (10%) compared with seven deaths (35%) in the control group (p = .127, relative risk, 0.29; 95% CI, 0.07 to 1.21). CONCLUSIONS: This study suggests that enteral sip feeding is effective in improving nutritional intake and status in stroke patients who do not have swallowing difficulties. There also may be some beneficial effects on clinical outcome, but larger studies are required to confirm this observation and define more precisely the magnitude of any favorable effects.

Nutritional support in elderly patients.

There are now many studies which have found that undernutrition is prevalent and often unrecognized in patients admitted to hospitals and institutions. There is also evidence which links protein-energy undernutrition or its markers with clinical outcomes in acute and non-acute hospital settings and that nutritional supplements can improve outcomes in some of these settings. Active nutritional support following the catabolic phase of acute illness and extending during the rehabilitation period may be of particular benefit in improving nutritional intake, status and or outcome. A randomized controlled trial is therefore needed to test this hypothesis.

Nutritional factors in stroke.

Observational studies support the role of modifying lifestyle-related risk factors such as diet, physical activity and alcohol use in stroke prevention. For example, increased Na intake is associated with hypertension, and reduction in salt consumption may significantly lower blood pressure and may reduce stroke mortality. Moderately elevated homocysteine levels may be associated with stroke and are associated with deficiency of dietary intake of folate, vitamin B6 and vitamin B12. Consumption of a diet rich in fruits, vegetables, folate, K, Ca, Mg, dietary fibre, fish and milk may protect against stroke. Regular physical activity may also protect against stroke through its role in controlling various risk factors such as hypertension, diabetes mellitus and obesity. The role of fat intake as a risk factor for stroke remains uncertain, whereas the association between stroke and cholesterol has more convincingly been demonstrated by the recent intervention trials using statins. There is also evidence that a low serum albumin may be causally linked to stroke risk and outcome and that a significant number of stroke patients are undernourished on admission and their nutritional status deteriorates further whilst in hospital. Undernutrition is associated with increasing morbidity and mortality and nutritional supplements may have some beneficial effect on some outcome measures.

Oxidative Damage, Antioxidants and Stroke.

Nutritional factors may have an important role to play in incidence and treatment of stroke. Many epidemiological studies report that people who eat a relatively large quantity of fruits, vegetables and grains have a lower risk of death, particularly from cardiovascular disease. Some of these studies consistently revealed an association between increased risk of stroke and low plasma concentrations of antioxidants. There is also strong indirect evidence that free radical production appears to be an important mechanism of brain injury after exposure to ischaemia and reperfusion. The role of free radical formation in the pathogenesis of ischaemic brain damage and the neuroprotective effect of antioxidants are not definitely established and need further studies.

Potentially treatable causes of poor outcome in acute stroke patients with urinary incontinence.

OBJECTIVE: To identify potentially treatable clinical risk factors responsible for poor outcome in acute stroke patients with urinary incontinence. MATERIAL AND METHODS: All acute stroke patients admitted to our hospital within a 12-month period were considered for inclusion in this observational prospective study. Their clinical details were recorded prospectively during the hospital stay and at 3 months. RESULTS: Two hundred and fifteen patients with complete records were enrolled in the study. After adjusting for age, disability, and comorbidity, urinary incontinence at admission was a significant predictor of stroke death at 3 months [hazard ratio 2.8 (95% CI 1.3 5.8), P = 0.006]. Stroke patients incontinent of urine were malnourished and had an increased risk of infective complications during the hospital stay compared with those without incontinence. CONCLUSION: Part of the poor outcome associated with incontinence of urine after acute stroke may be due to treatable conditions such malnutrition and infections.

Bilateral foot drop, weight loss and rectal bleeding as an acute presentation of Crohn's disease.

We report a 71 year old lady who presented with weight loss, rectal bleeding and bilateral foot drop having been previously fit and well. Clinical examination, laboratory investigation and postmortem examination confirmed the diagnosis of active Crohn's disease and acute peripheral neuropathy. The clinical course of this patient suggests that the peripheral neuropathy might have resulted from the common pathogenesis for Crohn's disease.

Assessment and treatment of nutritional status in stroke patients.

Stroke illness imposes a heavy and costly work load on hospital and community care services, and life after stroke can be a miserable affair for stroke patients and their carers. Nutritional factors may have an important role in acute stroke and its outcome. From the limited amount of research undertaken it has been shown that a significant number of patients with stroke are undernourished on admission and their nutritional status deteriorates further as an in-patient. This is especially so for those who are most dependent, in whom undernutrition is also associated with increasing morbidity and mortality. There is some evidence that nutritional supplementation may improve nutritional status and reduce morbidity and mortality. However most clinically available nutrition screening instruments lack sensitivity and specificity, and abnormal nutritional indicators may simply reflect effects of age, functional disability, or severe underlying disease. Therefore, causal relationship cannot be assumed without a sufficiently powerful intervention study which adequately adjusts for the effects of non-nutritional factors, such as the number and severity of comorbid conditions on clinical outcome. Meanwhile, doctors, nurses and members of the multidisciplinary team looking after stroke patients should be made aware of the likely impact of poor nutritional status on clinical outcome.

Nutrition, ageing and ill health.

There are physical, mental, social and environmental changes which take place with ageing; for example, decreased physical activity, increase in body fat, decrease in lean body mass and consequently decreased energy intake may be associated with physiological functions that affect metabolism, nutrient intake, physical activity and risk of disease. There are now many studies which have found that undernutrition is prevalent and often unrecognized in patients admitted to hospitals and institutions. There is also evidence which links protein-energy undernutrition or its markers with clinical outcomes in acute and non-acute hospital settings and that nutritional supplements can improve outcomes in some of these settings. However, most clinically-available nutrition screening instruments lack sensitivity and specificity, and abnormal nutritional indicators may simply reflect effects of age, functional disability, or severe underlying disease. Thus, causal relationship cannot be assumed without a sufficiently powerful intervention study which adequately adjusts for the effects of non-nutritional factors, such as the number and severity of co-morbid conditions on clinical outcome.

Iatrogenic causes of falls in hospitalised elderly patients: a case-control study.

OBJECTIVE: To explore risk factors associated with falls and to evaluate a strategy used by nurses to predict and prevent falls in a hospitalised cohort of elderly patients. DESIGN: A case-control study of risk factors for falls in hospital. SETTING: A district general hospital in the UK. SUBJECTS: Altogether 181 patients in an acute integrated medical unit who had fallen were matched for age with 181 patients in the next bed who had not fallen. RESULTS: It was found that 46% (84 of 181) of the fallers were taking one or more benzodiazepines compared with 27% (48 of 181) of the control patients (p<0.001). More fallers 20% (34 of 181) had their benzodiazepines prescribed during their current admission compared with 7% (13 of 181) of the control patients (p<0.001). Temazepam was the main benzodiazepine used by over 95% of cases and controls. Overall 25% (45 of 181) of the fallers had fallen before during the current admission. The logistic regression analysis showed that only a previous fall, benzodiazepine intake, and the need for maximum assistance were significant predictors of falling in hospital, odds ratios were 5.6 (95% confidence interval (CI) 2.7 to 11.6), 2.3 (95% CI 1.4 to 3.7), and 3.1 (95% CI 1.9 to 5.2) respectively. Most fallers had been identified at risk of falling (125; 69%) by ward staff and in 113 (90%) of those preventive measures had been undertaken. Falls were least likely to occur during visiting hours with a peak incidence during night-time. CONCLUSION: There is a need for evidenced based successful fall prevention strategies but our study also reinforces an urgent public health message that an alternative to benzodiazepines should be sought for night sedation for older patients.

A prospective study of primary and secondary risk factor management in stroke patients.

Stroke is a common event which often results in death or major loss of independence with immense human and financial costs, so identification of patients at risk, and prevention of stroke at the individual and population levels, is a high clinical and health priority. From August 1993 to July 1994, 468 stroke patients admitted to our hospital were assessed for the presence of stroke risk factors. All patients were followed up in hospital, and on discharge or death all hospital records were reviewed. We show that many risk factors remain uncorrected in stroke patients and that preventive measures are less than ideal at the community and hospital levels alike.

Nutritional status of hospitalized acute stroke patients.

The nutritional status of 201 hospitalized stroke patients was assessed from anthropometric, haematological and biochemical data in an observational prospective study. On admission, sixty-two (31%) stroke patients had BMI < 20, ninety-nine (49%) had a triceps skinfolds thickness below the 25th centile, twenty-five (12%) had a mid-arm circumference below the 25th centile and thirty-eight (19%) had a serum albumin concentration below 35 g/l. Baseline nutritional status was worse among those who later died or remained in hospital compared with those discharged and most patients who remained in hospital showed marked and significant deterioration in all measures of nutritional status within 4 weeks of hospitalization. After adjusting for age, stroke severity and co-morbidity, low serum albumin concentrations of these patients in hospital were a strong and independent predictor of death following acute stroke (odds ratio 1.13 (95% CI 1.01-1.27) for 1 g/l lower serum albumin concentration).

The knowledge of hospital patients about vascular diseases and their risk factors.

The knowledge of 28 stroke patients on the nature, consequences, treatment and risk factors of stroke and ischaemic heart disease was examined using a questionnaire and compared with that of 26 patients with ischaemic heart disease and 41 controls without evidence of vascular disease. Information was also collected on the patients' willingness to change their life-style, the information and advice they had received and their desire for more information. It was found that about half of the elderly stroke and heart disease patients had a reasonable knowledge of the condition and its related risk factors. Only eight (14%) patients remembered receiving information and advice in relation to their condition during their hospital stay compared with one (2%) control. There was a significant difference between the number of stroke and heart disease patients who wanted to know more about their condition compared with the control group (32 vs 14; p = 0.03). A quarter of the patients and half of the controls knew that fruit and vegetables were good for you and excessive fat and alcohol were less inducive to good health. Most patients with a risk factor were willing to exercise more, stop smoking, cut down on their drinking, or lose weight. These results suggest that elderly hospital patients have a reasonable basic knowledge about vascular diseases, but that a significant number want to know more and would be willing to change their life-style.