Protein-Energy Malnutrition in Elderly Medical Patients T. Constans, MD,* Y. Bacq, MD,t J.-F. Bre'chot, MD,$J.-L. Guilmot, MD,t P. Choutet, MD,t and

F. Larnisse, M D t Study Objective: To evaluate (1) the prevalence of protein- Results. (1) Prevalence of PEM was 30% in male and 41% energy malnutrition in elderly patients; (2) the changes in in female patients. (2) Both mid-arm circumferenceand serum nutritional status during the hospital stay; and (3) (main albumin level decreased over the first 15 days of hospital objective) the relationship between simple nutritional param- stay (53 patients, paired t test, P < 0.05). Triceps skinfold eters and short-term in-hospital mortality. thickness did not change. (3) A step-wise discriminant-funcDesign: Prospective time series at admission and on the 15th tion analysis determined the utility of the parameters at day of hospitalization. admission as predictors of in-hospital mortality before the Setting: Medical care unit in a teaching hospital. 15th day. Mid-arm circumference, triceps skinfold thickness, Participants: Consecutivesample of 324 hospitalized patients albumin, and prealbumin levels, as well as age, are predictors 270 years (86.4% of eligible patients). Norms of measure- of in-hospital mortality, with 73%sensitivity,69% specificity, ments were obtained from a referred sample of healthy and 70% of correctly classified patients of both sexes. control subjects (26 males and 36 females). Conclusions: Parameters used are predictors for short-term Main Outcome Measures: Mid-arm circumference, triceps in-hospital mortality of elderly patients hospitalized in an skinfold thickness, serum albumin, prealbumin, and retinol- acute medical unit. The lean body mass is preferentially bindingprotein levels were measured in patients at admission mobilized for energy during hospitalization. J Am Geriatr and on the 15th day. SOC40263-268,1992

rotein-energy malnutrition (PEM) in the hospital was first recognized in surgical',* and medical patient^.^ Older patients are more likely to become nutritionally deficient than young or adult pat i e n t ~ .A ~ -worsening ~ of the nutritional status over the period of hospitalization has been described,' and this trend might be frequent among older patients. The prevalence of PEM varies from one study to another according to the indices chosen for the assessment and the arbitrary cut-off points for normal and abnormal anthropometric and biological variable^.^,^ In addition, both the nutritional status and the biological variables are widely influenced by the disease condition as well as by reduced nutrient intake.'0,'' However, PEM is known to increase morbidity and mortality rates in aged Since direct measurements of the body composition are not possible in a large number of patients, we used the so-called nutritional parameters to conduct a prospective study with three purposes: (1) to evaluate the prevalence of protein-energy malnutrition in elderly people admitted to an acute medical unit; (2) to determine whether the nutritional status of older patients deteriorates over the hospital stay; (3) to appreciate the relationship between simple nutritional parameters and mortality in elderly patients.

P

From the *Service de Gkriatrie, HBpital de l'Ennitage, 37023 Tours Cedex; the tClinique Mkdicale A, HBpital Bretonneau; and the SLaboratoire de Biochimie, HBpital Trousseau, Centre Hospitalier Universitaire de Tours, 37044 Tours Cedex, France. The work was done in the Clinique M6dicale A, HBpital Bretonneau, 37044 Tours Cedex, France. The work was presented in part at the 19th International Congress of Internal Medicine, Brussels, August 29th-September Znd, 1988. Address reprint requests to Dr T. Constans, HBpital de l'Ennitage, CHU de Tours, 37023 Tours Cedex, France.

IAGS 40:263-268, 1992 0 1992 by the American Geriatrics Society

PATIENTS AND METHODS Patients and Control Subjects Three-hundred seventy-five patients aged 70 years and over were admitted to a medical care unit over a 6-month period. Twenty-one patients were excluded from the study beforehand because they died or were discharged before measurements had been performed. Five patients refused permission for their participation in the study. Twenty-five patients with edema or hepatopathy or both were excluded. Therefore the study was conducted with the remaining 324 (86.4%) elderly patients (128 men and 196 women aged 78.8 & 5.4 and 81.3 f 6.8 years, mean & SD, respectively). Forty-seven patients were hospitalized more than once during the 6month period; only data from the first admission were included in the analysis. Fifty-three patients (21 men and 32 women) were hospitalized 15 days or more. Twenty-six patients (11 men and 15 women) died before the 15th day of hospitalization. Most referrals came directly from general practitioners. The diagnoses on admission included cerebro-vascular diseases and various neurological disorders, infections of the respiratory or urinary tracts, respiratory, cardiac, or renal failure, malignancies, diabetes mellitus, gastro-intestinal diseases, dementia, depression, falls, endocrine disorders, malnutrition, musculoskeletal diseases, immobility, anemia, peripheral vascular diseases, and problems with the social support system. The control group consisted of 26 male (age 270 years) and 34 female (age 2 7 5 years) apparently healthy independant subjects, recruited from registered students of the University of the Third Age. The mean age of the controls was 75.8 & 4.2 years (range 70-87) and 80.1 f 4.2 years (range 75-92) for males and

0002-8614/92/$3.50

264

CONSTANS ET AL

females, respectively. All these control subjects were mobile, did not require help for walking or day-to-day living, and their degree of physical and mental activity was judged appropriate for age. Ability to go to the hospital for anthropometric measurements and blood sampling was required. A brief history and physical examination was performed on each subject to exclude those with any disease, diet: therapy, or drug known to affect nutritional status. Dietary history was not performed, but the subjects who usually took their meals alone were also excluded, since loneliness was considered as a risk factor for reduced food intake. Each patient or his/hex representative, and each control subject received information about the study and gave oral consent. The study was carried out in accordance with the ethical standards of the Committee on Human Experimentation of our hospital. Methods The following measurements were made in each control subject within the first 36 hours of admission of the patient (111) and, when appropriate, on the 15th day (D15) of hospitalization. (1) Anthropometric parameters: We measured the midarm circumference (MAC, cm), and the triceps skinfold thickness (TSF, mm) of the right arm, unless this arm had been altered by disease. Measurements were made according to the method defined by Tanner.15 The midpoint between the tip of the acromion and the olecranon process was marked while the subject held his forearm in horizontal position. The MAC was measured with a flexible non-stretch tape calibrated in mm. Three measurements were recorded on a subject's arm hanging freely beside the trunk. The precision of the measurement was f 0.1 cm, and the measurements were averaged for presentation. The triceps skinfold was pinched between thumb and index finger over the triceps muscle, the crest of the fold being parallel to the long axis of the hanging arm. The TSF was measured to the nearest 0.2 mm using an Harpenden skinfold caliper (British Indicators Ltd, St Albans, Herts, UK). MAC and TSF were measured in the supine position when the patient was unable to stand. However, values obtained in both positions are highly correlated.16 Three investigators (TC, YB, FL) carried out the anthropometric measurements. In order to minimize inter-observer error, MAC and TSF were measured three times, and the mean of three measurements was recorded. We previously tested the maximal inter-observer percentages of variation which were 1.2% and 5.8% for MAC and TSF respectively. When appropriate, the anthropometric measurements at D1S were performed by the investigator who measured the patient at D1. (2) Venous blood samples were collected after overnight fasting for measurement of plasma concentrations of albumin (Alb, g/d'L, bromocresol green, Technicon Instruments), prealbumin (PAlb, mg/dL), and retinol-binding protein (RBP, mg/dL), both by radial immunodiffusion technique (Behring Laboratory, Marburg, Germany). Accuracy and precision of biochemical measurements were monitored by including quality-control samples with each batch of test specimens.

JAGS-MARCH 1992-VOL.40, NO. 3

(3) PEM was defined with regard to the level of MAC and Alb. MAC is indicative of muscle protein mass and adipose reserve, and Alb evaluates visceral protein storage. PEM was considered as moderate if the MAC of a patient was below the tenth percentile of MAC distribution in controls, or if Alb was under 3.5 g/dL. PEM was considered as severe if both parameters were below these cut-off points. The physicians of our unit did not change their therapeutic practice during the study period. Some malnourished patients received nutritional supplementation. Statistical Analysis Data are presented as mean f SD. A one-factor ANOVA was used to compare age of patients. Paired Student's t test was used to compared values of the nutritional parameters on D1 and D15. For subsequent analysis, the patients were divided into two groups: patients who were still alive at D15 (n = 196) and patients who died during hospitalization before D15 (n = 26). These two groups constituted the dichotomized outcome variable "in-hospital mortality before D15." The relationship between the parameters studied and the outcome variable were analyzed by a step-wise discriminant-function analysis. The variables were introduced into the analysis on the basis of their discriminating power (Student's test). The procedure began by selecting the best discriminating variable. Then a second variable was selected as the most able to improve the value of the discrimination in combination with the first variable. The third and the subsequent variables were similarly selected. The separation of the groups was evaluated by the Mahalanobis distance. The process ended when the increase in the Mahalanobis distance was too small. Sensibility, specificity, and percentage of patients correctly classified were calculated. RESULTS The sex-related values of anthropometricand biological parameters recorded within the first 24 hours in 324 patients and in 60 control subjects are shown in Table 1. Tenth percentile values of MAC and Alb in control subjects are also indicated. Age was slightly lower in male control subjects than in male patients (75.8 +- 4.2 vs 78.8 f 5.4 years, respectively, mean f SD, Student's t test, P < 0.01). Consequently age might have contributed to the increased prevalence of PEM in male patients as compared to male control subjects since lean body mass declines with age.17This was not the case in women since age was not different between control subjects and patients (80.1 f 4.2 vs 81.3 +- 6.8 years, respectively, mean -I- SD, NS). Thirty-eight men had MAC under 24.39 cm or Alb under 3.5 g/dL. Therefore the prevalence of moderate PEM was 30% in men. In women, 80 patients had MAC under 24.37 cm, and 81 had Alb under 3.5 g/dL, which led to a prevalence of moderate PEM of 41% . The prevalence of severe PEM was as high as 15.6%in men and 21.4% in women. In male patients, age was similar between those who presented with severe PEM, moderate PEM, or no PEM (80.7 f 5.8 years, 78.5 f. 6.1 years, 78.4 f 4.9 years, respectively, one-factor ANOVA, f = 1.43,

PROTEIN-ENERGY MALNUTRITION IN AGED PATIENTS

JAGS-MARCH 1992-VOL 40, NO. 3

265

TABLE 1. NUTRITIONAL PARAMETERS IN PATIENTS AND CONTROL SUBIECTS Males Females

Controls

Patients

Controls

Patients

128/26.4(3.5) 34/27.4 (2.0) 128/10.0 (6.3) 34/17.7 (3.6) 125/3.56 (0.50) 32/4.35 (0.20) Alb*** 33/23.4 (4.4) 125/19.4 (8.2) PA# 33/6.6 (1.7) 125/5.6 (2.2) RBI'## All values are nlrnean (SD).* Mid-arm circumference (cm); ** triceps skinfold thickness (mm); *** serum albumin 26/28.6 (4.2) 26/10.7 (3.6) 21/4.44 (0.19) 21/27.8 (5.2) 21/7.6 (2.7)

MAC* TSF**

196/25.5 (4.1) 196/14.7(6.7) 182/3.52 (0.52) 183/19.7 (8.1) 183/5.8 (2.3)

concentration (g/dW; # serum prealbumin concentration (mgldu; ##serum retinol-binding protein concentration (mgldw. Tenth percentile values of MAC were 24.39 cm in control men and 24.37 cm in control women. Tenth percentile values of Alb were 4.26 g/dL in control men and 4.10 g/dL in control women.

TABLE 2. CHANGES IN PARAMETERS FROM D1 to D15 in 53 HOSPITALIZED PATIENTS

D1

5.4 (2.3) 3.43 (0.49) 18.3 (7.3) 25.6 (4.0) 12.5 (6.3) 3.17(0.53)t 17.8 (6.9) 5.6 (2.3) 25.2 (3.7)### 12.4(6.4) Values are mean (SD)at admission 0 1 ) or at 15th day 0 1 5 ) . * Mid-arm circumference; ** triceps skinfold thickness; *** serum albumin concentration;

D15

#serum prealbumin concentration; ##serum retinol-binding protein concentration. Student's t test for paired values, D1 v s D15; ###, P 5 0.05; t, P

I0.01.

TABLE 3. PARAMETERS ON ADMISSION IN 324 PATIENTS AS A FUNCTION OF THE OUTCOME VARIABLE "IN-HOSPITAL MORTALITY BEFORE 15TH DAY" Males Females All Patients Survived Age

(years)

MAC* TSF** Alb*** PA# RBI'##

Died

Survived

Died

Survived

Died

117/78.5 (5.2) 11/82.3 (6.5)###

181/81.1 (6.4) 15/84.7(6.4)###

298/80.0 (6.3) 26/83.7(6.4)t

117/26.6(3.4) 11/25.1 (3.6) 117/9.3 (3.9) 11/11.8 (8.0) 114/3.60 (0.54) 11/3.24 (0.54)### 114/19.8 (8.0) 11/15.0 (9.5) 114/5.7 (2.1) 11/43 (2.4)

181/25.7(4.0) 15/22.4(4.0)t 181/14.9 (6.7) 15/12.3 (7.4) 167/3.53 (0.50) 15/3.35 (0.71) 168/20.0(7.9) 15/16.1(8.7) 168/5.8 (2.3) 15/43 (1.8)

298/26.0(3.8) 26/23.5 (4.0)t 298/12.9(6.4) 26/12.1 (6.9) 281/3.56(0.49) 26/3.30 (0.63)### 282/20.0 (7.9) 26/15.6 (8.9)### 282/5.8 (2.3) 26/43 (2.0)

All values are nlmean (SD). * Mid-arm circumference (cm); ** triceps skinfold thickness (mm); *** serum albumin concentration (g/dW; #serum prealbumin concentration (mgldu; ## serum retinol-binding protein concentration (mgldu. Patients who died were 8.6% and 7.7% of male and female patients, respectively; difference between sexes is not significant. Student's t test; ###, P < 0.05; t, P < 0.01.

NS). In contrast the women who presented with moderate or severe PEM were older than those who had no PEM (84.8 f 7.6 years, 82.3 f 6.7 years, 78.3 f 5.1 years, respectively, one-factor ANOVA, f = 14.5, P C 0.001). Therefore, in women, difference in age might have partly accounted for the low nutritional status observed on admission. Among the 53 patients who were hospitalized for 15 consecutive days, we observed a decrease in MAC and Alb values from D1 to D15, while there were no changes of TSF, PAlb, and RBP (Table 2). Therefore, both muscular and visceral protein storage decreased over the first 15 days of hospitalization, while fat storage did not change. The characteristics of the nutritional parameters on admission (Dl) were divided into two groups according to the outcome variable "in-hospital mortality before D15" and are presented in Table 3. The data from subsequent discriminant-function analysis are listed in Table 4. As indicated, age, MAC, TSF, Alb, and PA are predictors of mortality for about 70% of the patients, with 73% sensitivity and 69%specificity for all patients of both sexes.

DISCUSSION The major findings of this study were (1) a high prevalence of PEM among elderly patients hospitalized in an acute medical unit; (2) a deterioration of the lean body mass over the first 15 days of hospitalization; (3) the utility of simple nutritional indices such as midarm circumference and plasma Alb concentration on admission as predictive indicators of the short-term mortality of elderly patients. In this study, weight and height were not measured. In older patients, weight cannot be easily and reliably measured due to immobilization and il1ne~s.I~ The high prevalence of vertebral osteoporosis and s inal deformities impair stature measurement.I*, I F Consequently, the calculation of a body mass index such as Quetelet's index (weight/height2) would amplify any errors of these measurements and is not likely to be a reliable indicator of nutritional status in older patients.' The MAC and the skinfold measurements are independent of height and less affected by state of hydration, heart failure, or ascites than weight." In this study, we excluded beforehand the patients with edema to minimize error in anthropometric measure-

266

CONSTANS ET AL

IAGS-MARCH 1992-VOL. 40, NO. 3

TABLE 4. DISCRIMINANT ANALYSIS OF THE ADMISSION PARAMETERS AS A FUNCTION OF THE OUTCOME VARIABLE ”IN-HOSPITAL MORTALITY BEFORE 15TH DAY” Parameter Coefficient Males Females All Patients

Constant Age (years) MAC*

TSF** Alb***

0.01307694 -0.00087556 0.00175682 -0.02318612 0.00106472

-0.03222914 0.00110938

-0.00239576 -0.0001 6787 0.00064370 -0.00216656

PA# Sensitivity (%) Specificity (%) Correctly classified (%)

0.03072002 0.01615506 63.6 73.3 73.1 83.3 68.3 69.0 81.6 68.7 69.4 * Mid-arm circumference (cm); ** triceps skinfold thickness (mm); *** serum albumin concentration CpIdW; # serum prealbumin concentration (mg/ dW. The calculation of the equation yields a negative value of y if the patient survived and a positive value of y if the patient died before the 15th day of hospitalization,

ments. In adult patients, MAC3,7,20,21 and TSFZ2are subjects from the same area (unpublished data) or to considered as reliable, inexpensive, and non-invasive those reported in an elder1 independent population indicators of the total body muscle and fat mass, re- from the UKZ8or USA?’,39*4‘Using the tenth percentile spectively. However anthropometric measurements of plasma albumin levels from control subjects as cutfrom elderly people may not be as accurate as those off points would have led to a high prevalence of PEM obtained from adults for two reason^:'^ (1) skinfold without any practical significance (92.2% and 79.6% elasticityz4and c~mpressibility~~ vary with age, (2) the for male and female patients, respectively). Therefore, ratio between subcutaneous adipose tissue and total we chose a plasma Alb level of 3.5 g/dL as the cut-off body fat tends to decrease with age.22,26 Despite these point to define PEM since it is widely aclimitations, anthropometricmeasurements are assumed cepted.2,7,14.31,41-43 As a consequence 28.1% of male to be indicative of long-term nutritional status in el- and 19.4% of female patients had plasma Alb levels derly patients as they provide a composite picture of that overlapped with values from control subjects. In the lon term adequacy of protein and energy in- contrast the patients who presented with moderate takes.’,’ $-The calculation of corrected midarm muscle- PEM had plasma Alb levels that were completely difmass area (CAMA) would amplify any error in MAC ferent from control values, as in Mitchell’s study.32 and TSF measurements. If CAMA is a reliable indicator The prevalence of PEM in the literature varies from of muscle mass in healthy adult subje~ts,‘~ its accuracy one study to another: 22%,4428%,4531%’” 32% in has not been proved among elderly people.’ In our patients over 60 years,” 44%,3 and 48%.7Bollet and study, PEM was defined according to cut-off points Owens3’ observe 17%to 45% of malnourished patients (10th percentile) from the sex-related values of MAC according to the index used.31The revalence of PEM measured in control subjects. MAC and TSF values of is higher in women than in men.’ g,45 Serum albumin our control subjects were comparable to values ob- level is lower than 3.5 g/dL in 45% of cases7 The tained in healthy elderly subjects from the UK28*29 and prevalence of PEM in our study (30% in men and 41% USA (upper age-group of Health And Ntitrition Ex- in women) was in accordance with these data. Only amination Survey one male and two female patients presented with seThe lasma Alb3,7.20,2’t31.32 and PAlb-RBP com- vere wasting malnutrition defined according to Friedplex9p20*’3T34 levels have been shown to reflect changes man’s criterion (CAMA lower than 16.0 cm2 in men in visceral protein status and current ability to synthe- and 16.9 cm2in women; data not shown).13 sise proteins in hospitalized patients. However plasma Nutritional evaluation of elderly patients at 8 and 26 protein level is not specific of nutritional status: infec- weeks in the course of hospitalization shows that the tious diseases, malignancies, and/or active inflamma- hospital per se is responsible for a gradual deterioration tory response might contribute to the diminution of of their nutritional status.45Such a deterioration has plasma protein levels.” Therefore hypoalbuminemia is not been demonstrated in elderly patients hospitalized likely to be due to disease itself, through changes in for a short stay in an acute medical unit. In our study, metabolism as well as PEM.”*” Nevertheless, the pres- midarm circumference and plasma albumin concentraence or the absence of sepsis does not influence the tion decreased significantly from D1 to D15, without predictive ability of serum albumin Despite any change in TSF and plasma PAlb and RBP concenthese limitations, serum albumin concentration is con- trations. These different changes from one protein to sidered as one of the best indicators of nutritional status another could be attributed to the large distribution and the best predictor of m ~ r t a l i t y . ~Thus ~ , ~ ~we - ~ ~volume and transcapillary transfer of albumin, on the chose to measure albumin, prealbumin, and retinol- one hand,46and the plasma half-life of each protein binding protein plasma concentrations since these pro- on the other hand, ie 21 days, 2 days, and 12 hours teins are the most frequently measured in hospital for Alb, PAlb, and RBP, respectively. The decrease in practice, and their analysis is relatively inexpensive. protein storage over the hospital stay was in accordance Both male and female control subjects had plasma with data in adult patient^.^ In the latter study, six albumin distributions similar to those of healthy adult nutritional parameters had worsened 15 days after

JAGS-MARCH 1992-VOL.40, NO.3

PROTEIN-ENERGY MALNUTRITION IN AGED PATIENTS

normal admission values in over 75% of patients followed-up. Several factors might account for these variations. First, the disease itself determines decline in lean body through changes in metabolism’ Setond, the medical team could underestimate the needs of the critically ill aged patient. Third, the intake of patients is Often reduced during hospitalization because of the explorations which need fasting and the poor palatabiliiy of hospital food. The present study did not allow an assessment of the relative roles of these factors. Although some malnourished patients were supplemented during their hospital course, the effects of supplementation were not evaluated. It has been recently demonstrated that nutritional supplementation is more effective to preserve nutritional state and reduce mortality in previously well nourished patients than in malnourished patient^.^' These data in malnourished patients have to be confirmed since PEM is frequently the result of various disease processes: anorexia or malignant diseases can be linked to treatable causes of PEM, eg drugs, depression, physical inability, recurrent infections, and poverty.47 MAC, Alb and RBP are lower in patients who subsequently die in the h o ~ p i t a l . ~Our ~ , results ~ ~ , ~ agree ~ with these findings. However the choice of limits for normal and abnormal values is always arbitrarily decided. PEM is not a consequence of an all-or-nothing concept: it would be better analyzed as a continuum of situations from severe undernutrition to adequate nutrition.’ This general view may be described using a discriminant-function analysis. In the present study, such an analvsis showed that aee ” as well as simde nutritional inhicators of protein and fat storage wLre predictors of short-term mortality in about 70% of patients. Although TSF did not change during hospitalization,as previously observed,13,37fat depletion also contributed t0 predict mortality in males. Other Studies have used multivariate techniques: in a geriatric rehabilitation unit, both the nutritional status and the actiVitieS Of daily living (ADL) score are highly correlated with the risk of subsequent complications or death,I4 Whereas in an acute care unit, decreased ADL score and decreased mental status, as well as living location, are strong predictors of in-hospital m~rtality.~’ This study confirms the high prevalence of proteinenergy malnutrition among elderly hospitalized patients compared to a closely related control population. Moreover the nutritional Status Of the patients deteriorated Over the first fifteen days of hospita~iza~on, and the lean body was first affected.Simple admission nutritional parameters are good predictors of shortterm in-hospital patients’ The efin fects of disease condition and previous nutritional status should now be investigated. ACKNOWLEDGMENTS we thank M~~ Sylviane vol of the Institut ~ b @ pour la Santb for her professional advice on statistical analysis, Mrs Doreen Raine for her help with the language! and Dr ‘Ouet for his reading of the revised version of the manuscript.

267

REFERENCES 1. Studley HO. Percentage of weight loss, a basic indication of surgical risk in patients with chronic peptic ulcers. JAMA 1936;106:458-460. 2. Bistrian BR, Blackbum GL, Halowell E et al. Protein status of general surgical patients. JAMA i974;230:858-860. 3. Bistrian BR, Blackburn GL, Vitale J et al. Prevalence of malnutrition in general medical patients. JAMA 1976;235:1567-1570. 4. Morgan DB, Newton HMV, Schorah CJ et al. Abnormal indices of nutrition in the elderly: a study of different clinical groups. Age Ageing 1986;15: 65-76. 5. Rudman D, Feller AG. Protein-calorie undernutrition in the nursing home. J Am Geriatr SOC1989;37173-183. 6. Lehmann AB. Review: Undemutrition in elderly people. Age Ageing 1989; 18:339-353. 7. Weinsier RL, Hunker EM, Krumdieck CL et al. Hospital malnutrition. A prospective evaluation of general medical patients during the course of hospitalization. Am J Clin Nutr 1979;32:418-426. 8. Apelgren KN, Rombeau JL, Miller RA et al. Malnutrition in Veterans Administration surgical patients. Arch Surg 1981;116:1059-1061. 9. Kergoat M-J, Leclerc BS, PetitClerc C et al. Discriminant biochemical markers for evaluating the nutritional status of elderly patients in longterm care. Am J Clin Nutr 1987;46:849-861, 10. Golden MHN. Transport proteins as indices of protein status. Am J Clin Nutr 1982;35:1159-1165. 11. Friedman PJ, Campbell AJ, Caradoc-Davies TH. Hypoalbuminaemia in the elderly is due to disease not malnutrition. J Clin Exp Gerontol 1985;7 191-204. 12. Bastow MD, Rawlings J, Allison SP. Undemuhition, hypothemia, and injury in elderly women with fractured femur: An injury response to altered metabolism? Lancet 1983;i:143-146. 13. Friedman PJXampbell AJ, Caradoc-Davies TH. Prospective trial of a new diagnostic criterion for severe wasting malnutrition in the elderly. Age Ageing 1985;14:149-154. 14. Sullivan DH, Patch GA, Walls RC et al. Impact of nutrition status on morbidity and mortality in a select population of geriatric rehabilitation patients. Am J Clin Nutr 1990;51:749-758. 15. Tanner JM, Whitehouse RH. Standards for subcutaneous fat in British children. Percentiles for thickness of skinfolds over triceps and below scapula. Br Med J 1962;1:446-450. 16. Womersley J, Dumin JVGA. An experimental study on variability of measurements of skinfold thickness on young adults. Hum Biol 1973;45: 281-292. 17. Forbes GB, Reina JC. Adult lean body mass declines with age: some longitudinal observations. Metabolism 1970;19:653-663. 18. Mitchell CO, Lipschitz DA. Detection of protein-calorie malnutrition in the elderly. Am J Clin Nutr 1982;35:398-406. 19. Bowman BB, Rosenberg IH. Assessment of the nutritional status of the elderly. Am J Clin Nutr 1982;35:1142-1151. 20. Jouquan J, Game M, Pennec Yet al. PrGvalence d e la dknutrition protidique a l’admission en mPdecine interne. Presse MPd 1983;12:877-881. 21. Willard MD, Gilsdorf RB, Price RA. Protein-calorie malnutrition in a community hospital. JAMA 1980;243:1720-1722. 22. Durnin JVGA, Womersley J. Body fat assessed from total body density and its estimation from skinfold thickness: Measurements on 481 men and women aged from 16 to 72 years. Br J Nutr 1974;32:77-97. 23. Chumlea WC, Roche A, Webb P. Body size, subcutaneous fatness and total body fat in older adults. Int J Obesity 1984;8:311-317. 24. Grahame R. A method for measuring human skin elasticity in vivo with observations on the effects of age, sex and pregnancy. Clin Sci 1970;39: 223-238. 25. Himes JH, Roche AF, Siervogel RM. Compressibility of skinfolds and the measurement of subcutaneous fatness. Am J Clin Nutr 1979;32: 1734-1 740. 26. Norris AH, Lundy T, Shock NW. Trends in selected indices of body composition in men between the ages 30 and 90 years. Ann NY Acad Sci 1963;110:623-639. 27. Heymsfield SB, McManus C, Smith J et al. Anthropometric measurement of muscle-mass: Revised equations for calculating bone-free arm muscle area. Am J Clin Nutr 1982;36:680-690. 28. Burr ML, Milbank JE, Gibbs D. The nutritional status of the elderly. Age Ageing 1982;i 1539-96. 29. McEvoy AW, James QFW. Anthropometric indices in normal elderly subjects. Age Ageing 1982;11:97-100. 30. Frisancho AR. New norms of upper limb fat and muscle areas for assessment of nutritional status. Am J Clin Nutr 1981;34:2540-2545. 3 1. Bollet AJ, Owens S. Evaluation of nutritional status of selected hospitalized patients. Am J Clin Nutr 1973;26:931-938. 32. Mitchell DA. The effect of age and sex on the routinely ~ used ~ measurements ~CO,l Lipschitz to assess the nutritional status of hospitalized patients. Am J CIin ~ u t 1982;36:340-349. r 33. Ingenbleek Y, Van den Schrieck HG, de Nayer P et al. Albumin, transfemn and the thyroxine-binding prealbumin/retinol-binding protein (TBPARBI‘) complex in assessment of malnutrition. Clin Chim Acta 1975;63: 61-67.

268

CONSTANS ET AL

34. Sachs E, Bemstein LH. Protein marken; of nutrition status as related to sex and age. Clin Chem 1986;32339-341. 35. Harvey KB, Moldawer LL, Bistrian BR et al. Biological measures for the formulation of a hospital prognosis index. Am J C l i Nutr 1981;34: 2013-2022. 36. Agarwal N, Acevedo F, Leighton LS et al. Predictive ability of various nutritional variables for mortality in elderly people. Am J Clin Nutr 1988; 48:1173-I 178. 37. Phillips P. Grip strength, mental performance and nutritional status as indicators of mortality risk among female geriatric patients. Age Ageing 1986;15:53-56. 38. Fulop T, Hermann F, Rapin CH. Prognostic role of serum albumin and prealbumin levels in elderly patients at admission to a geriatric hospital. Arch Gerontol Geriatr 1991;12:31-39 39. Sahyoun NR, Otradovec CL, Hartz SC et al. Dietary intakes and biochemical indicators of nutritional status in an elderly, institutionalized population. Am J Clin Nutr 1988;47524-533. 40. Mitchell CO, Lipschitz DA. A nutritional evaluation of healthy elderly. J Parenter Enteral Nutr 1980;4603. 4 1. Nixon DW, Heymsfield SB, Cohen AE et al. Protein-calorie undemutrition

IAGS-MARCH 1992-VOL. 40, NO. 3 in hospitalized cancer patients. Am J Med 1980;68:683-690. 42. Seltzer MH, Bastidas JA, Cooper DM et al. Instant nutritional assessment. J Parenter Enteral Nutr 1979;3:157-159. 43. Smith ]L, Wickiser AA, Korth LL et al. Nutritional status of an institutionalized aged population. J Am Coll Nutr 1984;3:13-25. 44. Albiin N, Asplund K, Bjenner L. Nutritional status of medical patients on emergency admission to hospital. Acta Med %and 1982;212:151-156. 45. Larsson J, Unosson M, Ek AC et al. Effect of dietary supplement on nutritional status and clinical outcomein 501 geriatricpatients-a randomized study. Clin Nutr 1990;9:179-184. 46. Lundsgaard-HansenP. Physiology and pathophysiology of colloid osmotic pressure and albumin metabolism. Curr Stud Hematol Blood Transfus 1986;53:1-17. 47. Morley JE, Silver AJ. Anorexia in the elderly. Neurobiol Aging 1988;9: 9-16. 48. Kemm JR, Allcock J. The distribution of supposed indicators of nutritional status in elderly patients. Age Ageing 1984;13:21-28. 49. Narain P, Rubenstein LZ,Wieland GD et al. Predictors of immediate and 6-month outcomes in hospitalized elderly patients. The importance of functional status. J Am Geriatr Soc 1988;36775-783.

Protein-energy malnutrition in elderly medical patients.

To evaluate (1) the prevalence of protein-energy malnutrition in elderly patients; (2) the changes in nutritional status during the hospital stay; and...
691KB Sizes 0 Downloads 0 Views