Clinical Nutrition xxx (2014) 1e9

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Clinical Nutrition journal homepage: http://www.elsevier.com/locate/clnu

Original article

The validity of Geriatric Nutrition Risk Index: Simple tool for prediction of nutritional-related complication of hospitalized elderly patients. Comparison with Mini Nutritional Assessment Wafaa Mostafa Abd-El-Gawad a, *, Rania Mohammed Abou-Hashem a, Mohamed Omar El Maraghy b, Ghada Essam Amin c a b c

Geriatrics and Gerontology Department, Faculty of Medicine, Ain Shams University, Abbassia, Cairo, Egypt Clinical Pathology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt Environmental and Occupational Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt

a r t i c l e i n f o

s u m m a r y

Article history: Received 24 June 2013 Accepted 18 December 2013

Background & aims: The Geriatric Nutritional Risk Index (GNRI) is a promising tool initially proposed to predict nutrition-related complications in sub-acute care setting. So, the main aim of this study was to validate the use of GNRI in hospitalized elderly patients by testing its ability to predict patients’ outcome through the comparison with Mini Nutritional Assessment (MNA). Methods: A prospective cohort study was conducted on 131 patients aged 60 and over admitted consecutively from October 2011 to September 2012 to the acute geriatrics medical ward in Ain Shams University hospitals, Cairo, Egypt. All patients were subjected to nutritional screening using GNRI and MNA and measurement of weight, body mass index (BMI), mid arm circumference (MAC), and calf circumference (CC), serum levels of total protein, albumin and prealbumin. Patients were followed for 6 months for the occurrence of major health complications as prolonged length of stay, infectious complications and mortality. Results: Mean age was 69.32  8.17 years. Lower GNRI scores were statically significantly associated with worse MNA scores, lower weight, BMI, MAC, CC and albumin (P value < 0.001 for all). Only with GNRI, increasing odds ratio (OR) was seen with increasing risk of nutrition-related complication (from mild to moderate to severe). ORs (95%CI) for three month mortality were 1.63(0.0.27e10.00), 5.03(1.36e18.52), and 11.24(3.03e41.67), and OR (95%CI) for six month mortality were 1.64(0.403e6.62), 4.29 (1.45e12.66), and 5.71(1.87e17.54) respectively compared to patients with no risk and. By regression, both severe and moderate grade of GNRI were independent predictors of three and six month mortality (P value for three month: 0.002, 0.015; for six month: 0.002, 0.008 respectively) after adjustment of age, sex, and cancer rather than MNA. Conclusions: GNRI showed a higher prognostic value for describing and classification of nutritional status and nutritional-related complications in hospitalized elderly patients in addition to its simplicity. Ó 2013 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

Keywords: GNRI MNA Hospitalized elderly Mortality

1. Introduction Older adults are one of the most heterogeneous and vulnerable groups who are at higher risk of nutritional problems.1,2 Malnutrition is underdiagnosed and frequently unrecognizable from the changes of the aging process. The physiological and social changes

* Corresponding author. Tel.: þ20 1002863434. E-mail addresses: [email protected] (W.M. Abd-El-Gawad), rania_ [email protected], [email protected] (R.M. Abou-Hashem), [email protected], [email protected] (M.O. El Maraghy), [email protected] (G.E. Amin).

resulting from aging together with multiple chronic diseases, high consumption of drugs, degenerative bone diseases affecting mobility, psychological distress and loss of appetite influence the nutritional status of this group particularly in view of increased life expectancy. The prevalence of protein-energy malnutrition in acutely hospitalized elderly patients is ranging from 20 to 50%.2 As a consequence of malnutrition, the frequency of infections, long hospital stay, morbidity and mortality are increased.3,4 Despite the annual increase in the number of elderly patients worldwide, the number of dietitian and health professionals are not increased to meet the greater demand of patients with higher number of various comorbidities.5,6 In the face of this problem,

0261-5614/$ e see front matter Ó 2013 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved. http://dx.doi.org/10.1016/j.clnu.2013.12.005

Please cite this article in press as: Abd-El-Gawad WM, et al., The validity of Geriatric Nutrition Risk Index: Simple tool for prediction of nutritional-related complication of hospitalized elderly patients. Comparison with Mini Nutritional Assessment, Clinical Nutrition (2014), http://dx.doi.org/10.1016/j.clnu.2013.12.005

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W.M. Abd-El-Gawad et al. / Clinical Nutrition xxx (2014) 1e9

nutritional screening tools become extremely important to classify those patients at nutritional risk from thousands of patients attending tertiary care hospitals especially in low and middle income countries like Egypt. The Geriatric Nutritional Risk Index (GNRI) is a new tool created to study and predict nutrition-related complications in elderly.7 Although it has been initially proposed for sub-acute care setting, preliminary studies have revealed its suitability to different settings such as acute and long-term cares.8e10 Beside this, some studies have also investigated the prognostic value of this index and it appears promising.8e12 However, literature addressing such issue is still poor, so the present study was designed to expand the existing knowledge, which is mainly referred to long-term care setting.7,9 Accordingly, the main aim of this study was to validate the use of GNRI in elderly patients admitted to acute geriatric medical wards through testing its ability to classify the patients according to nutrition-related risk of complications through the comparison with a well-validated tool, Mini Nutritional Assessment (MNA) with both its long and short forms-Arabic versions (MNA-LF-A and MNASF-A) and to predict the outcomes of those hospitalized elderly. The outcomes measured were morbidity (infections and prolonged length of stay (PLOS)), and inhospital, three and six month mortality.

to be in light clothing and without shoes. Measurements were recorded to the nearest 0.5 kg. Body mass index (BMI) was calculated as weight (in kg) divided by height squared (by m2). Waist circumference (WC) was recorded to the nearest 0.5 cm and it was measured midway between the lower rib margin and the iliac crest.13 Mid Arm Circumference (MAC) was measured by asking the patient to bend their non-dominant arm at the elbow at a right angle with the palm up then the distance between the acromial surfaces of the scapula and the olecranon process of the elbow was measured and the tape at the mid-point on the upper arm was tighten snugly. MAC was recorded to the nearest 0.1 cm. Calf circumference (CC) was measured by asking the patient to sit with the left leg hanging loosely, wrapping the tape around the calf at the widest part and noting the measurement with ensuring that the tape was at a right angle to the length of the calf. Then additional measurements above and below the point were taken to ensure that the first measurement was the largest. CC was recorded to the nearest 0.1 cm14 2.3.2. Geriatric Nutritional Risk Index (GNRI)7 The GNRI was developed by modifying the nutritional risk index13,14 for elderly patients. This index is calculated by using the following equation:

2. Materials and methods

GNRI ¼ ½1:489albuminðg=LÞ þ ½41:7ðweight=WLoÞ 2.1. Participants A prospective cohort study was conducted on 215 patients aged 60 and over admitted consecutively from October 2011 to September 2012 to the acute geriatrics medical ward of Geriatrics and Gerontology department in Ain Shams University hospitals, Cairo, Egypt. For purpose of the study, exclusion criteria were hyponatremia (135 mmol/L) and hypernatremia (145 mmol/L) (due to interaction with serum albumin level), diseases associated with high mortality or hypalbuminemia [like terminal cancer, severe hepatic disease (Child B and C), and severe renal insufficiency (creatinine clearance 15 mL/min)]. Also patients, who were dependent in activities of daily living score, refused to participate, lost during follow up or with any missing data, were also excluded. The study had been approved by the local ethical committees of geriatrics and gerontology department and all patients or their next kin provided informed consent to the work. 2.2. Data collection Data were collected on personal characteristics, co-existing comorbidities, clinical features, and laboratory results available within the first 48 h after presentation. 2.3. Nutritional assessment 2.3.1. Anthropometric and laboratory measurements Weight, height, body mass index (BMI) (in kg/m2), mid arm circumference (MAC), and calf circumference (CC) were performed as a part of anthropometric measures. Laboratory assessments done were serum levels of total protein (TP), albumin, prealbumin, total cholesterol (TC), triglycerides (TG), copper and zinc, in addition to a complete blood picture. Standing height was measured using a stadiometer on a hardfloor surface with a fixed vertical backboard and an adjustable head piece. The patients stood up straight with heels together and height was recorded to the nearest 0.5 cm. Weight was determined on a standardized scale placed on a hard-floor surface. Participants had

WLo: the ideal weight was calculated from the Lorentz equations. When the “weight/WLo” is equal or over 1, the ratio is set to 1. Categorization of the patients was performed according to the following cut-offs: major risk (GNRI < 82), moderate risk (GNRI 82 to 98) of nutritional-related complications.7 We utilized the modification proposed by Cereda et al.15 Severe risk (GNRI < 92) and moderate risk (GNRI 92e98) categories were included into one single category only to enable us to obtain a three-category tool similar to the MNA-LF-A and MNA-SF-A as these two categories are associated with increased risk of overall health complications.7,15 2.3.3. Mini Nutritional Assessment-Long form-Arabic version (MNA-LF-A) MNA is a well-validated tool recommended by European Society of Parenteral and Enteral Nutrition guidelines for screening and grading of malnutrition in elderly.16,17 The MNA is based on 18 items, including anthropometric, general state, dietary parameters and self-perception regarding health and nutrition. A maximal score is 30 points. Elderly were classified as well-nourished if MNA 24; at risk of malnutrition if MNA between 17 and 23.5; and malnourished if MNA

The validity of Geriatric Nutrition Risk Index: simple tool for prediction of nutritional-related complication of hospitalized elderly patients. Comparison with Mini Nutritional Assessment.

The Geriatric Nutritional Risk Index (GNRI) is a promising tool initially proposed to predict nutrition-related complications in sub-acute care settin...
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