Melinda M. Bopp

Protein‐Energy Undernutrition and the Risk of Mortality Within One Year of Hospital Discharge: A Follow‐Up Study

OBJECTIVE: The primary objective of this study was to confirm the results of a previous study that demonstrated a strong independent correlation between the severity of protein‐energy undernutrition and the risk of 1‐year postdischarge mortality in a population of older rehabilitation patients.

Protein-energy undernutrition and Life-threatening complications among the hospitalized elderly

AbstractOBJECTIVE: 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.

Nightly enteral nutrition support of elderly hip fracture patients: a phase I trial.

OBJECTIVE This non-blinded randomized controlled trial was the first phase of a planned series of investigations designed to test the efficacy of aggressive post-operative enteral nutrition support to decrease the rate of post-operative complications or improve long-term outcomes in specifically defined subgroups of elderly patients who have sustained a hip fracture requiring surgery. METHODS Eighteen patients (17 males) were randomized to the treatment (eight male subjects) or control groups. The control group (mean age 76.5+/-6.1 years) received standard post-operative care. Subjects in the treatment group (mean age 74.5+/-2.1 years) received 125 cc/hour of nasoenteral tube feedings over 11 hours each night in addition to standard post-operative nutritional care. RESULTS Both the treatment and control groups had reduced volitional nutrient intakes for the first 7 post-operative days (3,966+/-2,238 vs. 4,263+/-2,916 kJ/day [948+/-535 vs. 1019+/-697 kcal/day], p=0.815), but the treatment subjects had a greater total nutrient intake (7,719+/-2,109 vs. 4,301+/-2,858 kJ/day [1845+/-504 vs. 1028+/-683 kcal], p=0.012). On average, treatment subjects were tube fed for 15.8+/-16.4 days. There was no difference between the groups (treatment vs. controls) in the rate of post-operative life-threatening complications (25 vs. 30%, p=1.00) or in-hospital mortality (0 vs. 30%, p=0.216). Mortality within 6 months subsequent to surgery was lower in the treatment group compared to the controls (0 vs. 50%, p=0.036). DISCUSSION We conclude that nightly enteral feedings are a safe and effective means of supplementing nutrient intake. The greatest impact of nutrition support may be to reduce mortality.

Wii-Fit for Improving Gait and Balance in an Assisted Living Facility: A Pilot Study

Objectives. To determine the effects on balance and gait of a Wii-Fit program compared to a walking program in subjects with mild Alzheimers dementia (AD). Methods. A prospective randomized (1 : 1) pilot study with two intervention arms was conducted in an assisted living facility with twenty-two mild AD subjects. In both groups the intervention occurred under supervision for 30 minutes daily, five times a week for eight weeks. Repeated measures ANOVA and paired t-tests were used to analyze changes. Results. Both groups showed improvement in Berg Balance Scale (BBS), Tinetti Test (TT) and Timed Up and Go (TUG) over 8 weeks. However, there was no statistically significant difference between the groups over time. Intragroup analysis in the Wii-Fit group showed significant improvement on BBS (P = 0.003), and TT (P = 0.013). The walking group showed a trend towards improvement on BBS (P = 0.06) and TUG (P = 0.07) and significant improvement in TT (P = 0.06). Conclusion. This pilot study demonstrates the safety and efficacy of Wii-Fit in an assisted living facility in subjects with mild AD. Use of Wii-Fit resulted in significant improvements in balance and gait comparable to those in the robust monitored walking program. These results need to be confirmed in a larger, methodologically sound study.

Effects of Muscle Strength Training and Megestrol Acetate on Strength, Muscle Mass, and Function in Frail Older People

OBJECTIVES: To determine the independent and combined effects of progressive resistance muscle strength training (PRMST) and megestrol acetate (MA) on strength, muscle mass, and function in older recuperative care patients.

Progressive resistance muscle strength training of hospitalized frail elderly.

Sullivan DH, Wall PT, Bariola JR, Bopp MM, Frost YM: Progressive resistance muscle strength training of hospitalized frail elderly. Am J Phys Med Rehabil 2001;80:503–509. ObjectiveTo determine whether frail elderly patients recuperating from acute illnesses could safely participate in and gain appreciable improvement in muscle strength from progressive resistance muscle strength training. DesignMuscle strength (one repetition maximum), functional abilities (sit-to-stand maneuver and 20-sec maximal safe gait speed), and body composition were measured before and at the conclusion of a 10-wk program of lower limb progressive resistance muscle strength training. The nonrandomized study was conducted in a 30-bed geriatric rehabilitation unit of a university-affiliated Veterans Affairs hospital and a 28-bed transitional care unit of a community nursing home. Participants included 19 recuperating elderly subjects (14 male, 5 female; 13 ambulatory, 6 nonambulatory) >64 yr (mean age, 82.8 ± 7.9 yr). ResultsThe one repetition maximum increased an average of 74% ± 49% (median, 70%; interquartile range, 38%–95%, and an average of 20 ± 13 kg (P = 0.0001). Sit-to-stand maneuver times improved in 15 of 19 cases (79%). Maximum safe gait speeds improved in 10 of 19 cases (53%). Four of the six nonambulatory subjects progressed to ambulatory status. No subject experienced a complication. ConclusionsA carefully monitored program of progressive resistance muscle strength training to regain muscle strength is a safe and possibly effective method for frail elderly recuperating from acute illnesses. A randomized control study is needed to examine the degree to which progressive resistance muscle strength training offers advantages, if any, over routine posthospital care that includes traditional low-intensity physical therapy.

Hypoalbuminemia 3 Months After Hospital Discharge: Significance for Long‐Term Survival

Objectives: To determine change in albumin from hospital discharge to 3‐month follow‐up and the prognostic significance of persistent hypoalbuminemia in older veteran patients.

Nightly Enteral Nutrition Support of Elderly Hip Fracture Patients: A Pilot Study

Objectives: Assess whether postoperative nightly enteral nutrition support improves outcomes of elderly patients with an acute hip fracture Design: Randomized controlled trial Setting: A University and a Department of Veteran’s Affairs Hospital Subjects: Adults >64 years of age who underwent surgical repair of an acute hip fracture Interventions: Subjects randomized to the control (Ctrl) group received standard care while the treatment (Tx) group received standard care plus up to 1,375 Kcal [5,755 kJ/d] of nasoenteral tube feedings each night. When tube feedings had to be discontinued, Tx subjects were asked to drink an equivalent amount of the nutritional supplement each night. Measures of Outcome: Rate of postoperative complications and 6-month postoperative survival Results: Fifty-seven patients were randomized to the Tx (n = 27, mean age 75.9 ± 7.4 yrs) or Ctrl groups (age 81.7 ± 7.7 yrs). All subjects had reduced volitional nutrient intakes after surgery. During the first week subsequent to surgery, there was no difference between the treatment and control groups in the amount of nutrients that they volitionally consumed during the day. However, the treatment subjects had a greater total daily nutrient intake (Median 5,866 (IQR 5,024 to 7,335) kJ/d vs. 3,965 (IQR 2,968 to 4,664) kJ/d, p < 0.001). However, by the second postoperative week this difference was no longer statistically significant. Intolerance to the tube feedings developed commonly. There was no difference between the groups in the rate of postoperative life-threatening complications or mortality within six months subsequent to surgery. Conclusions: This study failed to confirm findings from a prior study of improved postoperative survival with nutrition support. However, it was conducted on multiple hospital wards which may have contributed to the higher rate of tube-related problems and less nutrient delivery signifying the need for further study.

Body Weight Change and Mortality in a Cohort of Elderly Patients Recently Discharged from the Hospital

Objectives: To evaluate the prognostic significance of weight change in frail elderly patients.

Changes in Prealbumin, Nutrient Intake, and Systemic Inflammation in Elderly Recuperative Care Patients

OBJECTIVES: To determine the relationship between prealbumin, nutrient intake, and indicators of inflammation for recuperative and rehabilitative care patients.