By Atalay, Betul Gulsen Yagmur, Cahide; Nursal, Tarik Zafer; Atalay, Hakan; Noyan, Turgut
The objective of this study is to examine the prevalence of malnutrition and evaluate the nutrition status and clinical outcome in hospitalized patients aged 65 years and older receiving enteral- parenteral nutrition. This retrospective study was carried out at Baskent University Hospital, Adana, Turkey. A total of 119 patients older than 65 years were recruited. Patients were classified into 3 groups: protein-energy malnutrition (PEM), moderate PEM, and well nourished according to subjective global assessment (SGA) at admission. All patients were fed by enteral or parenteral route. Acute physiological and chronic health evaluation (APACHE-2) and simplified acute physiology (SAPS 2) scores were recorded in patients followed in the intensive care unit (ICU). Nutrition status was assessed with biochemical (serum albumin, serum prealbumin) parameters. These results were compared with mortality rate and length of hospital stay (LOS). The subjects’ mean (+-SD) age was 73.1+-5.4 years. Using SGA, 5.9% (n = 7) of the patients were classified as severely PEM, 27.7% (n = 33) were classified as moderately PEM, and 66.4% (n = 79) were classified as well nourished. Some 73.1% (n = 87) of the patients were followed in the ICU. Among all patients, 42.9% (n = 51) were fed by a combined enteral-parenteral route, 31.1% (n = 37) by an enteral route, 18.5% (n = 22) by a parenteral route, and 7.6% (n = 9) by an oral route. The average length of stay for the patients was 18.9 +- 13.7 days. The mortality rate was 44.5% (n = 53). The mortality rate was 43% (n = 34) in well-nourished patients (n = 79), 48.5% (n = 16) in moderately PEM patients (n = 33), and 42.9% (n = 3) in severely PEM patients (n = 7) (P = .86). The authors observed no difference between well-nourished and malnourished patients with regard to the serum protein values on admission, LOS, and mortality rate. In this study, malnutrition as defined by SGA did not influence the mortality rate of critically ill geriatric patients receiving enteral or parenteral nutrition. Furthermore, no factor was found to be a good predictor of survival. (JPEN J Parenter Enteral Nutr. 2008;32:454-459) Keywords: aged; malnutrition; enteral-parenteral nutrition
Protein-energy malnutrition (PEM) is a common disorder in hospitalized elderly patients. Malnutrition is reported to occur in a large number of elderly patients on admission to a hospital.1 Forty percent of elderly patients admitted to the hospital in the United Kingdom are undernourished, and half are severely undernourished.2 When defined as a decrease in nutrient reserve, malnutrition is prevalent in 1%-15% of ambulatory outpatients, 25%- 60% of institutionalized patients, and 35%-65% of hospitalized patients.3
Extensive documentation exists of the strong relationship between PEM in chronic disease and increased morbidity, mortality, and extended hospital stays.4,5 The causality of these connections is not clear. In addition, reduced food intake and breakdown of body tissues are partly the result of biochemical mechanisms activated by the disease. Although there are data indicating that nutrition enhancement may improve the outcome, contrary data exist in the literature.6,12
To determine the prevalence of malnutrition and to evaluate the clinical outcome in hospitalized patients aged 65 years and older receiving enteral-parenteral nutrition, we conducted this retrospective study in a university hospital.
Methods
The study includes geriatric patients of at least 65 years of age admitted to Baskent University Hospital between April 2000 and September 2002 who required nutrition intervention. Patients were evaluated by a nutrition support team. Subjective global assessment (SGA) was performed by the nutrition team dietician. Patients were classified into 3 groups according to SGA: (1) having PEM, (2) having moderate PEM or being at risk for PEM, and (3) being well nourished at admission. For patients followed in the intensive care unit (ICU), acute physiological and chronic health evaluation (APACHE-2) and simplified acute physiology scores (SAPS 2) were recorded. Patients who received no food were not separately recorded. Nutrition status was assessed within the first 24 hours after consultation and weekly during hospitalization with the use of serum proteins (serum albumin and prealbumin). These results were compared with mortality rate and length of hospital stay (LOS).
The patients’ total energy requirements were calculated by the Harris-Benedict equation adjusted by stress factors. The daily target protein requirements were calculated as 0.8-1.2 g/kg. Whenever possible, enteral nutrition was used (Standart; Isosource Standart, Novartis Laboratories, Switzerland, or specific for disease; Glucerna, Nutrena, or Pulmocare; Abbott Laboratories, the Netherlands) continuously infused into the stomach through a 14 Fr nasogastric polyurethane feeding tube (Flocare nasogastric pur tube; Nutricia Healthcare, Switzerland) with the aid of a peristaltic pump. We aimed the tip of the feeding tube in the distal stomach. The correct positioning of the feeding tube was verified by bolus infusion of 20 mL air while auscultating the epigastrium. During follow-up, the air auscultation method was used daily. The head of the patient’s bed was raised at least 45[degrees], which was verified by the nutrition team nurse. The enteral formula was commenced continuously through the feeding tube at a rate of 25 mL/ h. The rate was increased by 25 mL/h at 6-hour periods until the calculated maximum rate was reached. During the study, the residual volume was measured and recorded at 6-hour intervals. If the gastric residual volume was more than twice the current hourly infusion rate or was > 150 mL, the infusion rate was lowered to the previous rate, and the incident was recorded as “residue.” Digestive complications caused by enteral nutrition, such as nausea, vomiting, abdominal distention, and diarrhea were also recorded for each patient for each day. Enteral intolerance is defined as insufficient gastrointestinal functions, chronic vomiting, or diarrhea. An inadequate nutrition session was defined as the provision of
Table 1. Most Common Clinical Diagnoses on Admission
Statistical analyses were performed with SPSS for Windows (release 8.0). Simple descriptive statistics were used for demographic analyses. Between 2 independent groups, continuous values were compared by Student t test or unpaired t test. Proportions were compared by the chi^sup 2^ test. One-way ANOVA was used to compare groups of 3. Only 9 patients were fed via the oral route. Because the group was small, this group was excluded from further analysis. This exclusion affected only the analysis using the feeding route. For multiple regression analysis, some variables were reclassified. The continuous variable LOS was separated, that is, LOS between 1 and 16 days and LOS more than 16 days (patients’ LOS median value was 16 days) and inadequate feeding period (1 for 1 to 5 days, 0 for >5 days). Other variables included in the model were feeding route (1 for enteral, 0 for enteral-parenteral), development of distention, the period of supporting mechanical ventilation, and the period of nasogastric feeding tube. The mean age of the 119 patients included in this study was 73.15 +- 5.45 years, and 51% were male. The average time of hospitalization was 18.9 +- 13.7 days. Because of complications, the average duration of the inadequate feeding period was 6.3 +- 4.9 days.
The clinical diagnoses that were most prevalent within the study population at the time of admission are listed in Table 1. Of the group, 73.1% (n = 87) were followed in the ICU and 37.8% (n = 45) were supported by mechanical ventilation. Malnutrition was present in 40 (33.6%) of the 119 included patients (Figure 1).
Results
We observed no differences in serum protein values on admission and the LOS between well-nourished and malnourished patients (Table 2).
Figure 1. Assessment of malnutrition according to the subjective global assessment.13 Prevalence of malnutrition was present in 40 (33.6%) of the 119 included patients.
Table 2. Serum Protein Values on Admission and Length of Hospital Stay in Well-Nourished and Malnourished Patients
Table 3. APACHE-2 and SAPS 2 Values in the Intensive Care Unit
Of the 79 well-nourished patients, according to SGA, 79.7% (n = 63) were followed in the ICU. The malnutrition rate in the ICU was 27.6% (n = 24). APACHE-2 and SAPS 2 scores were higher in severely PEM patients, but that was not statistically significant (Table 3). Among all patients, 42.9% (n = 51) were fed by enteral-parenteral route, 31.1% (n = 37) were fed by enteral-only route, 18.5% (n = 22) by parenteral route, and 7.6% (n = 9) by oral route. In patients who received parenteral nutrition, the route was central in 34.5% (n = 41) and peripheral in 26.9% (n = 32). Central parenteral nutrition was used for all 22 patients in whom enteral nutrition was not used. In patients who received enteral nutrition (n = 37), 54.1% (n = 20) had a blood glucose measurement > 150 mg/dL. This was 64.7% (n = 33) in patients who received enteralparenteral nutrition and 36.4% (n = 8) in patients who received parenteral nutrition (n = 22; P = .065).
In patients who received enteral nutrition (n = 37), 83.8 % (n = 31) achieved the goal rate. The enteral intolerance rate was 25.9%. The complications are shown in Table 4.
The daily target total energy requirements were calculated by the Harris-Benedict equation. The ratio of patients who reached this target was 68.6% (n = 35) in enteral-parenteral- supported patients (n = 57). This figure was 50% (n = 11) in patients who received only parenteral supplementation (n = 22; P = .02). The reasons in which enteral nutrition was not used in the latter group were as follows: 1 case of gastrointestinal bleeding, 1 case of pancreatitis, 11 cases of postoperative abdominal surgery, 4 cases of risk of pulmonary aspiration, and 5 patients who did not take enough oral diet.
We observed no differences on the serum albumin or serum prealbumin values on admission (P = .78) and after nutrition support (P = .35).
Table 4. Complications Among All Patients Receiving Enteral- Parenteral Nutrition
Table 5. Variables Predicting Length of Stay
Figure 2. Mortality rate and malnutrition. PEM indicates protein- energy malnutrition.
Table 6. Effect of Serum Protein Levels on Admission and Relation With Mortality
Logistic regression analysis showed that among the variables predicting LOS, inadequate feeding period and the duration of nasogastric tube feeding proved to be significant (Table 5).
Among all patients, the mortality rate was 44.5% (n = 53). The relation between mortality and serum protein levels on admission is shown in Table 6. Low serum albumin and prealbumin levels on admission did not affect mortality (P = .39, P = .72, respectively).
The mortality rate was 47.5% in patients with moderate and severe PEM, and 43.0% in well-nourished patients. Malnutrition according to SGA did not affect the mortality rate (P = .74; Figure 2).
Mortality was also related to vomiting during nutrition support, gender, and nutrition complications (P = .01, P= .04, P = .05, respectively). The mortality rate was 64.9% in men and 35.1% in women. However, we did not find any independent variables that affect mortality by regression analysis.
Conclusion
Evaluating nutrition status in elderly patients is difficult because of inadequate nutrition parameters. In particular, age- related chronic diseases affect nutrition status.14 The clinical assessment of nutrition status in elderly patients is difficult. However, body composition, particularly muscle mass and fat distributions, are important parameters. These changes could have been evaluated by subjective physical assessment. Therefore, weight loss and nutrition assessment are important parameters. It has been reported that using the SGA for elderly patients (older than 70 years) for malnutrition assessment is safe and valid.15 In this study, malnutrition prevalence assessment by SGA was 33.6%. However, the malnourished patients’ serum protein levels on admission were similar to that of well-nourished patients. As the energy requirements were calculated, we took into account stress factors. Although this practice may not be advocated by some authors for geriatric patients, our policy is to supply additional calories for additional stress.
We observed no differences on the serum albumin or serum prealbumin values on admission (P = .78) and after nutrition support (P = .35). We could not observe any change, probably because of the short duration of nutrition support (average, 10.95 +- 9.55 days). Bos et al16 reported that short-term protein and energy supplementation (10 days) in hospitalized malnourished geriatric patients did not affect biochemical parameters.
The decline in serum albumin concentration in hospitalized patients is due to decreased albumin synthesis.17 In the literature, the relationship between low serum albumin levels and mortality is remarkable: Mortality is 1.7% in patients whose albumin level is 35 g/L and 62% in those with serum albumin levels
In this study, the rate of mortality was high in both groups (malnourished vs nourished; P = .74). As a policy, when we were consulted for giving nutrition support, it was given to all patients without distinguishing the patient’s general condition or prognosis. Although the mortality rate of patients with malnutrition was high compared with well-nourished patients, the difference was not significant (P = .25).
Researchers have stated that mortality rate is affected by cancer, infection, old age (>/=60 years), and clinical treatment, but the existence of malnutrition is an independent factor affecting mortality. Moreover, researchers have pointed out that disease and nutrition interact, and question whether disease causes malnutrition or whether malnutrition negatively affects the disease.19 Thus, researchers have put forward that it is hard to say from the poor clinical results whether malnutrition on its own is responsible.19 In this study, we could not detect any relationship between malnutrition as measured by the SGA and mortality. Moreover, nutrition support did not influence the outcome. This could be linked to the relatively short stay of the patients, as this period may not be sufficient to detect a difference caused by nutrition support. Therefore, it is advised that patients with malnutrition should be followed after being discharged from the hospital. We believe that malnutrition is effective in a patient’s outcome, but the condition of the patient and the disease seems to be more decisive for the prognosis. We need more comprehensive studies to explain the relationship between malnutrition and mortality, to see the positive effects of nutrition support given to malnourished patients on nutrition parameters, and to get more definite results. Preventing the progress of malnutrition, assessing, and following elderly patients starting from the beginning of their stay in the hospital by regarding their enteral nutrition; giving extra nutrition support in a suitable way without deteriorating the patient’s general condition; giving long-term support to obtain improvement in nutrition parameters; and following the patient after outcomes are important steps toward improving the clinical results.
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Betul Gulsen Atalay, MSc; Cahide Yagmur, PhD; Tarik Zafer Nursal, MD; Hakan Atalay, MD; and Turgut Noyan, MD
Financial disclosure: none declared.
From the Department of Nutrition, Baskent University, Adana Teaching and Medical Research Center, Adana, Turkey (BGA); Department of Food Engineering, Cukurova University, Adana, Turkey (CY); Department of General Surgery, Baskent University, Adana Teaching and Medical Research Center, Adana, Turkey (TZN, TN); and Department of Cardiovascular Surgery, Baskent University, Adana Teaching and Medical Research Center, Adana, Turkey (HA).
Address correspondence to: Betul Gulsen Atalay, Cukurova University, Department of Food Engineering, Adana 01250, Turkey; e- mail: [email protected].
Copyright American Society for Parenteral and Enteral Nutrition Jul/ Aug 2008
(c) 2008 JPEN, Journal of Parenteral and Enteral Nutrition. Provided by ProQuest LLC. All rights Reserved.
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