Iron deficiency, fatigue and muscle strength and function in older hospitalized patients

$\bf Background/Objectives$ Iron deficiency is common in older patients. We investigated whether iron deficiency is an independent risk factor for functional impairment, low muscle function, fatigue, and rehabilitation progress in older hospitalized patients. $\bf Subjects/Methods$ Two hundred twenty-four patients (age range 65–95 years; 67% females) who were consecutively admitted to a geriatric acute care ward participated in this prospective longitudinal observational study. Ferritin, iron, transferrin in serum, and blood hemoglobin were measured and current iron supplementation was recorded. Fatigue and comorbidity were measured using the fatigue severity scale and Charlson Comorbidity Index, respectively. Barthel Index, handgrip strength, and isometric knee extension strength were conducted at the time of hospital admission and before discharge. $\bf Results$ Ninety-one (41%) patients had iron deficiency in which the majority had functional iron deficiency (78/91, 86%). Absolute iron deficiency with and without anemia was diagnosed in 12 (13%) and one patients, respectively. Barthel Index and handgrip and knee extension strength significantly improved during hospitalization in iron deficiency and non-iron deficiency groups. Knee extension strength showed better improvement in iron-deficient patients receiving iron supplementation and iron supplementation during hospital stay was the main predictor for improvement in knee extension strength. Comorbidity, iron deficiency, and changes in handgrip strength were the major independent risk factors for poor improvement in Barthel Index during hospitalization. There were significant associations between patients’ fatigue and iron deficiency, comorbidity, and female gender. $\bf Conclusion$ Iron deficiency is an independent risk factor for fatigue and poor functional recovery among older hospitalized patients. Iron supplementation seems to be capable of improving functional performance

Measured and predicted resting energy expenditure in malnourished older hospitalized patients

A number of equations have been proposed to predict resting energy expenditure (REE). The role of nutritional status in the accuracy and validity of the REE predicted in older patients has been paid less attention. We aimed to compare REE measured by indirect calorimetry (IC) and REE predicted by the Harris–Benedict formula in malnourished older hospitalized patients. Twenty-three malnourished older patients (age range 67–93 years, 65% women) participated in this prospective longitudinal observational study. Malnutrition was defined as Mini Nutritional Assessment Long Form (MNA-SF) score of less than 17. REE was measured (REE$_measured$) and predicted (REE$_predicted$) on admission and at discharge. REEpredicted within $\pm$ 10% of the REE$_measured$ was considered as accuracy. Nutritional support was provided to all malnourished patients during hospitalization. All patients were malnourished with a median MNA-LF score of 14. REE$_measured$ and REE$_predicted$ increased significantly during 2-week nutritional therapy (+212.6 kcal and +19.5 kcal, respectively). Mean REE$_predicted$ (1190.4 kcal) was significantly higher than REE$_measured$ (967.5 kcal) on admission ($\it p$ < 0.001). This difference disappeared at discharge ($\it p$ = 0.713). The average REE$_predicted$ exceeded the REE$_measured$ on admission and at discharge by 29% and 11%, respectively. The magnitude of difference between REE$_measured$ and REE$_predicted$ increased along with the degree of malnutrition ($\it r$ = 0.42, $\it p$ = 0.042) as deviations ranged from −582 to +310 kcal/day in severe to mildly malnourished patients, respectively. REE$_predicted$ by the Harris–Benedict formula is not accurate in malnourished older hospitalized patients. REE measured by IC is considered precise, but it may not represent the true energy requirements to recover from malnutrition. Therefore, the effect of malnutrition on measured REE must be taken into account when estimating energy needs in these patients

Refeeding syndrome in older hospitalized patients

Refeeding syndrome (RFS) is a serious metabolic disturbance that manifests after reintroducing nutrition to severely malnourished individuals. Especially susceptible are older patients, due to higher malnutrition rates, although the incidence remains uncertain. Our study aimed to assess the occurrence and management of RFS in malnourished older hospitalized patients. This prospective study included 156 malnourished older patients, with malnutrition identified using the Mini Nutritional Assessment-Short Form. We evaluated critical biochemical parameters at admission and for ten days after starting nutritional therapy. Using the consensus evidence-based approach, we managed and evaluated RFS. We also tracked mortality and unexpected hospital readmissions for six months after discharge. The average patient age was 82.3 $\pm$ 7.5 years, with 69% female. Patients showed hypophosphatemia (23%), hypomagnesemia (31%), and hypokalemia (6%) on admission. Prior to nutritional replenishment, patients were classified as being at low (64%), high (30%), or very high risk (6%) for RFS. After nutritional therapy, 14% and 5% developed imminent and manifest RFS, respectively. There were no significant differences in six-month post-discharge mortality rates or unexpected hospital readmissions between patients with or without RFS. Despite adherence to guideline-recommended management, RFS can persist. No elevated mortality was noted in RFS patients, potentially due to early diagnosis and treatment

Inflammation as a diagnostic criterion in the GLIM definition of malnutrition

$\textbf {Background/objectives:}$ In the recently introduced GLIM diagnosis of malnutrition (Global Leadership Initiative on Malnutrition), details of how to classify inflammation as an etiologic criterion are lacking. This study aimed to determine at what level of serum C-reactive protein (CRP) the risk of low food intake increases in acutely ill older hospitalized patients. $\textbf {Subjects/methods:}$ A total of 377 patients, who were consecutively admitted to a geriatric acute care ward, were analyzed. Nutritional intake was determined using the food intake item of Nutritional Risk Screening and the plate diagram method and patients were grouped into three categories as >75%, 50–75% and $\leq$50% of requirements. CRP was analyzed according to standard procedures and patients were classified into different CRP groups as follows: 0.0 0.99 mg/dl, 1.0–1.99 mg/dl, 2.0–2.99 mg/dl, 3.0–4.99 mg/dl, 5.0–9.99 mg/dl and $\geq$510.0 mg/dl. $\bf Results:$ Of the total population (mean age of 82.2 $\pm$ 6.6 years; 241 females), 82 (22%) had intake 75% of requirements ($\it P$ < 0.001). The group with serum-CRP levels above 3.0 mg/dl had a markedly higher proportion of patients with low food intake; i.e., <50% and <75% of the requirements. $\bf Conclusion:$ A serum-CRP of 3.0 mg/dl appears to be a reasonable threshold of acute inflammation leading to reduced food intake to serve as an orientation with regard to the inflammation criterion of the GLIM diagnosis in acutely ill older patients

Optimized refeeding vs. standard care in malnourished older hospitalized patients

Malnutrition is a prevalent geriatric syndrome with adverse health outcomes. This study aimed to assess the effectiveness of an optimized protocol for treatment of malnutrition in older hospitalized patients. We conducted a prospective, non-randomized cluster-controlled study with 156 malnourished patients in the intervention and 73 in the control group, determined using the Mini Nutritional Assessment-Short-Form. The intervention group received individualized nutritional care, including electrolyte and micronutrients monitoring, while the control received standard care. We primarily focused on complications such as infections, falls, unplanned hospital readmissions, and mortality, and secondarily focused on functional status and mobility improvements. Post-discharge follow-ups occurred at 3 and 6 months. Our findings demonstrated that the intervention group (age 82.3 $\pm$ 7.5 y, 69% female), exhibited greater previous weight loss (11.5 kg vs. 4.7 kg), more cognitive impairment and a longer hospital stay (19 days vs. 15 days). Binary logistic regression showed no difference in primary endpoint outcomes between groups during hospitalization. At 3- and 6-month follow-ups, the control group exhibited fewer adverse outcomes, particularly falls and readmissions. Both groups showed in-hospital functional improvements, but only controls maintained post-discharge mobility gains. The study concludes that the nutritional intervention did not outperform standard care, potentially due to study limitations and high-quality standard care in control group geriatric departments

Longitudinal changes of cytokines and appetite in older hospitalized patients

There are few data on the longitudinal association of cytokine and appetite among older hospitalized patients. We aimed to investigate the impact of the changes of inflammatory cytokines on appetite in older hospitalized patients. A total of 191 patients (mean age 81.3 $\pm$ 6.6 years, 64% women) participated in this prospective longitudinal observational study. Appetite was evaluated using the Edmonton Symptom Assessment System on admission and after seven days. Serum cytokines such as IL-1$\beta$, IL-6, IL-8, IL-10, IL-12p70, IL-17, IL-18, IL-23 and IL-33, IFN-$\alpha$2, IFN-$\gamma$, TNF-$\alpha$ and MCP-1 were measured both times. No significant differences in the mean serum levels of all the cytokines could be detected overtime in relation to appetite changes, except for IL-18. Appetite significantly deteriorated overtime in patients with increasing IL-18 levels and improved in those without significant changes in IL-18 levels. In a stepwise regression analysis, changes of IL-18 levels were the major independent predictor for the changes of patients’ appetite and explained 4% of the variance, whereas other cytokines and variables, such as age, sex, infection and disease, did not show any impact on appetite changes. We conclude that IL-18 seems to exert a significant impact on appetite in acutely ill older hospitalized patients and should, therefore, be considered as a potential target in the diagnosis, prevention and treatment of malnutrition

Sarcopenic dysphagia revisited

Oropharyngeal dysphagia (OD) is a frequent finding in older patients with potentially lethal complications such as aspiration pneumonia, malnutrition, and dehydration. Recent studies describe sarcopenia as a causative factor for OD, which is occasionally referred to as "sarcopenic dysphagia" in the absence of a neurogenic etiology. In most of the previous studies on sarcopenic dysphagia, the diagnosis was based only on clinical assessment. In this study, flexible endoscopic evaluation of swallowing (FEES) was used as an objective method to evaluate the presence of OD, its association with sarcopenia, and the presence of pure sarcopenic dysphagia. In this retrospective cross-sectional study, 109 acute care geriatric hospital patients with suspected OD received FEES examination and bioimpedance analysis (BIA) in clinical routine. 95% of patients had at least one neurological disease, 70% fulfilled the criteria for sarcopenia, and 45% displayed moderate or severe OD. Although the prevalence of sarcopenia and OD was high, there was no significant association between OD and sarcopenia. Considering these results, both the association between sarcopenia and OD and pure sarcopenic dysphagia appear questionable. Further prospective studies are needed to elucidate if sarcopenia is merely an epiphenomenon of severe disease or whether it plays a causative role in the development of OD

Impact of hearing loss on geriatric assessment

$\bf Background:$ Due to the aging society, the incidence of age-related hearing loss (ARHL) is strongly increasing. Hearing loss has a high impact on various aspects of life and may lead to social isolation, depression, loss of gain control, frailty and even mental decline. Comorbidity of cognitive and sensory impairment is not rare. This might have an impact on diagnostics and treatment in the geriatric setting. $\bf Objective:$ The aim of the study was to evaluate the impact of hearing impairment on geriatric assessment and cognitive testing routinely done in geriatrics. $\textbf {Material and Methods}$: This review is based on publications retrieved by a selective search in Medline, including individual studies, meta-analyses, guidelines, Cochrane reviews, and other reviews from 1960 until August 2020. $\bf Results:$ Awareness of sensory impairment is low among patients and health professionals working with elderly people. The evaluation of the hearing status is not always part of the geriatric assessment and not yet routinely done in psychiatric settings. However, neurocognitive testing as an important part can be strongly influenced by auditory deprivation. Misunderstanding of verbal instructions, cognitive changes, and delayed central processes may lead to a false diagnosis in up to 16% of subjects with hearing loss. To minimize this bias, several neurocognitive assessments were transformed into non-auditory versions recently, eg the most commonly used Hearing-Impaired Montreal Cognitive Assessment (HI-MoCA). However, most of them still lack normative data for elderly people with hearing loss. $\bf Conclusion:$ Hearing loss should be taken into consideration when performing geriatric assessment and cognitive testing in elderly subjects. Test batteries suitable for ARLH should be applied

Inflammation, appetite and food intake in older hospitalized patients

The effect of inflammation on appetite and food intake has been rarely studied in humans. In this study, we examined the association of C-reactive protein (CRP), as an inflammatory marker, with appetite and food intake among older hospitalized patients. A total of 200 older individuals, who were consecutively admitted to a geriatric acute care ward, participated in this prospective observational study. Appetite was evaluated using the Edmonton Symptom Assessment System (ESAS) and the Simplified Nutritional Appetite Questionnaire (SNAQ), respectively. Food intake was measured according to plate diagram method and participants were categorized as having food intake 3.0 (mg/dL) were considered as moderate to severe inflammation. Of total population with mean age 81.4 $\pm$ 6.6 years (62.5% females), 51 (25.5%) had no inflammation and 88 (44.0%) and 61 (30.5%) had mild and moderate to severe inflammation, respectively. According to MNA-SF, 9.0% and 60.0% had normal nutritional status or a risk of malnutrition, respectively, whereas 31.0% were malnourished. Based on the SNAQ-appetite-question, 32.5% of the patients demonstrated poor and very poor appetite whereas 23.5% reported severe loss of appetite according to ESAS. Ninety-five (48.0%) of the participants had food intake <75% of the meals offered. Significant associations between SNAQ-appetite ($\it p$ = 0.003) and ESAS-appetite ($\it p$ = 0.013) scores and CRP levels were observed. In addition, significant differences were observed in CRP levels between intake $\geq$75% and <75% of meals served ($\it p$ < 0.001). Furthermore, there were significant associations between appetite and nutritional status whereas malnourished older patients demonstrated a decreased appetite compared to those with normal nutritional status ($\it p$ = 0.011). In a regression analysis, inflammation was the major independent risk factor for patients' appetite ($\it p$ = 0.003) and food intake ($\it p$ = 0.011) whereas other variables such as infection ($\it p$ = 0.960), chronic inflammatory diseases ($\it p$ = 0.371), age ($\it p$ = 0.679) and gender ($\it p$ = 0.447) do not show any impact on appetite. Our findings confirm that poor appetite and low food intake are associated with inflammation in older hospitalized patients, suggesting that inflammation may contribute an important aspect to the development of malnutrition in these patients

Acute disease induced cognitive dysfunction in older patients

$\bf Background:$ It is unknown, how many older hospitalized patients experience cognitive changes independently from delirium. $\bf Methods:$ In this retrospective study, cognitive function was assessed with the Montreal Cognitive Assessment on admission and discharge in 103 acute care geriatric hospital patients. $\bf Results:$ Mean age was 80.8 $\pm$ 7.3 years. The total MoCA score on admission was 17.8 ($\pm$4.5) and at discharge 17.7 ($\pm$4.4). The mean difference of the total MoCA score was − 0.1 ($\pm$3.5). 12 (11.7%) patients suffered from delirium. 46 (44.7%) patients experienced significant changes of cognitive function  2 MoCA points without delirium. There was no significant association between delirium during hospital stay and the prevalence and magnitude of changes in total MoCA score. $\bf Conclusion:$ Cognitive changes frequently occur during acute disease of geriatric patients independently from delirium. We propose the term "acute disease induced cognitive dysfunction" (ADICD) for this entity