Overcoming protein-energy malnutrition in older adults in the residential care setting: A narrative review of causes and interventions

Malnutrition, in particular protein-energy malnutrition, is a highly prevalent condition in older adults, and is associated with low muscle mass and function, and increased prevalence of physical frailty. Malnutrition is often exacerbated in the residential care setting due to factors including lack of dentition and appetite, and increased prevalence of dementia and dysphagia. This review aims to provide an overview of the available literature in older adults in the residential care setting regarding the following: links between sarcopenia, frailty, and malnutrition (in particular, protein-energy malnutrition (PEM)), recognition and diagnosis of malnutrition, factors contributing to PEM, and the effectiveness of different forms of protein supplementation (in particular, oral nutritional supplementation (ONS) and protein-fortified foods (PFF)) to target PEM. This review found a lack of consensus on effective malnutrition diagnostic tools and lack of universal requirement for malnutrition screening in the residential care setting, making identifying and treating malnutrition in this population a challenge. When assessing the use of protein supplementation in the residential care setting, the two primary forms of supplementation were ONS and PFF. There is evidence that ONS and PFF increase protein and energy intakes in residential care setting, yet compliance with supplementation and their impact on functional status is unclear and conflicting. Further research comparing the use of ONS and PFF is needed to fully determine feasibility and efficacy of protein supplementation in the residential care setting.     

Malnutrition Prevalence according to the GLIM Criteria in Head and Neck Cancer Patients Undergoing Cancer Treatment

Malnutrition is highly prevalent in people with head and neck cancer (HCN) and is associated with poorer outcomes. However, variation in malnutrition diagnostic criteria has made translation of the most effective interventions into practice challenging. This study aimed to determine the prevalence of malnutrition in a HNC population according to the Global Leadership Initiative on Malnutrition (GLIM) criteria and assess inter-rater reliability and predictive validity. A secondary analysis of data available for 188 patients with HNC extracted from two cancer malnutrition point prevalence studies was conducted. A GLIM diagnosis of malnutrition was assigned when one phenotypic and one etiologic criterion were present. Phenotypic criteria were ≥5% unintentional loss of body weight, body mass index (BMI), and subjective evidence of muscle loss. Etiologic criteria were reduced food intake, and presence of metastatic disease as a proxy for inflammation. The prevalence of malnutrition was 22.6% (8.0% moderately malnourished; 13.3% severely malnourished). Inter-rater reliability was classified as excellent for the GLIM criteria overall, as well as for each individual criterion. A GLIM diagnosis of malnutrition was found to be significantly associated with BMI but was not predictive of 30 day hospital readmission. Further large, prospective cohort studies are required in this patient population to further validate the GLIM criteria.     

老年髋部骨折患者术前血清白蛋白及淋巴细胞总数改变对其预后的影响

目的：探讨术前血清白蛋白（ALB）及淋巴细胞总数（TLC）改变对老年髋部骨折预后的影响。方法回顾性地分析2006年7月至2010年12月在解放军总医院行手术治疗老年髋部骨折的640例患者的临床资料。分别于入院时检测ALB和TLC。临床随访指标包括患者住院时间、住院并发症、住院死亡率、术后3个月死亡率、术后12个月死亡率。将所得资料行多因素统计分析,评价ALB和TLC的变化对患者预后的临床意义。结果640例患者中低ALB患者283例（44.2%）,低TLC患者435例（68%）。ALB和TLC均低于正常值者,术后并发症发生率为13.3%,住院死亡率、术后3个月死亡率、术后1年死亡率分别为4.2%、6.7%、16.7%,均明显高于其他各组（P＜0.05）。多因素分析显示ALB及TLC可作为老年髋部骨折患者死亡风险的预测因素。结论老年髋部骨折患者入院时营养不良可预测术后不良临床结局, ALB及TLC可以作为患者营养不良及不良临床结局的预测因素。     

A Retrospective Analysis of Nutritional Parameters in Chronic Obstructive Pulmonary Disease between Sexes

The aim of this study was to reveal the relationships between nutritional parameters and pulmonary functions in patients with chronic obstructive pulmonary disease (COPD) in both sexes. Spirometric, laboratory, and demographic data of 450 consecutive patients were analysed retrospectively. Males had significantly greater pack-years of smoking, more severe airway obstruction, and lower body mass index (BMI). In non-smokers, BMI was significantly lower in men independent of age and pulmonary functions. Creatine kinase levels showed no correlation with any pulmonary function parameters. Serum albumin levels correlated better than BMI with pulmonary functions. In conclusion, females with COPD were maintained weight better than men.     

Body Composition Tools for Assessment of Adult Malnutrition at the Bedside

Because of the key role played by the body's lean tissue reserves (of which skeletal muscle is a major component) in the response to injury and illness, its maintenance is of central importance to nutrition status. With the recent development of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition diagnostic framework for malnutrition, the loss of muscle mass has been recognized as one of the defining criteria. Objective methods to evaluate muscle loss in individuals with acute and chronic illness are needed. Bioimpedance and ultrasound techniques are currently the best options for the clinical setting; however, additional research is needed to investigate how best to optimize measurements and minimize error and to establish if these techniques (and which specific approaches) can uniquely contribute to the assessment of malnutrition, beyond more subjective evaluation methods. In this tutorial, key concepts and statistical methods used in the validation of bedside methods to assess lean tissue compartments are discussed. Body composition assessment methods that are most widely available for practice and research in the clinical setting are presented, and clinical cases are used to illustrate how the clinician might use bioimpedance and/or ultrasound as a tool to assess nutrition status at the bedside. Future research needs regarding malnutrition assessment are identified.     

Malnutrition and Inflammation—“Burning Down the House”

A summary of my 2014 Rhoads Lecture is presented that explores our progress in understanding the complex interplay of malnutrition and inflammation. A historical perspective is provided that highlights the contributions of some of the key pioneers in the nutrition assessment field. Advances in agriculture, education, public health, healthcare, and living standards have affected traditional settings for malnutrition. The chronic disease, surgery, and injury conditions that are associated with modern healthcare are becoming prevalent settings for malnutrition. One consequence has been a growing appreciation for the contributions of inflammation to malnutrition in these clinical conditions. This recognition has driven a fresh look at how we define and think about malnutrition syndromes. An inflammatory component is included in the definitions suggested by the recent Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition consensus report that also describes characteristics recommended for the identification and documentation of malnutrition. Efforts are currently underway to evaluate the feasibility and validity of this approach. Recent advances in research highlight the profound impact of inflammation‐mediated erosion of muscle mass on clinical outcomes. Research to identify better biomarkers of inflammation and malnutrition must be a leading priority. New “omics” approaches are an especially promising avenue of biomarker investigation. Inflammation can be a good thing; let's try to keep it that way.     

Sarcopenia and Critical Illness

Sarcopenia is the age‐associated loss of lean skeletal muscle mass. It is the result of multiple physiologic derangements, ultimately resulting in an insidious functional decline. Frailty, the clinical manifestation of sarcopenia and physical infirmity, is associated with significant morbidity and mortality in the elderly population. The underlying pathology results in a disruption of the individual's ability to tolerate internal and external stressors such as injury or illness. This infirmity results in a markedly increased risk of falls and subsequent morbidity and mortality from the resulting traumatic injury, as well as an inability to recover from medical insults, resulting in critical illness. The increasing prevalence of sarcopenia and critical illness in the elderly has resulted in a deadly intersection of disease processes. The lethality of this combination appears to be the result of altered muscle metabolism, decreased mitochondrial energetics needed to survive critical illness, and a chronically activated catabolic state likely mediated by tumor necrosis factor–α. Furthermore, these underlying derangements are independently associated with an increased incidence of critical illness, resulting in a progressive downward spiral. Considerable evidence has been gathered supporting the role of aggressive nutrition support and physical therapy in improving outcomes. Critical care practitioners must consider sarcopenia and the resulting frailty phenotype a comorbid condition so that the targeted interventions can be instituted and research efforts focused.