Agathe Raynaud-Simon

Validation of the Mini Nutritional Assessment-Short Form in a population of frail elders without disability. Analysis of the Toulouse Frailty Platform population in 2013

ObjectiveTo assess the validity of the Mini Nutritional Assessment-Short Form (MNA-SF) in elderly patients from the Toulouse Frailty Platform.ParticipantsOverall, 267 patients aged 65 and over, without severe cognitive impairment (i.e. Mini Mental Status Examination > 20 and CDR<1), no physical disability (i.e. Activities of Daily Living ≥ 5) and no active cancer history (over the past 12 months) were included in 2013.MeasurementsReceiver operating characteristic (ROC) analyses were used to assess the predictive validity of the French version of the MNA-SF for good nutritional status (defined as a full MNA score≥24/30). Analyses were conducted in the overall sample and then in subgroups of frail and pre-frail subjects according to the frailty phenotype. Optimal cut-off points were determined to obtain the best sensitivity/specificity ratio and the highest number of correctly classified subjects.ResultsAmong 267 patients, mean age=81.5±5.8; women=67.0%; 138 (51.7%) were frail, 98 (36.7%) were pre-frail and 31 (11.6%) were robust. Given their MNA-SF scores, 201 (75.3%) had a good nutritional status, 61 (22.8%) were at risk of malnutrition and 5 (1.9%) were malnourished. In the overall sample, but also in subgroups of pre-frail or frail elders, the areas under ROC curves were 0.954, 0.948 and 0.958 respectively. The 11 points cut-off provided the best correct classification ratio (91.4%); sensitivity=94.0%, specificity=83.3%.ConclusionThe MNA-SF appeared to be a validated and effective tool for malnutrition screening in frail elders. Implementing this tool in clinical routine should contribute to improving the screening of malnourished frail individuals.

Inflammation and disability as risk factors for mortality in elderly acute care patients.

Although the role of inflammation has been studied in specific diseases or in community living elderly, data in hospitalized acute care elderly patients are scarce. The present study was designed to determine the predictive value of sociodemographic, clinical and biological factors for mortality in acute care geriatric wards. Retrospective study was conducted in two acute care wards in a university-based geriatric hospital with elderly patients (n=224) consecutively admitted to acute care wards with available medical files. Sociodemographic variables, primary medical diagnosis and number of associated conditions, dementia, depression, pressure sores, functional status (measure by the activities of daily living=ADL scale), weight, and plasma levels of albumin, transthyretin, C-reactive protein (CRP) and orosomucoid were recorded at admission. Patients who died in the acute care wards were compared to those who survived. The mean length of stay was 16+/-13 days; mortality was 12%. Univariate analysis revealed that disability, no anti-depressant drug, pressure ulcers, a higher number of associated conditions, living with another person, and biological markers of malnutrition (albumin <35g/l, transthyretin <200mg/l) and inflammation (CRP < or =30mg/l, orosomucoid > or =1.25g/l) were significantly associated with an increase in the risk of death. The logistic regression model retained CRP > or =30mg/l (odds ratio (OR)=3.72, 95% confidence interval (CI)=1.34-10.31; p=0.009) and disability for at least one ADL item (OR=2.16, 95% CI=1.55-2.99; p<0.001) as independent risk factors for death. We conclude that CRP and disability are strong independent risk factors for death in this population, and special attention should be paid to these patients in an integrated therapeutic approach to geriatric care.

Citrulline Supplementation Induces Changes in Body Composition and Limits Age-Related Metabolic Changes in Healthy Male Rats

BACKGROUND Aging is associated with profound metabolic disturbances, and citrulline may be of use to limit them. OBJECTIVE The aim of this work was to evaluate the long-term effect of citrulline supplementation on metabolism in healthy aged rats. METHODS Twenty-month-old male rats were randomly assigned to be fed (ad libitum) for 12 wk with either a citrulline-enriched diet (1 g ⋅ kg(-1) ⋅  d(-1)) or a standard diet [rendered isonitrogenous by addition of nonessential amino acids (NEAAs)]. Motor activity and muscle strength were measured, body composition was assessed, and muscle metabolism (protein structure, mitochondrial exploration, and transductional factors) and lipid metabolism (lipoprotein composition and sensitivity to oxidative stress) were explored. RESULTS Compared with the NEAA-treated group, citrulline supplementation was associated with lower mortality (0% vs. 20%; P = 0.05), 9% higher lean body mass (P < 0.05), and 13% lower fat mass (P < 0.05). Compared with the NEAA-treated group, citrulline-treated rats had greater muscle mass (+14-48% depending on type of muscle; P < 0.05 for tibialis, gastrocnemius, and plantaris). Susceptibility to oxidation of lipoproteins, as measured by the maximal concentration of 7-ketocholesterol after copper-induced VLDL and LDL oxidation, was lower in citrulline-treated rats than in NEAA-treated rats (187 ± 8 μmol/L vs. 243 ± 7 μmol/L; P = 0.0005). CONCLUSIONS Citrulline treatment in male aged rats favorably modulates body composition and protects against lipid oxidation and, thus, emerges as an interesting candidate to help prevent the aging process.

Catalase rs769214 SNP in elderly malnutrition and during renutrition: is glucagon to blame?

Impaired glucose tolerance is common during aging. The transcription factor PAX6 is involved in glucose homeostasis. Computational promoter sequence analysis of the catalase gene highlighted a putative PAX6 binding site on the rs769214 polymorphism A allele. Creation of this binding site has been suggested to explain renutrition inefficiency in malnourished elderly patients. Our aim was to evaluate the link between the rs769214 polymorphism of the catalase gene and glucose homeostasis in malnourished elderly patients at inclusion and during renutrition. Thirty-three malnourished elderly Caucasian inpatients were recruited. Nutritional and inflammatory statuses were assessed and a multiplex adipokine analysis was conducted at inclusion and discharge from the Geriatric Nutritional Care Unit at Charles-Foix Hospital (Ivry-sur-Seine, France). Serum glucagon, PAI-1, and TNF-α levels were significantly lower in the A-allele carriers at inclusion. During renutrition, A-allele carriers exhibited increased serum glucagon, PAI-1, and TNF-α variation. After renutrition, levels of these parameters were similar for A-allele carriers and G-allele carriers. A logistic ordinal multivariate regression analysis linked only variation of glucagon to rs769214 SNP. These results support a role for catalase SNP in the efficiency of renutrition in malnourished elderly patients via the modulation of glucagon secretion, probably involving PAX6.

Interest and limits of glomerular filtration rate (GFR) estimation with formulae using creatinine or cystatin C in the malnourished elderly population

Renal function is often altered in elderly patients. A lot of formulae are proposed to estimate GFR to adjust drug posology. French guidelines recommend the Cockcroft-Gault formula corrected with the body surface area (cCG), but the initially described unadjusted Cockcroft-Gault equation (CG) is mainly used in geriatric clinical practice. International recommendations have proposed the modification of diet in renal disease (MDRD) formula, since several authors recommended the Rule formula using cystatin C (cystC) in particular population. To appreciate the most accurate GFR estimation for posology adaptation in an elderly polypathological population, a cross-sectional study with prospective inclusion was carried out in Charles Foix Hospital. Plasma glucose levels (PGL), creatinine (CREA) levels and serum cystC, albumin (ALB), transthyretin (TTR), C-reactive protein (CRP), orosomucoid (ORO) total cholesterol (tCHOL) levels were determined among 193 elderly patients aged 70 and older. The results showed that in a malnourished, inflamed old population, CG, MDRD and Rule formulae resulted in different estimations of GFR, depending on nutritional and inflammatory parameters. Only cCG estimation was shown to be independent from these parameters. To conclude, cCG seems to be the most accurate and appropriate formula in a polypathological elderly population to evaluate renal function in order to adapt drug posology.

Fruit and vegetable intake in older hospitalized patients.

Purpose of reviewRegular intake of fruit and vegetables (F&Vs) has been widely recommended to improve the health of the population. Observational studies show a preventive effect of long-term consumption of adequate nutrients on cancer, diabetes, dementia and other age-related diseases. However, the short-term impact of F&V intake in more specific populations has been under-researched. In the hospital setting, economic choices and logistic problems result in poor quality of food in general, and particularly in fresh F&Vs. As hospital geriatricians, we set out to address the issue of F&V intake in elderly hospitalized patients, for whom we felt F&Vs might be beneficial in association with a protein and energy-dense diet. Recent findingsIn the community and in nursing homes, F&V consumption is associated with better overall food intake and improved quality of life in older patients. SummaryGeneral inspection of the literature suggests that F&Vs may be beneficial to elderly hospitalized patients, but no clinical studies have been conducted. There is a need to address the question of the impact of improved quality and quantity of F&Vs on quality of life, total food intake and constipation, particularly in hospitalized elderly patients who often stay in hospital for long periods. Positive results might help to promote F&V consumption in diverse populations, with the objective of improving eating pleasure for better health.

Graft healing after extensive necrotizing fasciitis of the leg in an 85-year-old man

Dear Editor, In this letter we would like to share the experience of the management of a necrotizing fasciitis (NF) in an elderly patient. NF is a group of rare and life-threatening bacterial infections characterized by widespread necrosis of the subcutaneous tissue and fascia, vascular occlusions, and ischemia. The first case was described by Wilson in the 1950s. Type 2 diabetes and older age are established risk factors for this condition. Many NF patients are found to be using non-steroidal antiinflammatory drugs. Mortality rates range from 25–70%, depending on prognostic factors, such as older age, female sex, rate of necrosis extension, hemodynamic failure or pre-existing cardiovascular condition. Mortality can also be associated with biological markers, such as hypoalbuminemia. Accurate early diagnosis and surgical intervention combined with administration of appropriate parenteral antibiotics remain the cornerstones of NF treatment. Clinical descriptions in very elderly or highly comorbid patients are uncommon. The benefit–risk ratio for this aggressive – but necessary – therapeutic approach results in an undertreatment of NF, hence increased mortality. Furthermore, there are middle-term outcomes to consider, such as wound healing, nutritional assistance, pain and functional management. These issues typically require a multidimensional management approach, and collaboration between plastic surgeons, anesthetists and geriatricians. The following case report aimed to examine the different steps of treatment with a focus on the healing procedure that might not be widely known by geriatricians. Mr S is an 85-year-old Sri-Lankan man with a history of type 2 diabetes, hypertension and myocardial infarction. He used to live alone with visits from a nurse to administer his medication, and he used a walking stick. Mr S was admitted to the Bichat Hospital intensive care unit for septic shock. He had been reporting intense pain in the left lower limb for a couple of days, and had self-medicated with an emulsion comprising a non-steroidal anti-inflammatory. The diagnosis of NF was immediately suspected and quickly confirmed as he immediately underwent surgery. The pathology examination of the excised tissues confirmed the extensive infection with necrosis resulting in dissociation between muscular fascia and connective adipose tissue. The microbiological test on surgical biopsies was positive for group A Streptococcus. Extensive surgical excision of all the cutaneous and subcutaneous tissues of the left leg was carried out (Fig. 1a), and ad-hoc intravenous antibiotherapy was prescribed. After 11 days, the patient was referred to our acute geriatric care unit. The first concern to address was management of the large, circumferential, degloving wound of the lower limb. Spontaneous healing did not appear a possible option, and the wound was already extremely painful. High daily doses of morphine resulted in delirium and hallucinations. We finally opted for a tailored surgical approach with cutaneous grafts to accelerate recovery. Three procedures of excision and split-thickness skin grafts harvested on the anterior face of the thigh were completed to cover most of the leg. Graft adherence and viability were good, despite the persistence of localized wounds (Fig 1b). The patient’s general condition and nutritional status were in fast decline, with baseline plasma albumin concentration dropping as low as 14 g/L. Furthermore, Mr S experienced recurrent episodes of delirium. In postacute care, the patient was treated by daily dressing

ESPEN Guideline on clinical nutrition and hydration in geriatrics

BACKGROUND Malnutrition and dehydration are widespread in older people, and obesity is an increasing problem. In clinical practice, it is often unclear which strategies are suitable and effective in counteracting these key health threats. AIM To provide evidence-based recommendations for clinical nutrition and hydration in older persons in order to prevent and/or treat malnutrition and dehydration. Further, to address whether weight-reducing interventions are appropriate for overweight or obese older persons. METHODS This guideline was developed according to the standard operating procedure for ESPEN guidelines and consensus papers. A systematic literature search for systematic reviews and primary studies was performed based on 33 clinical questions in PICO format. Existing evidence was graded according to the SIGN grading system. Recommendations were developed and agreed in a multistage consensus process. RESULTS We provide eighty-two evidence-based recommendations for nutritional care in older persons, covering four main topics: Basic questions and general principles, recommendations for older persons with malnutrition or at risk of malnutrition, recommendations for older patients with specific diseases, and recommendations to prevent, identify and treat dehydration. Overall, we recommend that all older persons shall routinely be screened for malnutrition in order to identify an existing risk early. Oral nutrition can be supported by nursing interventions, education, nutritional counseling, food modification and oral nutritional supplements. Enteral nutrition should be initiated if oral, and parenteral if enteral nutrition is insufficient or impossible and the general prognosis is altogether favorable. Dietary restrictions should generally be avoided, and weight-reducing diets shall only be considered in obese older persons with weight-related health problems and combined with physical exercise. All older persons should be considered to be at risk of low-intake dehydration and encouraged to consume adequate amounts of drinks. Generally, interventions shall be individualized, comprehensive and part of a multimodal and multidisciplinary team approach. CONCLUSION A range of effective interventions is available to support adequate nutrition and hydration in older persons in order to maintain or improve nutritional status and improve clinical course and quality of life. These interventions should be implemented in clinical practice and routinely used.

PP054-SUN: Immunonutrition: Effect of age on Arginine and Related Amino Acids Systemic Bioavailability After Surgical Stress

gastrointestinal disorders. However, inappropriate chronic exposure and/or prescription have been recently associated with a number of adverse events, especially in the elderly. Among known drug-class effects of PPI, hypomagnesaemia has been recently shown by a growing number of case reports and series. However, epidemiological studies addressing this topic, especially in older subjects, are still needed. Methods: We cross-sectionally investigated the relationship between PPI use and magnesium status in a large cohort of community-dwelling older volunteers from the Baltimore Longitudinal Study of Aging (BLSA). 4017 older subjects 65 years or older (1983 women and 2034 men) with complete data on serum magnesium levels and PPI use were evaluated. Subjects were categorized according to PPI use. Linear regression models adjusted for age and sex (Model 1) and for additional confounders including BMI, mineral and magnesium supplements, creatinine, calcium serum levels, TSH, use of diuretics, digitalis, antibiotics, calcineurin inhibitors, presence of chronic disease (type 2 diabetes, cardiovascular diseases, cancer) (Model 2) were used to address the relationship between PPI use and serum magnesium levels. Results: 505 subjects (12.6%) were PPI users. After adjustment for age and sex, PPI users exhibited significantly lower magnesium levels than non-users counterpart (1.99±0.22 vs 2.03±0.20mg/ml, p < 0.001). PPI use was negatively associated with serum magnesium levels independent of multiple confounders ( 0.041±0.009, p < 0.0001). Conclusion: In community-dwelling older subjects the use of PPIs is negatively and independently associated with serum magnesium levels.