Deficient dietary vitamin K intake among elderly nursing home residents in Hong Kong

There is strong evidence supporting the importance of vitamin K in bone health and the aetiological role of vitamin K deficiency in osteoporosis. In view of the common occurrence of osteoporosis among older subjects in Hong Kong, we have studied the dietary vitamin K intakes in 100 residents of a nursing home (43 men, 57 women; median age 81.0 years) and 88 free-living subjects attending a day care centre (13 men, 75 women; median age 71.5 years). The subjects were interviewed and the average vitamin K intake in the preceding week was estimated, using a diet recall questionnaire modified from our previous surveys of dietary patterns in local Chinese people. The median vitamin K intake was much lower in nursing home residents than in free-living subjects (4.50 vs 488.09 microg/day or 0.13 vs 8.74 microg/kg/day, P<0.001). An intake that was below the recommended daily intake was far more common among nursing home residents (86.0 vs 11.4%, P < 0.001). Among nursing home residents, there was a negative correlation between age and vitamin K intake (r = -0.217, P = 0.030), but there was a positive correlation between body weight and vitamin K intake (r = 0.244, P = 0.015). No such relationship was seen among free-living subjects. Elderly nursing home residents in this study generally had a poor dietary vitamin K intake and might therefore be predisposed to osteoporosis. The importance of green leafy vegetables as a rich source of vitamin K should be emphasised.     

Nutrient density and variation in nutrient intake with changing energy intake in multimorbid nursing home residents

Background:  The low energy intake seen in some institutionalised elderly has led to a focus on energy dense diets. The present study aimed to investigate nutrient density in the diet of nursing home residents, and calculate how changes in energy intake affect nutrient intake.
Methods:  The investigation comprised a longitudinal observational study analysing the relation between energy and nutrient intake in a general nursing home in Sweden. Food intake was weighed for 5 days every sixth month over 1.5 years and nutrient density was calculated. The 52 multimorbid residents [mean (range) age 84 (67–102) years] with three complete 5-day weighed food records were included in the study. A mixed linear model was used to calculate changes in nutrient intake with changing energy intake.
Results:  Nutrient density was adequate for vitamins A, B₁₂, thiamine, riboflavin and niacin, and low for vitamins D and E, folate, potassium, magnesium and iron. The mixed linear model showed that the fat-soluble vitamins, as well as folate and vitamin B₁₂, increased the most with increasing energy intake, whereas sodium, potassium, thiamine and selenium had the smallest increase.
Conclusions:  Nutritional density of the food should be considered when planning diets for elderly patients with poor appetite.     

Provision of small, frequent meals does not improve energy intake of elderly residents with dysphagia who live in an extended-care facility

Malnutrition and dehydration are potential consequences of dysphagia, a common swallowing disorder among elderly individuals. Providing smaller, more frequent meals has been suggested (but not demonstrated) to improve energy intake among this group. Accordingly, this study was designed to assess whether the same energy content in five vs three daily meals would improve energy intake. Thirty-seven residents of an extended-care facility, aged older than 65 years, previously evaluated for dysphagia, and receiving a texture-modified diet, agreed to participate in a crossover study with random assignment to three or five meals during an initial 4-day study period, followed by the opposite meal pattern in a second period. Six were excluded from analysis, as their medical condition deteriorated before or during the study. Food and fluids consumed by participants during each study period were weighed before and after each meal. Average energy intakes were similar between the three- and five-meal patterns (1,325+/-207 kcal/day vs 1,342+/-177 kcal/day, respectively; P=0.565); fluid intake was higher with five meals (698+/-156 mL/day) vs three (612+/-176 mL/day; P=0.003). Because offering five daily feedings did not improve energy intakes when compared with three, dietitians caring for this vulnerable group might need to consider other nutrition intervention strategies.     

Smaller but energy and protein-enriched meals improve energy and nutrient intakes in elderly patients

The purpose of the present study was to investigate if smaller but energy and protein enriched meals could improve energy and nutrient intakes in elderly geriatric patients. Ten patients, between 77 and 87 years of age were included in the study, performed at a Geriatric rehabilitation ward. The first week after inclusion, the patients were offered a three days' standard hospital menu and the second week, a three days' energy and protein-enriched menu. The consumption of food and the fluid intake were recorded using a pre-coded food record book during both the menus and analysed by the Swedish National Food Administration. The patients' energy requirements were calculated according to the Nordic Nutrition Recommendation for elderly subjects. When the standard hospital menu was offered, six patients had lower energy intake, -67 to -674 kcal/day, than the calculated energy requirements. The daily energy intake increased by 37 %, with the energy and protein-enriched menu compared with the standard hospital menu. Furthermore, the daily intake of protein, fat, carbohydrate, certain vitamins and minerals was significantly higher with the energy and protein-enriched menu compared with the standard hospital menu. CONCLUSION: This study showed that the intake of energy and nutrients increased with the energy and protein-enriched menu in elderly patients on a geriatric rehabilitation ward.     

Update on diabetes in the elderly and in nursing home residents

Diabetes is common in the elderly population and in nursing home residents. More than 20% of adults aged 65 to 75 years and 40% of adults older than 80 years suffer from diabetes. Physiological changes in elderly individuals, such as decreased physical activity, abdominal obesity, and increased inflammatory state, increase insulin resistance in peripheral tissue and reduce glucose-dependent insulin release, leading to carbohydrate intolerance and diabetes. The clinical presentation in the elderly and nursing home residents is frequently guided by the high rate of comorbidities such as hypertension, depression, and cardiovascular diseases. Treatment recommendations for glycemic control in elderly ambulatory patients are similar to those in long-term care facilities. Healthy patients with diabetes should aim for near-normal fasting plasma glucose and an HbA1C of about 7%; however, treatment goals must be individualized in patients with impaired cognitive and physical ability, reduced life expectancy, and heavy burden of comorbid disease. Elderly individuals and nursing home residents are at increased risk of hypoglycemia during pharmacological treatment. In general, a conservative and stepwise approach to the treatment of the elderly patient with diabetes is suggested. Treatment may be initiated with dietary and physical activity modification and with a single oral agent, followed by a combination of oral agents and insulin therapy if needed. Evidence from clinical trials indicates that improving glycemic control, as well as cardiovascular risk factors, reduces morbidity and mortality in older individuals with diabetes.     

Influenza vaccine effectiveness among elderly nursing home residents: a cohort study.

Outbreaks of influenza in nursing homes still occur, even when a large portion of residents have been inoculated with inactivated vaccine. Data were collected in 1991--1992 from 83 eligible skilled nursing homes located in southern Lower Michigan to determine the effectiveness of inactivated influenza vaccine in preventing influenza-like illness and influenza-associated pneumonia. Surveillance was conducted to identify the occurrence of influenza in the homes and, at the end of the season, specific data were gathered on all residents of homes with influenza activity. Age- and sex-adjusted estimates of vaccine effectiveness were calculated using Cox proportional hazards models for each nursing home. Estimates were pooled using precision-based weights calculated from data for each home. Vaccine was found to be 33% effective in preventing total respiratory illness (influenza-like illness and clinically diagnosed pneumonia). In prevention of pneumonia alone, vaccine was 43% effective. The estimate for prevention of pneumonia rose to 55% if the period under consideration was limited to the time of peak influenza activity. Given the number of eligible homes and the cohort methodology used, the results support continuation of current policy, encouraging use of vaccine in all nursing home residents.     

Intra-individual postural blood pressure variability and stroke in elderly nursing home residents

Orthostatic hypotension (OH) is a potential risk factor for adverse cardiovascular events, but OH is highly variable and may not be detected on a single occasion. To assess the relation between intra-individual variability of systolic orthostatic blood pressure change (DeltaSBP) and cardiovascular outcomes, an algorithm was developed to identify DeltaSBP instability using repeated supine and standing BP measurements. A cohort of 673 nursing home residents underwent baseline postural BP measurements (supine to 1 minute of standing, four times in a single day) and were followed for up to 2 years. Two groups (stable vs. unstable) were identified based on an analysis of DeltaSBP variance components. Differences in outcomes were compared via Cox survival analysis. At baseline 12.6% were unstable, defined as a one standard deviation difference of at least 20.2 mmHg between DeltaSBP readings. Unstable subjects were more likely to have OH on at least one measurement (systolic BP drop of 20 mmHg or more; 85% vs. 36%, respectively) and to be on psychotropic medication at baseline (47% vs 35%) (P-values <0.001). Other characteristics (including previous stroke) did not differ. During a mean follow-up of 10.3 months, stroke incidence was higher in unstable subjects (13.1% vs. 4.9%; P = 0.012), but ischemic heart disease and mortality rates were not significantly different (respectively, 13.5% vs. 7.4%, P = 0.115; 14.8% vs. 10.7%, P = 0.178). Survival analyses (adjusted for age, sex, psychotropic medications, body mass index, ischemic heart disease, and supine systolic pressure) confirmed a higher risk of stroke in unstable subjects (relative risk = 3.7, 95% CI: 1.6-8.4). Highly variable orthostatic BP measures may reflect impaired BP regulatory mechanisms in elders with occult cerebrovascular disease, or may directly affect cerebral blood flow. Orthostatic BP variability may be a better indicator of future stroke than a single supine or orthostatic change measure.     

Hip protectors decrease hip fracture risk in elderly nursing home residents: a Bayesian meta-analysis

OBJECTIVE: To design a Bayesian random effects model for pooling binary outcome data from cluster randomized trials (CRTs) with individually randomized trials (IRTs) and then use this model to determine if hip protectors decrease the risk of hip fracture in elderly nursing home residents. STUDY DESIGN AND SETTING: Eight electronic databases were searched; abstracts and papers were reviewed in duplicate. Randomized controlled trials of hip protectors in nursing homes were included. The pooled mean odds ratio (OR) of a hip fracture in an individual allocated to hip protectors with 95% credibility interval (CRI) was calculated. RESULTS: We included four trials of 1,922 individuals (including three CRTs). The pooled OR of an elderly nursing home resident sustaining one or more hip fractures with hip protector allocation was 0.40 (95% CRI 0.25, 0.61). The model was robust in multiple sensitivity analyses assuming alternative intracluster correlation coefficient values. CONCLUSION: The Bayesian approach may be used in meta-analyses of IRTs and CRTs. Using this approach, we have determined that hip protectors decrease the risk of hip fracture in elderly nursing home residents. Methodologic limitations of the included trials and a possible herd effect in CRTs may have influenced these results.     

Bioelectrical impedance vector analysis and mini nutritional assessment in elderly nursing home residents

Objective  

The aim of this study was to establish the presence of malnutrition in elderly institutionalized people through Mini Nutritional Assessment (MNA) scores and to observe the changes of nutritional status through the Bioelectrical Impedance Vector Analysis (BIVA).