Zekeriya Ulger

Malnutrition in Turkish nursing homes: A correlate of short term mortality

ObjectiveElderly nursing home residents are under high risk of malnutrition. Early interventions to prevent malnutrition may play a critical role in malnutrition-mortality correlation. This study aimed to obtain insight into the prevalence of malnutrition in nursing homes in the capital city of Turkey and the role of malnutrition in predicting the risk for short-term mortality.DesignThis study was conducted in seven different residential care facilities in Ankara.MeasurementsNutritional status was evaluated by Mini Nutritional Assessment-Short Form.ResultsThe mean age of the 534 participants was 79.46±7.22 years. Nutritional assessment revealed that 15.9% of all older adults suffered from malnutrition and another 53.6% were at risk of malnutrition. The mortality rate for all subjects was 118 (22.1%) over 18 months, which was significantly higher in participants with malnutrition.ConclusionsWe noted a high prevalence of malnutrition and a strong correlation of increased mortality with malnutrition in nursing home residents. Given the negative impact of malnutrition on mortality and morbidity, an emphasis should be placed on an effective nutritional policy in nursing homes.

Association of Bioelectrical Impedance Analysis–Derived Phase Angle and Sarcopenia in Older Adults

Background: Sarcopenia is an important problem for older adults, leading to morbidity and mortality; therefore, early detection with a precise method is essential. We aimed to investigate the role of bioelectrical impedance analysis–derived phase angle as a determinant of sarcopenia. Materials and Methods: A cross section of 263 community-dwelling and hospitalized older adults (>65 years) were assessed in terms of sarcopenia with bioelectrical indices and anthropometric measurements. Sarcopenic and nonsarcopenic groups were compared, and significant determinants of sarcopenia were further analyzed with multivariate logistic regression analysis. Results: Forty patients were diagnosed with sarcopenia. The following were significant correlates of sarcopenia: female sex, low weight/height, low body mass index, decreased muscle strength, low calf circumference, low skeletal muscle mass/index, high impedance at 50 kHz, a history of hypertension, worse nutrition status, and low phase angle. Diagnostic parameters with well-known association were omitted, and sex, height, weight, body mass index, creatinine, nutrition status, phase angle, impedance at 50 kHz, and hypertension category were included in regression analysis. The following were independent associated factors with sarcopenia: phase angle (odds ratio [OR]: 0.59, 95% confidence interval [95% CI]: 0.40–0.87, P = .008), body mass index (OR: 0.84, 95% CI: 0.77–0.93, P = .001) impedance at 50 kHz (OR: 1.010, 95% CI: 1.006–1.015, P < .001), and height (OR: 0.93, 95% CI: 0.88–0.97, P = .001). Receiver operating characteristic analysis revealed that the optimal phase angle cutoff value to detect sarcopenia was ⩽4.55º. Conclusions: Bioelectrical phase angle can be useful for diagnosis of sarcopenia.

A letter on the canadian emergency department study

only diffuse slow waves could be detected. Valproate was stopped because she experienced valproate-induced hyperammonemia. Because of the acute illness and dementia, oral intake remained poor, and tube feeding was required. Weaning of tube feeding was to be considered on follow-up. NCSE is described as a change in mental processes and behavioral disturbances with continuous epileptiform discharges on EEG without major motor signs. It is likely that it is due to previous silent infarcts and underlying Alzheimer’s disease. Time from symptom onset to treatment of 12 days and from admission to treatment of 5 days are close to the recently reported durations in a retrospective review of NCSE in a major hospital. Diagnosis of NCSE is challenging especially in elderly adults because it can mimic delirium and such patients can easily have a CAM score of 3 or greater, which is suggestive of delirium. It can also mimic behavioral and psychiatric disturbances in elderly adults with underlying dementia. The current case illustrates how NCSE could present as “refusal to eat,” a common problem in older adults with dementia. The clues to NCSE in this case were the history of generalized tonic– clonic convulsions, impaired mental status, and subtle ocular movement abnormalities. In individuals in whom there is high clinical suspicion of NCSE but unremarkable initial EEG, continuous EEG should be considered because 50% of NCSE can be detected only using continuous EEG. Common etiologies of NCSE include intracranial infection (60%), metabolic disturbances (20%), and severe systemic infections (8%). There is limited evidence that NCSE can lead to permanent neurological damage. In a recent retrospective review involving 34 individuals with NCSE, 26.5% recovered, 50% had partial improvement, and 23.5% did not recover or died. NCSE can also result in other complications in elderly adults, including pneumonia and falls. In conclusion, an elderly adult with underlying dementia with NCSE can present as “refusal to eat.” Clinicians should pay attention to the history of seizures and subtle clinical signs to arrive at an early diagnosis of NCSE, which is treatable.

Can We Equate All Proton Pump Inhibitors with One Another

To the Editor: In response to our study on the diagnostic challenges of distinguishing protracted from new-onset delirium, Alici raises two important questions for research on the persistence of delirium: use of the Confusion Assessment Method (CAM) for assessing the presence of persistent delirium and frequency of reassessments. As for the CAM, use of the question “Is there evidence of an acute change in mental status from baseline” is potentially problematic for two reasons. First, the question does not specify which baseline the interviewer is referring to, the original baseline before admission (weeks or months earlier) or a more-recent baseline since admission. Second, it does not distinguish new-onset delirium from a fluctuation in mental state in the context of persistent delirium. The original baseline was used as the reference; most informants told the interviewer that the patient’s mental state had not been the same since admission to the hospital. Admittedly, this is an additional potential limitation of the study. There is a need to develop and validate a CAM modified to assess the persistence of delirium. As to the frequency of reassessments for persistent delirium, daily face-to-face reassessments may be feasible in hospital and postacute care settings, but they are not feasible after discharge in most healthcare systems (including our system), where patients may be dispersed over a large metropolitan area and may move to different settings during the follow-up period. It was challenging to complete even the two face-to-face reassessments described in the present study. The limited number of reassessments was, nonetheless, an acknowledged limitation of the study. Future studies of the persistence of delirium conducted in special healthcare contexts (e.g., managed care programs) may be able to conduct more-frequent reassessments over longer follow-up periods.

Effect of Multimodal Exercise Program on Physical Function, Falls, and Injuries in Older Women.

1. Sumer F, Arik G, Aycicek S et al. Study of factors associated with incomplete bladder emptying in older women. J Am Geriatr Soc 2016;64:456– 457. 2. Park J, Palmer MH. Factors associated with incomplete bladder emptying in older women with overactive bladder symptoms. J Am Geriatr Soc 2015;63:1426–1431. 3. Groutz A, Blaivas JG, Chaikin DC. Bladder outlet obstruction in women: Definition and characteristics. Neurourol Urodyn 2000;19: 213–230. 4. McCrery RJ, Appell RA. Bladder outlet obstruction in women: Iatrogenic, anatomic, and neurogenic. Curr Urol Rep 2006;7:363–369. 5. Yoshimura N, Chancellor MB. Differential diagnosis and treatment of impaired bladder emptying. Rev Urol 2004;6(Suppl 1):S24–S31. 6. Shakeri S, Rasekhi AR, Yazdani M et al. The incidence of diverticula of urinary bladder in patients with benign prostatic hypertrophy and the comparison between cystoscopy and cystography in detecting bladder diverticula. Iran Red Crescent Med 2007;9:36–41. 7. Prakash, Rajini T, Bhardwaj AK et al. Urinary bladder diverticulum and its association with malignancy: An anatomical study on cadavers. Rom J Morphol Embryol2010;51:543–545. 8. Echaiz JF, Cass C, Henderson JP et al. Low correlation between self-report and medical record documentation of urinary tract infection symptoms. Am J Infect Control 2015;43:983–986. 9. Giesen LG, Cousins G, Dimitrov BD et al. Predicting acute uncomplicated urinary tract infection in women: A systematic review of the diagnostic accuracy of symptoms and signs. BMC Fam Pract 2010;11:78.

Only Frailty? What About Other Factors Affecting Cognition?

1. Naharci MI. Associations between inflammation and cognitive function in African Americans and European Americans. J Am Geriatr Soc 2015;63:1279–1280. 2. Windham BG, Simpson BN, Lirette S et al. Associations between inflammation and cognitive function in African Americans and European Americans. J Am Geriatr Soc 2014;62:2303–2310. 3. Fried LP, Tangen CM, Walston J et al. Frailty in older adults: Evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001;56A:M146– M156. 4. Studenski S, Perera S, Patel K et al. Gait speed and survival in older adults. JAMA 2011;305:50–58.

FMF and Sjogren's Syndrome Overlap in an Elderly Patient: A Rare Coincidence or a Causal Association?

Sixty five-year-old female patient admitted to our clinic with complaint of intermittent fever and abdominal pain for forty years. We learned that she has mouth and eye dryness. Laboratory examination revealed elevated levels of inflammatory parameters. In chest X-ray there was reticular appearance. Then we suspect that rheumatic diseases and serological examination revealed positive ANA and anti-centromere antibodies. Minor salivary gland biopsy was reported as ‘chronic inflammation with focus score 2’. The patient was diagnosed with Sjogren’s syndrome. Because of recurrent abdominal pain with febrile episodes, we suspect of Familial Mediterranean Fever (FMF). We detected homozygous MEFV mutation in genetic mutation analysis and then FMF was diagnosed. In literature, this is the first case, coincidence of Sjogren’s syndrome and FMF, in the geriatric age group and the second case in all age groups.

Is it possible using handgrip strength instead of body mass index in MNA-SF test to assess the nutritional status of geriatric patients?

OBJECTIVE To explore the relationships among ethnicity/race, gender, demographics, age-group and dietary health in a nationally representative sample of older adults. DESIGN Cross-sectional study. SETTING Data for this study were collected by interview in the mobile examination centers from the National Health and Nutrition Examination Surveys, 2011 - 2012. PARTICIPANTS U.S. representative sample of adults aged 55 years and older (N = 1860) from five ethnic/racial groups. All participants read, understood, and signed informed consent forms under data collection procedures by trained individuals. MEASUREMENTS Sociodemographics were collected by trained interviewers using a general questionnaire. Food groups were determined by 24-hour recall using the validated USDA Automated Multiple-Pass Method. Data were presented by cross-tabulation and logistic regression to investigate relationships among race/ethnicity, gender, and age groups. RESULTS Over 70% of older adults failed to consume 2.75 cups of combined fruits and vegetables. Other Hispanics (Hispanics excluding Mexican Americans) had higher Odds of sugar-containing food consumption compared to non-Hispanic Whites (adjusted model). Being older and female were protective factors for over-consumption of sugar. CONCLUSION Older Americans are not meeting dietary guidelines and there are differences by gender and ethnicity. Since diet has been associated with quality of life and medical costs, public health interventions can benefit by knowing age-, gender- and racial/ethnic- specific dietary behaviors.IntroductionIn Mini-Nutritional Assessment-Short Form (MNA-SF) test, a practical and reliable alternative parameter is still necessary for patients with difficult body mass index evaluation. We aimed to show whether or not handgrip strength may be used instead of body mass index (BMI) in MNA-SF test.Materials and MethodsMNA-SF test scores, calf circumferences (CC), handgrip strength (HGS), and BMI of 191 patients were evaluated. The first one of calculated MNA-SF tests was with BMI, the second one with CC, and the last one with HGS. Zero point was given if CC was <31 cm and 3 points were given if CC was ≥31 cm. Zero, 1, 2, and 3 points were given if the loss of HGS when compared to expected HGS were ≥%60, from ≥%30 to <%60, from ≥%10 to <%30, and <%10 or greater than expected HGS, respectively. MNA-SF scores and nutritional status according to these three measures were compared.ResultsMean age and median MNA-SF scores of the patients were 75±7.6 years and 12 points (min-max: 0-14) respectively. There were strongly positive correlations between MNA-SF scores with BMI and CC, with BMI and HGS, and with CC and HGS (r=0.938 p<0.001, r=0.938 p<0.001, r=0.914 p<0.001, respectively). Substantial agreement in nutritional status of the patients were seen between MNA-SF groups with BMI and CC, with CC and HGS, and with BMI and HGS (kappa: 0.795 p<0.001, kappa: 0.709 p<0.001, and kappa: 0.760 p<0.001, respectively).ConclusionsHGS might be considered instead of BMI in MNA-SF test to assess nutritional status of geriatric patients.

Study of Factors Associated with Incomplete Bladder Emptying in Older Women

bump in the HSA literature in 2014. Friedman and colleagues suggest that, with the burgeoning older population, an increased focus on fostering better aging trajectories is warranted but has yet to reach its full potential. We completely agree. That said, the HSA paradigm faces challenges that the frailty paradigm does not in terms of scope (including biomedical and psychosocial components) and conceptualization (absence of a consensus definition). There are many constituent components of HSA, capturing components similar to frailty (e.g., physiological functioning and reserve), as well as psychosocial components (e.g., social engagement and psychological well-being), but it is encouraging that HSA research is keeping pace with frailty and that both are on the rise. Further articulation of the HSA literature and greater focus on fostering better aging trajectories can ensure that the discipline ages well.

P-467: Is frailty a prognostic factor for critically ill elderly patients?

Aim The study aimed to investigate the effects of frailty on clinical outcomes of patients in an intensive care unit (ICU).