Health effects of protein intake in healthy elderly populations: a systematic literature review

The purpose of this systematic review is to assess the evidence behind the dietary requirement of protein and to assess the health effects of varying protein intake in healthy elderly persons in order to evaluate the evidence for an optimal protein intake. The literature search covered year 2000-2011. Prospective cohort, case-control, and intervention studies of a general healthy population in settings similar to the Nordic countries with protein intake from food-based sources were included. Out of a total of 301 abstracts, 152 full papers were identified as potentially relevant. After careful scrutiny, 23 papers were quality graded as A (highest, n = 1), B (n = 18), or C (n = 4). The grade of evidence was classified as convincing, probable, suggestive, or inconclusive. The evidence is assessed as: probable for an estimated average requirement (EAR) of 0.66 g good-quality protein/kg body weight (BW)/day based on nitrogen balance (N-balance) studies and the subsequent recommended dietary allowance (RDA) of 0.83 g good-quality protein/kg BW/day representing the minimum dietary protein needs of virtually all healthy elderly persons. Regarding the optimal level of protein related to functional outcomes like maintenance of bone mass, muscle mass, and strength, as well as for morbidity and mortality, the evidence is ranging from suggestive to inconclusive. Results from particularly prospective cohort studies suggest a safe intake of up to at least 1.2-1.5 g protein/kg BW/day or approximately 15-20 E%. Overall, many of the included prospective cohort studies were difficult to fully evaluate since results mainly were obtained by food frequency questionnaires that were flawed by underreported intakes, although some studies were 'calibrated' to correct for under-or over-reporting. In conclusion, the evidence is assessed as probable regarding the EAR based on N-balance studies and suggestive to inconclusive regarding an optimal protein intake higher than the estimated RDA assessed from N-balance studies, but an exact level cannot be determined. Potentially adverse effects of a protein intake exceeding 20-23 E% remain to be investigated

From Frailty to Gerastenia

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Nutritional Status According to Mini Nutritional Assessment in an Institutionalized Elderly Population in Sweden

Background: In 1992, local municipalities in Sweden took over full responsibility for the long-term care of elderly. This has led to an increased care burden for the various assisted accommodation services run by the municipalities. Objective: Since ageing and chronic diseases are risk factors for protein-energy malnutrition, we evaluated the nutritional status of all individuals in assisted accommodation, i.e., service flats (SF), old people’s homes (OPH), group living for the demented (GLD), and nursing homes (NH), in three Swedish municipalities. Methods: Of 994 eligible subjects, 872 were examined; the average age was 84.5 ± 8 years, and 69% were female. The Mini Nutritional Assessment (MNA) scale (0–30 points) was used, consisting of 18 point-weighted questions in four categories, i.e., anthropometry, global and dietary issues, and self-assessment. Results: MNA <17, i.e., malnutrition, was noted in 36% of the study population. Divided according to accommodation type, the MNA scores were <17 in 21% of individuals in SF, 33% of those in OPH, 38% of those in GLD, and 71% of those in NH. The corresponding values for MNA scores 17–23.5 (risk for malnutrition) were 49, 51, 57, and 29%, respectively. Average body mass index (BMI) values were 24.2 ± 5 (SF), 23.6 ± 5 (OPH), 23.9 ± 4 (GLD), and 22.3 ± 4 (NH). BMI values ≤20 were found in 18% of those in SF, in 25% of those in OPH, in 19% of those in GLD, and in 33% of those in NH. Both MNA and BMI correlated with upper arm and calf circumference, with r values ranging from 0.4 to 0.7 (p < 0.001). MNA and BMI correlated significantly (r = 0.52, p < 0.001). Age correlated with MNA and BMI with r values of 0.1 (p < 0.01) and 0.14 (p < 0.001), respectively. Subjects with signficant help requirements during meals ate fewer whole meals per day than those who could feed themselves. Conclusions: Based on the MNA, one third of the study subjects living in assisted accommodation, and more than half of those living in NH, appeared to be malnourished. Further studies are necessary to assess to what extent these nutritional disturbances are reversible

Indications for percutaneous endoscopic gastrostomy and survival in old adults

Background : Many diseases striking old adults result in eating difficulties. Indications for selecting individuals for percutaneous endoscopic gastrostomy (PEG) are unclear and everybody may not benefit from the procedure. Objective : The aim of this study was to evaluate indications for and survival after PEG insertion in patients older than 65 years. Design and Methods : A retrospective analysis including age, gender, diagnosis, indication, and date of death was made in 201 consecutive individuals, 94 male, mean age 79±7 years, who received a nutritional gastrostomy. Results: Dysphagia was present in 86% of the patients and stroke was the most common diagnosis (49%). Overall median survival was 123 days and 30-day mortality was 22%. Patients with dementia and Mb Parkinson had the longest survival (i.e. 244 and 233 days), while those with other neurological diseases, and head and neck malignancy had the shortest (i.e. 75 and 106 days). There was no difference in mortality in patients older or younger than 80 years, except in patients with dementia. Conclusions: Old age should not be a contraindication for PEG. A high 30-day mortality indicates that there is a need of better criteria for selection and timing of PEG insertion in the elderly

Frailty, Sarcopenia, and Malnutrition Frequently (Co-)occur in Hospitalized Older Adults:A Systematic Review and Meta-analysis

OBJECTIVES: The purpose of this systematic review and meta-analysis was to summarize the prevalence of, and association between, physical frailty or sarcopenia and malnutrition in older hospitalized adults. DESIGN: A systematic literature search was performed in 10 databases. SETTING AND PARTICIPANTS: Articles were selected that evaluated physical frailty or sarcopenia and malnutrition according to predefined criteria and cutoffs in older hospitalized patients. MEASURES: Data were pooled in a meta-analysis to evaluate the prevalence of prefrailty and frailty [together (pre-)frailty], sarcopenia, and risk of malnutrition and malnutrition [together (risk of) malnutrition], and the association between either (pre-)frailty or sarcopenia and (risk of) malnutrition. RESULTS: Forty-seven articles with 18,039 patients (55% female) were included in the systematic review, and 39 articles (8868 patients, 62% female) were eligible for the meta-analysis. Pooling 11 studies (2725 patients) revealed that 84% [95% confidence interval (CI): 77%, 91%, I2 = 98.4%] of patients were physically (pre-)frail. Pooling 15 studies (4014 patients) revealed that 37% (95% CI: 26%, 48%, I2 = 98.6%) of patients had sarcopenia. Pooling 28 studies (7256 patients) revealed a prevalence of 66% (95% CI: 58%, 73%, I2 = 98.6%) (risk of) malnutrition. Pooling 10 studies (2427 patients) revealed a high association [odds ratio (OR): 5.77 (95% CI: 3.88, 8.58), P < .0001, I2 = 42.3%] and considerable overlap (49.7%) between physical (pre-)frailty and (risk of) malnutrition. Pooling 7 studies (2506 patients) revealed a high association [OR: 4.06 (95% CI: 2.43, 6.80), P < .0001, I2 = 71.4%] and considerable overlap (41.6%) between sarcopenia and (risk of) malnutrition. CONCLUSIONS AND IMPLICATIONS: The association between and prevalence of (pre-)frailty or sarcopenia and (risk of) malnutrition in older hospitalized adults is substantial. About half of the hospitalized older adults suffer from 2 and perhaps 3 of these debilitating conditions. Therefore, standardized screening for these conditions at hospital admission is highly warranted to guide targeted nutritional and physical interventions

A Core Outcome Set for nutritional intervention studies in older adults with malnutrition and those at risk: a study protocol

BACKGROUND: Malnutrition (i.e., protein-energy malnutrition) in older adults has severe negative clinical consequences, emphasizing the need for effective treatments. Many, often small, randomized controlled trials (RCTs) testing the effectiveness of nutritional interventions for the treatment of malnutrition showed mixed results and a need for meta-analyses and data pooling has been expressed. However, evidence synthesis is hampered by the wide variety of outcomes and their method of assessment in previous RCTs. This paper describes the protocol for developing a Core Outcome Set (COS) for nutritional intervention studies in older adults with malnutrition and those at risk. METHODS: The project consists of five phases. The first phase consists of a scoping review to identify frequently used outcomes in published RCTs and select additional patient-reported outcomes. The second phase includes a modified Delphi Survey involving experienced researchers and health care professionals working in the field of malnutrition in older adults, followed by the third phase consisting of a consensus meeting to discuss and agree what critical outcomes need to be included in the COS. The fourth phase will determine how each COS outcome should be measured based on a systematic literature review and a second consensus meeting. This will be followed by a dissemination and implementation phase. Patient and Public Involvement (PPI) representatives will contribute to study design, oversight, consensus, and dissemination. CONCLUSIONS: The result of this project is a COS that should be included in any RCT evaluating the effect of nutritional interventions in older adults with malnutrition and those at risk. This COS will facilitate comparison of RCT results, will increase efficient use of research resources and will reduce bias due to measurement of the outcome and publication bias. Ultimately, the COS will support clinical decision making by identifying the most effective approaches for treating and preventing malnutrition in older adults

Evidence-Based Recommendations for Optimal Dietary Protein Intake in Older People: A Position Paper From the PROT-AGE Study Group

New evidence shows that older adults need more dietary protein than do younger adults to support good health, promote recovery from illness, and maintain functionality. Older people need to make up for age-related changes in protein metabolism, such as high splanchnic extraction and declining anabolic responses to ingested protein. They also need more protein to offset inflammatory and catabolic conditions associated with chronic and acute diseases that occur commonly with aging. With the goal of developing updated, evidence-based recommendations for optimal protein intake by older people, the European Union Geriatric Medicine Society (EUGMS), in cooperation with other scientific organizations, appointed an international study group to review dietary protein needs with aging (PROT-AGE Study Group). To help older people (>65 years) maintain and regain lean body mass and function, the PROT-AGE study group recommends average daily intake at least in the range of 1.0 to 1.2 g protein per kilogram of body weight per day. Both endurance-and resistance-type exercises are recommended at individualized levels that are safe and tolerated, and higher protein intake (ie, >= 1.2 g/kg body weight/d) is advised for those who are exercising and otherwise active. Most older adults who have acute or chronic diseases need even more dietary protein (ie, 1.2-1.5 g/kg body weight/d). Older people with severe kidney disease (ie, estimated GFR <30 mL/min/1.73m(2)), but who are not on dialysis, are an exception to this rule; these individuals may need to limit protein intake. Protein quality, timing of ingestion, and intake of other nutritional supplements may be relevant, but evidence is not yet sufficient to support specific recommendations. Older people are vulnerable to losses in physical function capacity, and such losses predict loss of independence, falls, and even mortality. Thus, future studies aimed at pinpointing optimal protein intake in specific populations of older people need to include measures of physical function. Copyright (C) 2013 - American Medical Directors Association, Inc

Sarcopenia: European consensus on definition and diagnosis: Report of the European Working Group on Sarcopenia in Older People

The European Working Group on Sarcopenia in Older People (EWGSOP) developed a practical clinical definition and consensus diagnostic criteria for age-related sarcopenia. EWGSOP included representatives from four participant organisations, i.e. the European Geriatric Medicine Society, the European Society for Clinical Nutrition and Metabolism, the International Association of Gerontology and Geriatrics—European Region and the International Association of Nutrition and Aging. These organisations endorsed the findings in the final document. The group met and addressed the following questions, using the medical literature to build evidence-based answers: (i) What is sarcopenia? (ii) What parameters define sarcopenia? (iii) What variables reflect these parameters, and what measurement tools and cut-off points can be used? (iv) How does sarcopenia relate to cachexia, frailty and sarcopenic obesity? For the diagnosis of sarcopenia, EWGSOP recommends using the presence of both low muscle mass + low muscle function (strength or performance). EWGSOP variously applies these characteristics to further define conceptual stages as ‘presarcopenia', ‘sarcopenia' and ‘severe sarcopenia'. EWGSOP reviewed a wide range of tools that can be used to measure the specific variables of muscle mass, muscle strength and physical performance. Our paper summarises currently available data defining sarcopenia cut-off points by age and gender; suggests an algorithm for sarcopenia case finding in older individuals based on measurements of gait speed, grip strength and muscle mass; and presents a list of suggested primary and secondary outcome domains for research. Once an operational definition of sarcopenia is adopted and included in the mainstream of comprehensive geriatric assessment, the next steps are to define the natural course of sarcopenia and to develop and define effective treatmen