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

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

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

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

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

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

Neglected but Potent Dry Forest Players: Ecological Role and Ecosystem Service Provision of Biological Soil Crusts in the Human-Modified Caatinga

Biological soil crusts (biocrusts) have been recognized as key ecological players in arid and semiarid regions at both local and global scales. They are important biodiversity components, provide critical ecosystem services, and strongly influence soil-plant relationships, and successional trajectories via facilitative, competitive, and edaphic engineering effects. Despite these important ecological roles, very little is known about biocrusts in seasonally dry tropical forests. Here we present a first baseline study on biocrust cover and ecosystem service provision in a human-modified landscape of the Brazilian Caatinga, South America's largest tropical dry forest. More specifically, we explored (1) across a network of 34 0.1 ha permanent plots the impact of disturbance, soil, precipitation, and vegetation-related parameters on biocrust cover in different stages of forest regeneration, and (2) the effect of disturbance on species composition, growth and soil organic carbon sequestration comparing early and late successional communities in two case study sites at opposite ends of the disturbance gradient. Our findings revealed that biocrusts are a conspicuous component of the Caatinga ecosystem with at least 50 different taxa of cyanobacteria, algae, lichens and bryophytes (cyanobacteria and bryophytes dominating) covering nearly 10% of the total land surface and doubling soil organic carbon content relative to bare topsoil. High litter cover, high disturbance by goats, and low soil compaction were the leading drivers for reduced biocrust cover, while precipitation was not associated Second-growth forests supported anequally spaced biocrust cover, while in old-growth-forests biocrust cover was patchy. Disturbance reduced biocrust growth by two thirds and carbon sequestration by half. In synthesis, biocrusts increase soil organic carbon (SOC) in dry forests and as they double the SOC content in disturbed areas, may be capable of counterbalancing disturbance-induced soil degradation in this ecosystem. As they fix and fertilize depauperated soils, they may play a substantial role in vegetation regeneration in the human-modified Caatinga, and may have an extended ecological role due to the ever-increasing human encroachment on natural landscapes. Even though biocrusts benefit from human presence in dry forests, high levels of anthropogenic disturbance could threaten biocrust-provided ecosystem services, and call for further, in-depth studies to elucidate the underlying mechanisms

Neglected but Potent Dry Forest Players: Ecological Role and Ecosystem Service Provision of Biological Soil Crusts in the Human-Modified Caatinga

Biological soil crusts (biocrusts) have been recognized as key ecological players in arid and semiarid regions at both local and global scales. They are important biodiversity components, provide critical ecosystem services, and strongly influence soil-plant relationships, and successional trajectories via facilitative, competitive, and edaphic engineering effects. Despite these important ecological roles, very little is known about biocrusts in seasonally dry tropical forests. Here we present a first baseline study on biocrust cover and ecosystem service provision in a human-modified landscape of the Brazilian Caatinga, South America's largest tropical dry forest. More specifically, we explored (1) across a network of 34 0.1 ha permanent plots the impact of disturbance, soil, precipitation, and vegetation-related parameters on biocrust cover in different stages of forest regeneration, and (2) the effect of disturbance on species composition, growth and soil organic carbon sequestration comparing early and late successional communities in two case study sites at opposite ends of the disturbance gradient. Our findings revealed that biocrusts are a conspicuous component of the Caatinga ecosystem with at least 50 different taxa of cyanobacteria, algae, lichens and bryophytes (cyanobacteria and bryophytes dominating) covering nearly 10% of the total land surface and doubling soil organic carbon content relative to bare topsoil. High litter cover, high disturbance by goats, and low soil compaction were the leading drivers for reduced biocrust cover, while precipitation was not associated Second-growth forests supported anequally spaced biocrust cover, while in old-growth-forests biocrust cover was patchy. Disturbance reduced biocrust growth by two thirds and carbon sequestration by half. In synthesis, biocrusts increase soil organic carbon (SOC) in dry forests and as they double the SOC content in disturbed areas, may be capable of counterbalancing disturbance-induced soil degradation in this ecosystem. As they fix and fertilize depauperated soils, they may play a substantial role in vegetation regeneration in the human-modified Caatinga, and may have an extended ecological role due to the ever-increasing human encroachment on natural landscapes. Even though biocrusts benefit from human presence in dry forests, high levels of anthropogenic disturbance could threaten biocrust-provided ecosystem services, and call for further, in-depth studies to elucidate the underlying mechanisms

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

COVID-19 in old age

Schwerwiegend verlaufende COVID-19-Erkrankungen betreffen vorwiegend die ältere Bevölkerung. Die Mortalität der hospitalisierten COVID-19-Patienten im Alter über 80 Jahre liegt international bei bis zu 54 %. Daher ist ein Blick auf die Erkrankung aus geriatrischer Perspektive erforderlich. Diagnostik und Therapie der COVID-19-Erkrankung unterscheiden sich bei den älteren Patienten nicht grundsätzlich von der bei jüngeren Patienten. Allerdings ist bei Patienten im hohen Alter gehäuft mit einer atypischen Symptomatik zu rechnen. Der Rehabilitationsbedarf nach durchgemachter Infektion ist bei älteren COVID-19-Patienten deutlich höher als bei jüngeren Patienten. Paradoxerweise steht der Notwendigkeit vermehrter Rehabilitationsleistungen jedoch ein sinkendes Angebot geriatrischer Rehabilitationsmöglichkeiten gegenüber, da viele Abteilungen entweder geschlossen oder deren Behandlungskapazitäten reduziert wurden. Generell sollten Quarantäne- und Isolationsmaßnahmen in der älteren Bevölkerung verstärkt auf ihre Verhältnismäßigkeit überprüft werden, da die gesundheitlichen und emotionalen Auswirkungen gravierend sein können. Angesichts der ungünstigen Prognose bei hochaltrigen COVID-19-Patienten kommt der Berücksichtigung des Patientenwillens eine besondere Bedeutung zu. Daher sollten Angehörige und Ärzte sich frühzeitig, d. h. möglichst bereits vor dem Auftreten einer Infektion, bemühen, diesen zu eruieren und angemessen zu dokumentieren. Erfreulicherweise lassen die bisherigen Daten hoffen, dass die Impfung mit den in Deutschland zugelassenen mRNA-Impfstoffen gegen SARS-CoV‑2 auch im hohen Alter gut wirksam ist.Predominantly the older population is affected by a severe course of COVID-19. The mortality of hospitalized patients with COVID-19 above the age of 80 years is up to 54% in international studies. These observations indicate the necessity to highlight the geriatric perspective on this disease. The diagnostics and treatment of COVID-19 do not differ between younger and older patients but atypical symptoms should be expected more frequently in old age. Older subjects show an increased need for rehabilitation after COVID-19. Paradoxically, increasing rehabilitation demands go along with a reduced availability of geriatric rehabilitation options, the latter being a consequence of closure or downsizing of rehabilitation departments during the pandemic. In general, measures of isolation and quarantine should be diligently balanced as the health and emotional consequences of such measures may be severe in older persons. In light of the poor prognosis of older COVID-19 patients, advanced care planning becomes even more relevant. Caregivers and physicians should be encouraged to compose advanced care directives that also reflect the specific circumstances of COVID-19. Fortunately, current data suggest that the effectiveness of the vaccination with the mRNA-vaccines approved in Germany may be equally high in older compared to younger persons