G. Schlierf

Nutritional support and functional status in undernourished geriatric patients during hospitalization and 6-month follow-up.

The objective of this study, designed as a randomized controlled prospective intervention study, was to evaluate the effect of nutritional supplementation on functional status and need of care in undernourished geriatric patients during hospitalization, and up to 6 months after discharge. Participants consisted of 46 undernourished geriatric patients from a geriatric acute care hospital aged 75 years or older without malignant disease, or need for tube feeding or parenteral nutrition. Patients in the supplement group (SG, N=20) were offered 400 mL (2100 kJ) daily of a liquid supplement during hospital stay and 200 mL (1050 kJ) per day for the following 6 months at home. Patients in the control group (CG, N=26) had usual care without supplements. The main outcome measure was functional status based on the Barthel Activities of Daily Living score (ADL) at hospital admission, discharge and after 6 months, with higher scores indicating greater independence and a maximum score of 100 points. In supplemented patients with good acceptance (SG+, N=11), a median improvement of 20 points was observed between admission and discharge, and a further improvement of 5 points at home. Median changes were 0 and −10 points in supplemented patients with poor acceptance (SG-, N=9) and 5 and 2.5 points in CG, respectively. In SG+, the proportion of independent patients (>65 points) increased continuously from 36% at admission to 63% at discharge, to 72% after 6 months, and was significantly higher compared to CG at discharge (63% vs 19%, pš 0.05) and after 6 months (72% vs 39%, p<0.05). 64% of the patients in SG+ improved during hospitalization, compared to 23% in CG (p<0.05). In the six months at home, 18% of SG+ improved; none of SG+ deteriorated in hospital or at home. In contrast, deterioration of the ADL score occurred in considerable proportions of SG− (22% in hospital, 22% at home) and CG (4% at hospital, 12% at home) patients. The proportion of patients who improved was smaller in SG− (44% at hospital, 22% at home) as well as in CG (23% at hospital, 35% at home), compared to SG+. In conclusion, a positive functional course was evident in supplemented patients with good acceptance during hospitalization, and further improvement was observed during the following 6 months at home. Nutritional support may contribute to reconvalescence and recovery of undernourished geriatric patients.

Prospective value of self-report and performance-based tests of functional status for 18-month outcomes in elderly patients.

To determine predictors of death, nursing home placement and hospital admission, a prospective study was carried out in a university-affiliated geriatric hospital and a general practice. One hundred and thirty-five patients consecutively admitted from home to the geriatric hospital and discharged home again (site 1), and 144 patients, aged 70 years and over, of a general practice (site 2) were recruited for a comprehensive geriatric assessment program. At baseline, none was completely dependent on others, or severely demented. At follow-up after 18 months, 46 subjects (17%) had died, 20 subjects (7%) had been institutionalized, and 79 had been admitted to hospital (28 %) in the interim. Univariate analysis demonstrated a significant association between Barthel Activities of Daily Living (ADL), Lawton-Brody Instrumental Activities of Daily Living (IADL), Mini-Mental State Examination (MMSE), Balance and Gait Evaluation, Timed “Up and Go”, Timed Test of Money Counting, Grip-Strength and Williams Board Test, and death as well as nursing home placement. Barthel-ADL were significantly correlated with hospital admission. In a logistic regression analysis, Barthel-ADL were independent predictors for death; Barthel-ADL, Timed “Up and Go”, Timed Test of Money Counting, and Williams Board Test were independent predictors for nursing home placement. No independent predictor was found for hospital admission. It is concluded that self-report and performance-based measures of functional capabilities are useful instruments to identify patients at risk for nursing home placement and death. Factors contributing to hospital admissions are other than those measured by the applied tests.

Drug-prescribing patterns in old age : a study of the impact of hospitalization on drug prescriptions and follow-up survey in patients 75 years and older

SummaryA prospective drug surveillance study was undertaken in 300 elderly patients admitted to a geriatric clinic. Prescribing patterns were determined on admission, at discharge and 3, 6 and 18 months after discharge.Patients referred from long-term care institutions were on significantly more drugs than non-institutionalized subjects. A 34% reduction in the number of medicines prescribed at discharge was accompanied by a significant decrease in the mean number of prescriptions per patient, from 4.3 to 2.8, irrespective of whether the patient was institutionalized. Polypharmacy, defined by 5 or more concomitant drugs, declined from 43 to 17%.Dosage schedules were simplified in the majority of patients, as expressed by a significant decrease in the mean number of daily doses to be taken from 6.7 on admission to 4.4 at discharge. Cardiovascular drugs, diuretics and psychotropic drugs accounted for 64% of all drug prescriptions. At discharge, prescription frequencies were reduced for most medication categories, except diuretics and gastrointestinal drugs, which were being taken more often. The prescribing frequency of cardiac glycosides, the single most frequently prescribed drug class, decreased from 60 to 33% of the patients.Three months after discharge, prescribing patterns and frequencies were found to be very similar to the pre-admission situation. Eighteen months after discharge, overall drug use had increased by 15% compared to admission, and polypharmacy was recorded in 54% of patients.It is concluded that a substantial reduction in drug prescriptions was possible in the majority of elderly patients, particularly if they are institutionalized, on admission to a geriatric clinic. However, modification of therapy, including individualization of dosages and simplification of regimens, initiated by the hospital, were either not maintained for a period of 3 months, or the recommendations of the hospital physicians had little influence on the prescribing habits of general practitioners.Further studies to be done on a long-term basis appear to be worthwhile in order to analyse the determinants of drug use and the circumstances pulting old people at risk of polypharmacy. The problem is not restricted to nursing-home residents.

Mitigation of alimentary lipemia by postprandial exercise-Phenomena and mechanisms

The effects of a single bout of exercise at 40% of maximum aerobic capacity with regard to alimentary lipemia and postprandial lipoproteins was studied in a cross-over design in 12 young healthy male volunteers. In addition to lipids and lipoproteins, lipoprotein lipase, free glycerol, free fatty acids, plasma insulin, and C-peptide concentrations were quantitated. Postprandial exercise reduced alimentary lipemia by 34% while lipoprotein lipase activity rose by 42%. The postprandial fall of high-density lipoprotein (HDL)3 was abolished and the rise of HDL2 accentuated. Free glycerol and free fatty acid concentrations were higher following the meal plus exercise regimen compared to the meal alone. It is concluded that at least part of the chronic effect of exercise may come from additive effects such as observed from individual bouts of muscular activity.

Sitosterol in juvenile type II hyperlipoproteinemia

The effect of beta-sitosterol on plasma lipids and lipoproteins was evaluated in a randomized double-blind cross-over trial in 15 children and adolescents with familial hypercholesterolemia over a period of 6 months. Twelve patients completed the study, with good adherence to drug intake. Sitosterol lowered the plasma total choelsterol by 6%, LDL cholesterol by 7% and HDL cholesterol by 15% (P less than 0.05). This insufficient response of total and LDL cholesterol and the marked fall of HDL cholesterol appears to advise against the use of beta-sitosterol granulate in juvenile type II hyperlipoproteinemia.

Adrenergic regulation of lipolysis in abdominal adipocytes of obese subjects during caloric restriction: reversal of catecholamine action caused by relief of endogenous inhibition.

Abstract. The effects of adrenaline, noradrenaline, and of the α2‐ and β‐selective agonists clonidine and isoproterenol were studied in fifteen obese subjects before and after 4 weeks of caloric restriction (300 cal day‐1). Basal glycerol release averaged 1·4 μmol (106 cells)‐1 (180 min)‐1 before starvation and 2·8 μmol (106 cells)‐1 (180 min)‐1 during starvation (P≤ 0·1). Before starvation adrenaline and noradrenaline caused a 2–3‐fold increase of glycerol release. This lipolytic effect disappeared during starvation. An inhibitory effect of adrenaline was observed instead which was maximal at an adrenaline concentration of 1 μmol 1‐1 (P≤ 0·05). The dose‐response relationships of the α2 and β‐selective agents clonidine and isoproterenol were not appreciably changed by caloric restriction.

Biliary and plasma lipids and lipid-lowering chemotherapy Studies with clofibrate, fenofibrate and etofibrate in healthy volunteers

Abstract The effects of the lipid-lowering drugs clofibrate, etofibrate and fenofibrate on plasma lipids and lipoproteins and on biliary lipid composition were compared with placebo in double-blind cross-over studies in healthy young male volunteers. Within two weeks, plasma total cholesterol and LDL cholesterol levels fell on clofibrate administration (by means of 9 and 16%) and on feno-fibrate administration (by means of 17 and 16%). The “lithogenic index” — as a measure of biliary cholesterol saturation — rose significantly with clofibrate and etofibrate, but not with fenofibrate. These results suggest that drugs with similar effects on plasma lipids and lipoproteins may affect biliary lipid composition in different ways. The risk of cholelithiasis, therefore, must be evaluated separately for each drug in question, while the final answer can only come from long-term epidemiologic studies.

Diurnal Patterns of Blood Sugar, Plasma Insulin, Free Fatty Acid and Triglyceride Levels in Normal Subjects and in Patients with Type IV Hyperlipoproteinemia and the Effect of Meal Frequency

Diurnal patterns of plasma triglycerides, free fatty acids, blood sugar and insulin were studied in 6 normal subjects and in 6 patients with the type IV hyperlipoproteinemia in order to assess the eff

Actual versus prescribed timing of lovastatin doses assessed by electronic compliance monitoring.

SummaryThe objective of the study was to compare compliance with and the hypocholesterolaemic effect of lovastatin given once daily as a morning or an evening dose. Twenty-four out-patients with familial hypercholesterolaemia were randomly assigned to receive placebo first, then lovastatin 20 mg, to be taken once daily for 4 weeks, either with the breakfast or evening meal, in a single-blind fashion.Drug compliance was assessed by pill counts and continuous electronic monitoring. Two compliance parameters were evaluated, consumption, defined as percentage of prescribed doses taken, and time compliance, the percentage of total dosing events recorded within defined intervals (6.00–10.00 h, and 17.00–21.00 h), for the morning and evening regimes.Both regimes satisfactorily reduced the total and LDL-cholesterol concentrations, and there was no significant difference in the extent of the reductions.Pill counts overestimated compliance, as revealed by the monitoring method. The times of actual consumption of doses by the patients often differed from that prescribed, predominantly in patients who were told to take the evening dose. Partial time compliance may have confounded the efficacy of the drugs. Electronic compliance monitoring appears to be particularly useful in chronopharmacological studies.

Nocturnal inhibition of lipolysis in man by nicotinic acid and derivatives

SummaryThe effect of nicotinic acid and several derivatives on the nocturnal level of free fatty acids was studied in 12 healthy young women and men. Free fatty acids are an important precursor of plasma triglycerides and their concentration is highest at night. The drugs used were nicotinic acid,β-pyridylcarbinol, mesoinositol hexanicotinate and xantinol nicotinate. The highest plasma nicotinic acid level was observed withβ-pyridyl-carbinol, but significant reduction in free fatty acids during the entire night was only achieved with inositolhexanicotinate and xantinol nicotinate. There was no correlation between the plasma levels of free fatty acids and nicotinic acid at any sampling time. If prolonged reduction in free fatty acid concentration is desired in the therapy of hyperlipidemias, the inositol and xantinol esters of nicotinic acid appear to be superior to the other preparations.