Gerontology 1992;38:105-110
Department of Medicine 3, Karolinska Institute, Söder Hospital, Stockholm, Sweden
Keyw ords Undernutrition Elderly subjects Internal medicine
Nutritional Status in Recently Hospitalized and Free-Living Elderly Subjects
Abstract
Weight index (WI), triceps skinfold (TSF), serum albumin and delayed cutaneous hypersensitivity reaction (DCH) were mea sured in 96 hospitalized elderly patients and in 100 age- and sex-matched free-living controls. Using the 10th percentile of data obtained in the controls, WI was subnormal in 35 % of the patients. Corresponding findings with regard to TSF, serum albumin and DCH were 32, 50 and 31 %, respectively. The findings in the controls were mainly within the range observed in national reference groups. Patients were considered mal nourished if they showed at least two variables (of which one was required to be anthropometric) below the cut-off limits used. When these limits were set at the 10th percentile of the recordings in the controls, the occurrence of undernutrition in the patients was 39%. By using the 5th percentile the corre sponding figure was 16%. Malnourishment was most pro nounced in patients with multiple organ disease and malig nancy. It is concluded that low nutritional indices are a com mon occurrence in elderly subjects admitted to hospital and that undernutrition is related to the nature of the disease rather than age.
Received: April 13,1991 Accepted: July 21,1991
Tommy Cederholm Department of Medicine 3 Karolinska Institute, Söder Hospital S -l 18 83 Stockholm (Sweden)
©1992 S. Karger AG. Basel 0304-324X/92/ 0382—0105$2.75/0
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 6:44:11 PM
Tommy Cederholm Kjell Hellström
The elderly are particularly vulnerable to nutritional deficiencies due to increased health problems and not rarely deranged eat ing habits. Undernutrition is known to be associated with depleted body stores [ 1], mus cular weakness [2] and lowered resistance to infections [3], i.e. factors of importance for the recovery from disease. To provide infor mation about the nutritional status in the elderly we examined newly hospitalized pa tients and free-living sex- and age-matched subjects recruited from the population regis ter.
Material and Methods Subjects The study group comprised 96 patients over the age of 70 years. All had been consecutively admitted on an emergency basis to the Department of Internal Medicine at St. Erik’s Hospital, which served an urban population. Cardiac disease was the major disorder in 35%. Other diagnoses were respiratory diseases (11 %), cerebrovascular diseases (11 %) and malignancy (8 %). More than one major disorder (multiple organ disease) was found in 13%. The age and sex distribution in the subgroups of patients with different diagnoses were similar. From the population register, 166 free-living individuals were randomly selected to mirror the pa tients in terms of age and sex. Moreover, they lived in the same residential area as the patients ensuring that socioeconomic factors would differ as little as possible. Only persons who had not been hospitalized during the preceding 2 years were selected. Thirty-two of the 166 were excluded as they did not fulfil the required criterias. Of the remaining subjects, 100 were willing to par ticipate and they were designated as controls. The age (80 ± 1 years) was the same in the patients and in the controls as was the percentage of females in both groups (61 and 68 %, respectively). The number of sub jects living alone was 69% in the patients and 62% in the controls (NS). The controls were not necessarily healthy and 40% were prescribed medication such as digitalis, diuretics, thyroid preparations and/or beta blocking agents. Informed consent was obtained prior to participation.
106
Protocol The patients were nutritionally assessed within the first few days of admission. Ninety controls were examined in the outpatient clinic and 10 in their own homes. The variables tested were: weight index (WI), triceps skinfold (TSF), serum albumin and delayed cutaneous hypersensitivity reaction (DCH). Serum al bumin was preferred to transferrin and prealbumin which have faster turnovers [4], since we consider the more long-term variations in the nutritional status as being of greater interest in an elderly population. WI (%) was defined as actual weight/reference weight (RW). The latter was calculated according to the regression equations: RW (women) = 0.65 X height 40.4 and RW ( men) = 0.80 X height - 6.20 as sug gested by Warnold and Lundholm [5]. TSF was mea sured with a Harpenden® caliper at the back of the right upper arm [6]. Serum albumin was determined by the bromocresol green binding method. In testing DCH, extracts (0.1 ml, respectively) of Candida (1.000 PNU/ml). mumps (40 CFU/ml) and PPD (purified protein derivative of tuberculin) (2 TU/0.1 ml) antigen (Hollistcr-Stier, USA; Connaught Lab., USA; Statens seruminstitut, Denmark, respectively) were injected intracutancously at the lateral margin of the left upper arm. The size of induration was registered after 4872 h and expressed as the sum of the longest diameter and the one in angular direction [7], The nutritional scores were expressed as failure (% of patients) to reach the 10th and 5th percentile of the data registered in the local control group. The results were also expressed in relation to national reference groups. WI was regarded as low or very low when it was between 80 and 70%, and < 70%, respectively, of the standard WI observed in a middle-aged and elderly reference population [8]. Registrations of TSF and DCH between the 10th and the 5th percentile and < 5th percentile encountered in two other national ref erence groups were regarded as being low [9] and very low [7], respectively. These limits for DCH corre sponded to an induration of 7-10 and 0-6 mm, respec tively. TSF displays sex- and age-related variations that must be taken into consideration [9]. The two cut off limits for serum albumin was mean minus 2 SD and mean minus 4 SD, corresponding to 33-36 and < 3 3 g'l respectively [L.G. Allgen, pers. commun.]. Patients classified as undernourished were required to display at least two variables below the cut-off limits chosen, of which one had to be anthropometric.
Cederholm/Hcllstrom
Statistics Data were presented as mean ± SE. Student’s t test, x2 test, Fisher’s exact test and Mann-Whitncy U
Nutritional Status in the Elderly
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Introduction
Table 1. WI, TSF, serum albumin and median value of DCH in patients and controls and the values corre sponding to the l Oth and 5th percentile recorded in the controls WI, % Patients Women (59) Men (37) Controls Women (68) Men (32) Women 10th percentile 5th percentile Men 10th percentile 5th percentile
89.6 ±2.82** 85.0±2.18 NS 100.5 ±1.88 95.1 ±2.07 84 80 84 80
TSF, mm
Serum albumin, g/1 DCH, mm
14.9 ±0.90* 11.1 ±0.90 NS
37.7 ±0.54*** 38.5 ±0.78***
8** 13 NS
18.0±0.75 11.1 ±0.63 11.6 7.2 7.2 5.8
42.4 ±0.33 42.5 ±0.45 39 38 39 38
21 18 7 5 7 5
test were used in the statistical calculations with the aid of MIMER-ST statistical package and the BMDP statistical software programme (SOLO). The levels of statistical significance are given as: * p < 0.05, ** p < 0.01, *** p < 0.001. The study was approved by the local Ethics Committee.
Results
All of the variables showed lower values in the female patients than in the female con trols (table 1). WI, serum albumin and DCH also tended to be reduced in the male patients, however the differences with the male con trols were only significant for serum albu min. The number of patients with recordings in the various variables below the 10th percen tile of the controls ranged between 31 and 50% (table 2). On the basis of these data and on the above mentioned criteria for malnourishment, 39% of the patients were classified as malnourished. Using the data for the 5th
percentile the corresponding figure was 16% (table 2). If the cut-off limits were taken from the reference groups (denoted as low or very low) the percentage of patients classified as undernourished was somewhat lower (ta ble 2). Likewise, 1-4% of the controls were considered malnourished. As many as 77% of the patients had values below the 10th percen tile and 60% had values below the 5th percen tile in at least one of the four variables exam ined. There were no differences between the un dernourished and nonundernourished pa tients in age (81 ± 1 and 80 ± 1 years, respec tively), sex (65 and 59% females, respectively) or living conditions (73 and 66% living singly, respectively). Undernutrition was most pronounced in those with multiple organ disease and malig nancy (table 3). The occurrence of undernu trition was also significantly increased in pa tients with cardiac diseases and in the group with various diagnoses.
107
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Number of subjects in parentheses. Student’s t test was used in the statistical evaluation ofWI, TSF and serum albumin, while the Mann-Whitney U test was employed for DCH which showed a skewed distribution.
Table 2. A: patients (%) with recordings below the 10th and 5th percentile (perc) of data obtained in the controls; B: patients and controls (%) with recordings classified as low or very low in relation to corresponding findings in the reference population (the cut-off limits and the definition of undernutrition are given in the text) Controls
Patients
< 10th-> 5th perc < 5th perc WI TSF DCH Serum albumin Percent undernutrition
9 24 15 10 39
Table 3. Patients (%) with re cordings below the 10th percentile of data obtained in the controls
B
B
A
26 8 16 40 16
low
very low
low
very low
17 23 16 18 31
11 14 34 10 13
3 3 12 0 4
2 4 9 0 1
Diagnosis
Wl
TSF
Serum DCH albumin
Undernutrition1
Cardiac disease (34) Respiratory disease (11) Cerebrovascular disease (11) Malignancy (9) Multiple organ disease (12) Various diagnoses (19) Control group (100)
35
29
41
15
32**
27
27
55
55
36NS
36 56
18 44
27 67
27 33
18NS 56**
42
67
75
75
67***
32
26
63
26
37* 7
Number of patients in parentheses. Comparison with the control group was evaluated with Fisher’s 2 X 2 exact test and the level of significance was modified according to the met hod of Bonferroni [ 10]. 1 Undernutrition is defined as > = two recordings, including at least one anthropometric, below the 10th percentile of data obtained in the con trols.
The mechanisms leading to low nutritional indices differ from patient to patient. Super imposed on an inadequate food intake, energy requirements may increase as for example in
108
Cederholm/Hellstrôm
chronic obstructive airways disease [11] and congestive heart failure [12]. The variables used in the current study to characterize the nutritional status are specific in the sense that they often improve upon nutritional interven tion [13-15]. However, they may be the sub
Nutritional Status in the Elderly
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 6:44:11 PM
Discussion
indicates that disease plays a major role in the development of a negative energy balance. In the current study the highest prevalence and the most advanced forms of malnourishment were observed in patients with multiple organ disease and malignancy. Irrespective of the diagnosis, the occurrence of malnutrition was significantly increased in all patient groups except for the very small groups with respira tory and acute cerebrovascular diseases. Undernutrition is often overlooked. The ultimate objective of an early diagnosis of malnourishment is to improve the quality of patient care by reducing the effects of malnu trition. This study confirms earlier findings that undernutrition is commonly observed in elderly subjects admitted to hospital.
109
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ject of changes not necessarily associated with nutritional deficiency [16, 17]. Anthropomet ric measurements are affected by variations in body fluids. Hypoalbuminemia is caused by liver, kidney and inflammatory diseases via mechanisms such as decreased liver synthesis, increased urinary losses and capillary leakage [18, 19]. Moreover, impaired DCH has been observed in malignancy not associated with undernutrition, during immunosuppressive treatment and viral infections [20]. There are reasons to believe that the low measurements of serum albumin and DCH in our patients in part may be due to the concurrent diseases per se. These circumstances underline the impor tance of using a combination of indicators in the assessment of the nutritional status. The cut-off limits used to define malnutri tion were arbitrarily selected on the basis of data for each variable observed in population studies. By these means the prevalence of low nutritional indices in the free-living subjects was small even though some of them were not necessarily healthy. These findings are in keeping with earlier observations made in western countries [21, 22], Undernutrition in the patients was more pronounced and occurred much more fre quently. Using either the 5th or th 10th per centile of recordings in the controls as cut-off limits, as many as 16 or 39% of the patients were regarded as undernourished. These find ings are in fair agreement with other reports of patients examined in services of internal medicine [23,24], Long-stay geriatric patients also show decreased nutritional markers but usually not as pronounced as in acutely ill admitted patients [25, 26], The variations en countered in different studies may mainly be due to differences in patient selection, refer ence groups, cut-off limits and in the criteria used for undernutrition [27], The marked difference in undernutrition between free-living and hospitalized persons
References 1 Steffee WP: Malnutrition in hospi talized patients. JAMA 1980:244: 2630-2635. 2 Lopes J, Russell McR. Whitwell J, Jeejeebhoy KN: Skeletal muscle function in malnutrition. Am J Clin Nutr 1982;36:602-610. 3 Chandra RK: Nutritional regulation of immunity and risk o f infection in old age. Immunology 1989:67:141 — 147. 4 Carpentier YA, Barthel J. Bruyns J: Plasma protein concentration in nu tritional assessment. Proc Nutr Soc 1982;41:405-417. 5 Warnold I. Lundholm K: Clinical significance of preoperative nutri tional status in 215 noncancer pa tients. Ann Surg 1984; 199:299— 305. 6 Jeliffe DB: The Assessment of the Nutritional Status of the Communi ty. Geneva, WHO, 1966. 7 Symreng T, Groth O, Norr A, Schildt B. Zetterqvist H: Delayed hypersensitivity-critical evaluation of five recall antigens in a large refer ence population. Clin Nutr 1983:1: 265-273. 8 Bengtsson C, Hultén B. Larsson B. Noppa H, Steen B. Warnold I: Nya lângdvikttabeller for medclàlders och àldre man och kvinnor. Lakartidningen 1981;78:3152-3154. 9 Symreng T: Arm anthropometry in a large reference population and in surgical patients. Clin Nutr 1983; 1: 211-219. 10 Wallenstein S. Zuckcr CL, Fleiss JL: Some statistical methods useful in circulation research. Circ Res 1980: 47:1-9. 11 Goldstein SA, Thomashow BM. Kvetan V, Askanazi J. Kinney JM, Elwyn DH: Nitrogen and energy re lationships in malnourished pa tients with emphysema. Am Rev RespirDis 1988:138:636-644. 12 Pittman JG. Cohen P: The patho genesis of cardiac cachexia. N Engl J Med 1964;271:403-409.
13 Chandra RK, Joshi P, Au B, Wood ford G. Chandra S: Nutrition and immunocompetence of the elderly: effect of short-term nutritional sup plementation on cell-mediated im munity and lymphocyte subsets. Nutr Res 1982:2:223-232. 14 Lipschitz DA. Mitchell CO. The correctability of the nutritional, im mune and hematopoietic manifesta tions of protein calorie malnutrition in the elderly. J Am Coll Nutr 1982: 1:17-25. 15 Otte KE, Ahlburg P, D’Amore F. Stellfeld M: Nutritional repletion in malnourished patients with emphy sema. JPEN 1989:13:152-156. 16 Pettigrew RA: Identification and assessement of the malnourished pa tient. Baillieres Clin Gastroenterol 1988;2:729-749. 17 McLaren DS: A fresh look at pro tein-energy malnutrition in the hos pitalized patient. Nutrition 1988:4:
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24 Rodriguez-Gonzales A, SantolariaFemandez F. Gonzalez-Reimers E, Batista-Lopcz N, Jorgc-Hernandez JA: The evaluation of nutritional status in general medical patients. Clin Nutr 1988;7:177-181. 25 Sahyoun NR. Otradovec CL. Hartz SC. Jacob RA, Peters H. Russel RM, McGandy RB: Dietary intakes and biochemical indicators of nutri tional status in an elderly, institu tionalized population. Am J Clin Nutr 1988:47:524-533. 26 Smith JL. Wickiser AA, Korth LL, Grandjean AC, Schaefer AE: Nutri tional status of an institutionalized aged population. J Am Coll Nutr 1984;3:13-25. 27 Fidanza F: Nutritional measure ments in the population: What is normality? Clin Nutr 1984:3:1-3.
1- 6 .
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18 Golden MHN: Transport proteins as indices of protein status. Am J Clin Nutr 1982;35:1159-1 165. 19 Fleck A, Hawker F, Wallace PL Raines G, Trotter J, Ledingham IMCA, Caiman KC: Increased vas cular permeability: A major cause of hypoalbuminemia in disease and in jury. Lancet 1985;ii:781-783. 20 Miller CL: Immunological assays as measurements of nutritional status: a review: JPEN 1978;2:554-566. 21 Munro HN, McGandy RB, Hartz SC, Russell RM, Jacob RA, Otradovec CL: Protein nutriture of a group of free-living elderly. Am J Clin Nutr 1987:46:586-592. 22 Thorslund S, Toss G, Nilsson I. von Schenk H, Symreng T, Zetterqvist H: Prevalence of protein-energy malnutrition in a large population of elderly people at home. Scand J Prim Health Care 1990;8:243-248. 23 Albiin N, Asplund K, Bjermer L: Nutritional status o f medical pa tients on emergency admission to hospital. Acta Med Scand 19$2;212: 151-156.
Department of Medicine 3, Karolinska Institute, Söder Hospital, Stockholm, Sweden
Keyw ords Undernutrition Elderly subjects Internal medicine
Nutritional Status in Recently Hospitalized and Free-Living Elderly Subjects
Abstract
Weight index (WI), triceps skinfold (TSF), serum albumin and delayed cutaneous hypersensitivity reaction (DCH) were mea sured in 96 hospitalized elderly patients and in 100 age- and sex-matched free-living controls. Using the 10th percentile of data obtained in the controls, WI was subnormal in 35 % of the patients. Corresponding findings with regard to TSF, serum albumin and DCH were 32, 50 and 31 %, respectively. The findings in the controls were mainly within the range observed in national reference groups. Patients were considered mal nourished if they showed at least two variables (of which one was required to be anthropometric) below the cut-off limits used. When these limits were set at the 10th percentile of the recordings in the controls, the occurrence of undernutrition in the patients was 39%. By using the 5th percentile the corre sponding figure was 16%. Malnourishment was most pro nounced in patients with multiple organ disease and malig nancy. It is concluded that low nutritional indices are a com mon occurrence in elderly subjects admitted to hospital and that undernutrition is related to the nature of the disease rather than age.
Received: April 13,1991 Accepted: July 21,1991
Tommy Cederholm Department of Medicine 3 Karolinska Institute, Söder Hospital S -l 18 83 Stockholm (Sweden)
©1992 S. Karger AG. Basel 0304-324X/92/ 0382—0105$2.75/0
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 6:44:11 PM
Tommy Cederholm Kjell Hellström
The elderly are particularly vulnerable to nutritional deficiencies due to increased health problems and not rarely deranged eat ing habits. Undernutrition is known to be associated with depleted body stores [ 1], mus cular weakness [2] and lowered resistance to infections [3], i.e. factors of importance for the recovery from disease. To provide infor mation about the nutritional status in the elderly we examined newly hospitalized pa tients and free-living sex- and age-matched subjects recruited from the population regis ter.
Material and Methods Subjects The study group comprised 96 patients over the age of 70 years. All had been consecutively admitted on an emergency basis to the Department of Internal Medicine at St. Erik’s Hospital, which served an urban population. Cardiac disease was the major disorder in 35%. Other diagnoses were respiratory diseases (11 %), cerebrovascular diseases (11 %) and malignancy (8 %). More than one major disorder (multiple organ disease) was found in 13%. The age and sex distribution in the subgroups of patients with different diagnoses were similar. From the population register, 166 free-living individuals were randomly selected to mirror the pa tients in terms of age and sex. Moreover, they lived in the same residential area as the patients ensuring that socioeconomic factors would differ as little as possible. Only persons who had not been hospitalized during the preceding 2 years were selected. Thirty-two of the 166 were excluded as they did not fulfil the required criterias. Of the remaining subjects, 100 were willing to par ticipate and they were designated as controls. The age (80 ± 1 years) was the same in the patients and in the controls as was the percentage of females in both groups (61 and 68 %, respectively). The number of sub jects living alone was 69% in the patients and 62% in the controls (NS). The controls were not necessarily healthy and 40% were prescribed medication such as digitalis, diuretics, thyroid preparations and/or beta blocking agents. Informed consent was obtained prior to participation.
106
Protocol The patients were nutritionally assessed within the first few days of admission. Ninety controls were examined in the outpatient clinic and 10 in their own homes. The variables tested were: weight index (WI), triceps skinfold (TSF), serum albumin and delayed cutaneous hypersensitivity reaction (DCH). Serum al bumin was preferred to transferrin and prealbumin which have faster turnovers [4], since we consider the more long-term variations in the nutritional status as being of greater interest in an elderly population. WI (%) was defined as actual weight/reference weight (RW). The latter was calculated according to the regression equations: RW (women) = 0.65 X height 40.4 and RW ( men) = 0.80 X height - 6.20 as sug gested by Warnold and Lundholm [5]. TSF was mea sured with a Harpenden® caliper at the back of the right upper arm [6]. Serum albumin was determined by the bromocresol green binding method. In testing DCH, extracts (0.1 ml, respectively) of Candida (1.000 PNU/ml). mumps (40 CFU/ml) and PPD (purified protein derivative of tuberculin) (2 TU/0.1 ml) antigen (Hollistcr-Stier, USA; Connaught Lab., USA; Statens seruminstitut, Denmark, respectively) were injected intracutancously at the lateral margin of the left upper arm. The size of induration was registered after 4872 h and expressed as the sum of the longest diameter and the one in angular direction [7], The nutritional scores were expressed as failure (% of patients) to reach the 10th and 5th percentile of the data registered in the local control group. The results were also expressed in relation to national reference groups. WI was regarded as low or very low when it was between 80 and 70%, and < 70%, respectively, of the standard WI observed in a middle-aged and elderly reference population [8]. Registrations of TSF and DCH between the 10th and the 5th percentile and < 5th percentile encountered in two other national ref erence groups were regarded as being low [9] and very low [7], respectively. These limits for DCH corre sponded to an induration of 7-10 and 0-6 mm, respec tively. TSF displays sex- and age-related variations that must be taken into consideration [9]. The two cut off limits for serum albumin was mean minus 2 SD and mean minus 4 SD, corresponding to 33-36 and < 3 3 g'l respectively [L.G. Allgen, pers. commun.]. Patients classified as undernourished were required to display at least two variables below the cut-off limits chosen, of which one had to be anthropometric.
Cederholm/Hcllstrom
Statistics Data were presented as mean ± SE. Student’s t test, x2 test, Fisher’s exact test and Mann-Whitncy U
Nutritional Status in the Elderly
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 6:44:11 PM
Introduction
Table 1. WI, TSF, serum albumin and median value of DCH in patients and controls and the values corre sponding to the l Oth and 5th percentile recorded in the controls WI, % Patients Women (59) Men (37) Controls Women (68) Men (32) Women 10th percentile 5th percentile Men 10th percentile 5th percentile
89.6 ±2.82** 85.0±2.18 NS 100.5 ±1.88 95.1 ±2.07 84 80 84 80
TSF, mm
Serum albumin, g/1 DCH, mm
14.9 ±0.90* 11.1 ±0.90 NS
37.7 ±0.54*** 38.5 ±0.78***
8** 13 NS
18.0±0.75 11.1 ±0.63 11.6 7.2 7.2 5.8
42.4 ±0.33 42.5 ±0.45 39 38 39 38
21 18 7 5 7 5
test were used in the statistical calculations with the aid of MIMER-ST statistical package and the BMDP statistical software programme (SOLO). The levels of statistical significance are given as: * p < 0.05, ** p < 0.01, *** p < 0.001. The study was approved by the local Ethics Committee.
Results
All of the variables showed lower values in the female patients than in the female con trols (table 1). WI, serum albumin and DCH also tended to be reduced in the male patients, however the differences with the male con trols were only significant for serum albu min. The number of patients with recordings in the various variables below the 10th percen tile of the controls ranged between 31 and 50% (table 2). On the basis of these data and on the above mentioned criteria for malnourishment, 39% of the patients were classified as malnourished. Using the data for the 5th
percentile the corresponding figure was 16% (table 2). If the cut-off limits were taken from the reference groups (denoted as low or very low) the percentage of patients classified as undernourished was somewhat lower (ta ble 2). Likewise, 1-4% of the controls were considered malnourished. As many as 77% of the patients had values below the 10th percen tile and 60% had values below the 5th percen tile in at least one of the four variables exam ined. There were no differences between the un dernourished and nonundernourished pa tients in age (81 ± 1 and 80 ± 1 years, respec tively), sex (65 and 59% females, respectively) or living conditions (73 and 66% living singly, respectively). Undernutrition was most pronounced in those with multiple organ disease and malig nancy (table 3). The occurrence of undernu trition was also significantly increased in pa tients with cardiac diseases and in the group with various diagnoses.
107
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Number of subjects in parentheses. Student’s t test was used in the statistical evaluation ofWI, TSF and serum albumin, while the Mann-Whitney U test was employed for DCH which showed a skewed distribution.
Table 2. A: patients (%) with recordings below the 10th and 5th percentile (perc) of data obtained in the controls; B: patients and controls (%) with recordings classified as low or very low in relation to corresponding findings in the reference population (the cut-off limits and the definition of undernutrition are given in the text) Controls
Patients
< 10th-> 5th perc < 5th perc WI TSF DCH Serum albumin Percent undernutrition
9 24 15 10 39
Table 3. Patients (%) with re cordings below the 10th percentile of data obtained in the controls
B
B
A
26 8 16 40 16
low
very low
low
very low
17 23 16 18 31
11 14 34 10 13
3 3 12 0 4
2 4 9 0 1
Diagnosis
Wl
TSF
Serum DCH albumin
Undernutrition1
Cardiac disease (34) Respiratory disease (11) Cerebrovascular disease (11) Malignancy (9) Multiple organ disease (12) Various diagnoses (19) Control group (100)
35
29
41
15
32**
27
27
55
55
36NS
36 56
18 44
27 67
27 33
18NS 56**
42
67
75
75
67***
32
26
63
26
37* 7
Number of patients in parentheses. Comparison with the control group was evaluated with Fisher’s 2 X 2 exact test and the level of significance was modified according to the met hod of Bonferroni [ 10]. 1 Undernutrition is defined as > = two recordings, including at least one anthropometric, below the 10th percentile of data obtained in the con trols.
The mechanisms leading to low nutritional indices differ from patient to patient. Super imposed on an inadequate food intake, energy requirements may increase as for example in
108
Cederholm/Hellstrôm
chronic obstructive airways disease [11] and congestive heart failure [12]. The variables used in the current study to characterize the nutritional status are specific in the sense that they often improve upon nutritional interven tion [13-15]. However, they may be the sub
Nutritional Status in the Elderly
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 6:44:11 PM
Discussion
indicates that disease plays a major role in the development of a negative energy balance. In the current study the highest prevalence and the most advanced forms of malnourishment were observed in patients with multiple organ disease and malignancy. Irrespective of the diagnosis, the occurrence of malnutrition was significantly increased in all patient groups except for the very small groups with respira tory and acute cerebrovascular diseases. Undernutrition is often overlooked. The ultimate objective of an early diagnosis of malnourishment is to improve the quality of patient care by reducing the effects of malnu trition. This study confirms earlier findings that undernutrition is commonly observed in elderly subjects admitted to hospital.
109
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ject of changes not necessarily associated with nutritional deficiency [16, 17]. Anthropomet ric measurements are affected by variations in body fluids. Hypoalbuminemia is caused by liver, kidney and inflammatory diseases via mechanisms such as decreased liver synthesis, increased urinary losses and capillary leakage [18, 19]. Moreover, impaired DCH has been observed in malignancy not associated with undernutrition, during immunosuppressive treatment and viral infections [20]. There are reasons to believe that the low measurements of serum albumin and DCH in our patients in part may be due to the concurrent diseases per se. These circumstances underline the impor tance of using a combination of indicators in the assessment of the nutritional status. The cut-off limits used to define malnutri tion were arbitrarily selected on the basis of data for each variable observed in population studies. By these means the prevalence of low nutritional indices in the free-living subjects was small even though some of them were not necessarily healthy. These findings are in keeping with earlier observations made in western countries [21, 22], Undernutrition in the patients was more pronounced and occurred much more fre quently. Using either the 5th or th 10th per centile of recordings in the controls as cut-off limits, as many as 16 or 39% of the patients were regarded as undernourished. These find ings are in fair agreement with other reports of patients examined in services of internal medicine [23,24], Long-stay geriatric patients also show decreased nutritional markers but usually not as pronounced as in acutely ill admitted patients [25, 26], The variations en countered in different studies may mainly be due to differences in patient selection, refer ence groups, cut-off limits and in the criteria used for undernutrition [27], The marked difference in undernutrition between free-living and hospitalized persons
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