Abstract
OBJECTIVE: To determine whether elderly patients with protein-energy undernutrition at admission are at increased risk for subsequent life-threatening events after controlling for illness severity.
DESIGN: Prospective cohort study.
SETTING: University-affiliated Department of Veterans Affairs hospital.
PATIENTS: Five hundred eighty-six nonterminal patients (mean age 74±6 [SD] years, 98% male, 86% white) with a length of stay of 3 days or more.
MAIN OUTCOME MEASURES: Life-threatening complications.
RESULTS: Subsequent to admission, 37 subjects (6.3%) experienced at least 1 life-threatening complication. All of the putative nutrition variables examined and many non-nutrition, illness severity measures were strongly correlated with the risk of a life-threatening complication by univariate analyses (P<.05 for all analyses). After controlling for illness severity, admission serum albumin, prealbumin, and cholesterol were no longer significantly correlated with the outcome. In contrast, weight loss (>5% within 6 months), body mass index, mid-arm circumference, and suprailiac skinfold thickness remained strong independent predictors. The adjusted relative risk of a life-threatening complication ranged from 2.9 (95% confidence interval [CI], 1.3 to 6.4) for a body mass index <22 kg/m2 to 7.1(95% CI, 2.0 to 25.7) for a suprailiac skinfold thickness in the lower tertile for the study population. The putative nutrition and illness severity variables were highly intercorrelated.
CONCLUSIONS: There is a complex interrelationship between nutritional status, illness severity, and clinical outcomes among the hospitalized elderly. The serum secretory proteins and cholesterol are correlated with other indicators of illness severity and adverse outcomes, but may not be good markers of nutritional risk. In contrast, weight loss, a low body mass index, and other indicators of lean and fat mass depletion appear to place the patient at increased risk for adverse outcomes independent of illness severity. Whether it is possible to reverse such established nutritional deficits and reduce complication risk in the acute care setting remains to be determined.
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References
Volkert D, Kruse W, Oster P, Schlierf G. Malnutrition in geriatric patients: diagnostic and prognostic significance of nutritional parameters. Ann Nutr Metab. 1992;36:97–112.
Potter JF, Schafer DF, Bohi RL. In-hospital mortality as a function of body mass index: an age-dependent variable. J Gerontol. 1988;43:M59–63.
Constans T, Bacq Y, Brechot JF, Guilmot JL, Choutet P, Lamisse F. Protein-energy malnutrition in elderly medical patients. J Am Geriatr Soc. 1992;40:263–8.
Cederholm T, Jagren C, Hellstrom K. Outcome of protein-energy malnutrition in elderly medical patients. Am J Med. 1995;98:67–74.
Covinsky KE, Martin GE, Beyth RJ, Justice AC, Sehgal AR, Landefeld CS. The relationship between clinical assessments of nutritional status and adverse outcomes in older hospitalized medical patients. J Am Geriatr Soc. 1999;47:532–8.
Avenell A, Handoll HH. Nutritional supplementation for hip fracture aftercare in the elderly. Cochrane Database Syst Rev. 2000;CD001880.
Heyland DK, MacDonald S, Keefe L, Drover JW. Total parenteral nutrition in the critically ill patient: a meta-analysis. JAMA. 1998;280:2013–19.
Souba WW. Nutritional support. N Engl J Med. 1997;336:41–8.
Sullivan DH. The role of nutrition in increased morbidity and mortality. Clin Geriatr Med. 1995;11:661–74.
Sullivan DH, Nelson CL, Bopp MM, Puskarich-May CL, Walls RC. Nightly enteral nutrition support of elderly hip fracture patients: a phase I trial. J Am Coll Nutr. 1998;17:155–61.
Bastow MD, Rawlings J, Allison SP. Benefits of supplementary tube feeding after fractured neck of femur: a randomized controlled trial. BMJ. 1983;278:1589–92.
Delmi M, Rapin CH, Bengoa JM, Delmas PD, Vasey H, Bonjour JP. Dietary supplementation in elderly patients with fractured neck of the femur. Lancet. 1990;335:1013–6.
Schurch MA, Rizzoli R, Slosman D, Vadas L, Vergnaud P, Bonjour JP. Protein supplements increase serum insulin-like growth factor-I levels and attenuate proximal femur bone loss in patients with recent hip fracture. A randomized, double-blind, placebo-controlled trial. Ann Intern Med. 1998;128:801–9.
Stableforth PG. Supplement feeds and nitrogen and calorie balance following femoral neck fracture. Br J Surg. 1986;73:651–5.
Karkeck JM. Nutrition support for the elderly. Nutr Clin Pract. 1993;8:211–9.
McCamish MA. Malnutrition and nutrition support interventions: cost, benefits, and outcomes. Nutrition. 1993;9:556–7.
Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189–98.
Lockrem JD, Lopez E, Gallagher J, Church GE, Estafanous FG. Severity of illness: APACHE II analysis of an ICU population. Cleve Clin J Med. 1991;58:477–86.
Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373–83.
Agarwal N, Acevedo F, Leighton LS, Cayten CG, Pitchumoni CS. Predictive ability of various nutritional variables for mortality in elderly people. Am J Clin Nutr. 1988;48:1173–8.
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;36:775–83.
Epstein AM, Stern RS, Tognetti J, Begg CB, Hartley RM, Cumella E Jr. The association of patients’ socioeconomic characteristics with the length of hospital stay and hospital charges within diagnosis-related groups. N Engl J Med. 1988;318:1579–85.
Iezzoni LI, Ash AS, Coffman GA, Moskowitz MA. Predicting in-hospital mortality. A comparison of severity measurement approaches. Med Care. 1992;30:347–59.
Green J, Passman LJ, Wintfeld N. Analyzing hospital mortality. The consequences of diversity in patient mix. JAMA. 1991;265:1849–53.
Cohen HJ, Saltz CC, Samsa G, McVey L, Davis D, Feussner JR. Predictors of two-year post-hospitalization mortality among elderly veterans in a study evaluating a geriatric consultation team. J Am Geriatr Soc. 1992;40:1231–5.
Pompei P, Charlson ME, Ales K, MacKenzie CR, Norton M. Relating patient characteristics at the time of admission to outcomes of hospitalization. J Clin Epidemiol. 1991;44:1063–9.
Sullivan DH, Patch GA, Baden AL, Lipschitz DA. An approach to assessing the reliability of anthropometrics in elderly patients. J Am Geriatr Soc. 1989;37:607–13.
Katz S, Ford AB, Moskowitz RW, Jackson BA, Joffee MW, Cleveland MA. Studies of illness in the aged. The index of ADL: a standardized measure of biological and psychosocial function. JAMA. 1963;185:914–9.
Lawton MP. Assessing the competence of older people. In: Kent D, Kastenbaum R, Sherwood S, eds. Research Planning and Action for the Elderly. New York: Behavioral Publications; 1972:123–45.
Sullivan DH, Patch GA, Walls RC, Lipschitz DA. Impact of nutritional status on morbidity and mortality in a select population of geriatric rehabilitation patients. Am J Clin Nutr. 1990;51:749–58.
Buzby GP, Mullen JL, Matthews DC, Hobbs CL, Rosato EF: Prognostic nutritional index in gastrointestinal surgery. Am J Surg. 1980;139:160–7.
Sullivan DH, Walls RC. The risk of life-threatening complications in a select population of geriatric patients: the impact of nutritional status. J Am Coll Nutr. 1995;14:29–36.
Landi F, Zuccala G, Gambassi G, et al. Body mass index and mortality among older people living in the community. J Am Geriatr Soc. 1999;47:1072–76.
Rudman D, Mattson DE, Nagraj HS, et al. Prognostic significance of serum cholesterol in nursing home men. J Parenter Enteral Nutr. 1988;12:155–58.
Hebuterne X, Broussard JF, Rampal P. Acute renutrition by cyclic enteral nutrition in elderly and younger patients. JAMA. 1995;273:638–43.
Campbell IT. Assessing the efficacy of nutritional support. Baillieres Clin Endocrinol Metab. 1997;11:753–69.
Watters JM, Kirkpatrick SM, Norris SB, Shamji FM, Wells GA. Immediate postoperative enteral feeding results in impaired respiratory mechanics and decreased mobility. Ann Surg. 1997;226:369–77.
Whittaker JS, Ryan CF, Buckley PA, Road JD. The effects of refeeding on peripheral and respiratory muscle function in malnourished chronic obstructive pulmonary disease patients. Am Rev Respir Dis. 1990;142:283–88.
Sullivan DH. What do the serum proteins tell us about our elderly patients? J Gerontol A Biol Sci Med Sci. 2001;56:M71–4.
Spiekerman AM. Proteins used in nutritional assessment. Clin Lab Med. 1993;13:353–69.
Forse RA, Shizgal HM. Serum albumin and nutritional status. J Parenter Enteral Nutr. 1980;4:450–4.
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This work was supported by a grant from the Department of Veterans Affairs, Health Services Research and Development Service.
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Sullivan, D.H., Bopp, M.M. & Roberson, P.K. Protein-energy undernutrition and life-threatening complications among the hospitalized elderly. J GEN INTERN MED 17, 923–932 (2002). https://doi.org/10.1046/j.1525-1497.2002.10930.x
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DOI: https://doi.org/10.1046/j.1525-1497.2002.10930.x