Evaluation of the Quality of Prognosis Studies in Systematic Reviews Unintended weight loss in the elderly living at home: The aged in home care project (ADHOC) Effects of a dietetic treatment in older, undernourished, community-dwelling individuals in primary care: a randomized controlled trial The impact of body mass index in old age on cause-specific mortality Dietary intake and eating patterns of elderly people in Israel: who is at nutritional risk? Prognostic significance of monthly weight fluctuations among older nursing home residents. Trajectory and determinants of nutritional health in older patients during and six-month post-hospitalisation. High prevalence of undernutrition in Dutch community-dwelling older individuals. Can physical activity attenuate aging-related weight loss in older people? The Yale Health and Aging Study, 1982-1994. Cost-effectiveness of nutritional intervention in elderly subjects after hip fracture. A randomized controlled trial Periodontal disease and weight loss in older adults. Short-term individual nutritional care as part of routine clinical setting improves outcome and quality of life in malnourished medical patients. The first year of hyperinflation in the former Soviet Union: nutritional deprivation among elderly pensioners, 1992. Nutritional supplementation and dietary advice in geriatric patients at risk of malnutrition. Helping understand nutritional gaps in the elderly (HUNGER): a prospective study of patient factors associated with inadequate nutritional intake in older medical inpatients. Indicators of nutritional risk in a rural elderly Hispanic and non-Hispanic white population: San Luis Valley Health and Aging Study. Dietary counselling and food fortification in stable COPD: a randomised trial Early determinants for the development of undernutrition in an older general population: Longitudinal Aging Study Amsterdam. Malnutrition in a home-living older population: prevalence, incidence and risk factors. A prospective study. Intensive nutritional supplements can improve outcomes in stroke rehabilitation Post-discharge nutritional support in malnourished elderly individuals improves functional limitations. Should oral nutritional supplementation be given to undernourished older people upon hospital discharge? A controlled trial. Malnutrition and cognitive impairment among people 60 years of age and above living in regular housing and in special housing in Sweden: a population-based cohort study.
Prognosis studies are investigations of future events or the evaluation of associations between risk factors and health outcomes in population s of patients ( 1 ) . The results of such studies improve our underst and ing of the clinical course of a disease and assist clinicians in making informed decisions about how best to manage patients . Prognostic research also informs the design of intervention studies by helping define subgroups of patients who may benefit from a new treatment and by providing necessary information about the natural history of a disorder ( 2 ) . There has recently been a rapid increase in the use of systematic review methods to synthesize the evidence on research questions related to prognosis . It is essential that investigators conducting systematic review s thoroughly appraise the method ologic quality of included studies to be confident that a study 's design , conduct , analysis , and interpretation have adequately reduced the opportunity for bias ( 3 , 4 ) . Caution is warranted , however , because inclusion of method ologically weak studies can threaten the internal validity of a systematic review ( 4 ) . This follows abundant empirical evidence that inadequate attention to biases can cause invalid results and inferences ( 5 - 9 ) . However , there is limited consensus on how to appraise the quality of prognosis studies ( 1 ) . A useful framework to assess bias in such studies follows the basic principles of epidemiologic research ( 10 , 11 ) . We focus on 6 areas of potential bias : study participation , study attrition , prognostic factor measurement , confounding measurement and account , outcome measurement , and analysis . The main objectives of our review of review s are to describe methods used to assess the quality of prognosis studies and to describe how well current practice s assess potential biases . Our secondary objective is to develop recommendations to guide future quality appraisal , both within single studies of prognostic factors and within systematic review s of the evidence . We hope this work facilitates future discussion and research on biases in prognosis studies and systematic review s. Methods Literature Search and Study Selection We identified systematic review s of prognosis studies by search ing MEDLINE ( 1966 to October 2005 ) using the search strategy recommended by McKibbon and colleagues ( 12 ) . This strategy combines broad search terms for systematic review s ( systematic review .mp ; meta- analysis .mp ) and a sensitive search strategy for prognosis studies ( cohort , incidence , mortality , follow-up studies , prognos * , predict * , or course ) . We also search ed the reference lists of included review s and method ologic papers to identify other relevant publications . We restricted our search to English- language publications . One review er conducted the search and selected the studies . Systematic review s , defined as review s of published studies with a comprehensive search and systematic selection , were included if they assessed the method ologic quality of the included studies by using 1 or more explicit criteria . We excluded studies if they were meta-analyses of independent patient data only , if their primary goal was to investigate the effectiveness of an intervention or specific diagnostic or screening tests , or if they included studies that were not done on humans . Data Extraction and Synthesis Individual items included in the quality assessment of the systematic review s were recorded as they were reported in the publication ( that is , the information that would be available to readers and future review ers ) . We review ed journal Web sites and contacted the authors of the systematic review s for additional information when authors made such an offer in their original papers . When review s assessed different study design s by using different sets of quality items , we extracted only those items used to assess cohort studies . We constructed a comprehensive list of distinct items that the review s used to assess the quality of their included studies . The full text of each review was screened . All items used by the review authors to assess the quality of studies were extracted into a computerized spreadsheet by 1 review er . Two experienced review ers , a clinical epidemiologist and an epidemiologist , independently synthesized the quality items extracted from the prognosis review s to determine how well the systematic review s assessed potential biases . We did this in 3 steps : 1 ) identified distinct concepts or domains addressed by the quality items ; 2 ) grouped each extracted quality item into the appropriate domain or domains ; and 3 ) identified the domains necessary to assess potential biases in prognosis studies . We then used this information to assess how well the review s ' quality assessment included items from the domains necessary to assess potential biases . After completing each of the first 3 steps , the review ers met to attempt to reach a consensus . The consensus process involved each review er presenting his or her observations and results , followed by discussion and debate . A third review er was available in cases of persistent disagreement or uncertainty . In the first step , all domains addressed by the quality items were identified . The first review er iteratively and progressively defined the domains as items were extracted from the included review s. The second review er defined domains from a r and om list of all extracted quality items . Limited guidance was provided to the review ers so that their assessment s and definitions of domains would be independent . The review ers agreed on a final set of domains that adequately and completely defined all of the extracted items . In the second step , review ers independently grouped each extracted item into the appropriate domains . Review ers considered each extracted item by asking , What is each particular quality item addressing ? or What are the review 's authors getting at with the particular quality assessment item ? . Items were grouped into the domain or domains that best represented the concepts being addressed . For example , the extracted items at least 80 % of the group originally identified was located for follow-up and follow-up was sufficiently complete or does n't jeopardize validity were each independently classified by both review ers as assessing the domain completeness of follow-up adequate , whereas the extracted item quantification and description of all subjects lost to follow-up was classified as assessing the domain completeness of follow-up described . In the third step , we identified the domains necessary to assess potential biases . Each review er considered the ability of the identified domains to adequately address , at least in part , 1 of the following 6 potential biases : 1 ) study participation , 2 ) study attrition , 3 ) prognostic factor measurement , 4 ) confounding measurement and account , 5 ) outcome measurement , and 6 ) analysis . Domains were considered to adequately address part of the framework if information garnered from that domain would inform the assessment of potential bias . For example , both review ers judged that the identified domain study population represents source population or population of interest assessed potential bias in a prognosis study , whereas the domain research question definition did not , although the latter is an important consideration in assessing the inclusion of studies in a systematic review . Finally , on the basis of our previous ratings , we looked at whether each review included items from the domains necessary to assess the 6 potential biases . We calculated the frequency of systematic review s by assessing each potential bias and the number of review s that adequately assessed bias overall . From this systematic synthesis , we developed recommendations for improving quality appraisal in future systematic review s of prognosis studies . We used Microsoft Access and Excel 2002 ( Microsoft Corp. , Redmond , Washington ) for data management and SAS for Windows , version 9.1 ( SAS Institute , Inc. , Cary , North Carolina ) for descriptive statistics . Role of the Funding Sources The funding sources , the Canadian Institutes of Health Research , the Canadian Chiropractic Research Foundation , the Ontario Chiropractic Association , and the Ontario Ministry of Health and Long Term Care , did not have a role in the collection , analysis , or interpretation of the data or in the decision to su bmi t the manuscript for publication . Results We identified 1384 potentially relevant articles . Figure 1 shows a flow chart of studies that were included and excluded . Figure 2 shows the number of review s identified by year of publication . We excluded 131 systematic review s of prognosis studies that did not seem to include any quality assessment of the included studies ; this represented 44 % of prognosis review s. We included 163 review s of prognosis studies in our analysis ( 13 - 175 ) . The most common topics were cancer ( 15 % ) , musculoskeletal disorders and rheumatology ( 13 % ) , cardiovascular ( 10 % ) , neurology ( 10 % ) , and obstetrics ( 10 % ) . Other review s included a wide range of health and health care topics . Sixty-three percent of the review s investigated the association between a specific prognostic factor and a particular outcome ; the remainder investigated multiple prognostic factors or models . The number of primary studies included in each systematic review ranged from 3 to 167 ( median , 18 [ interquartile range , 12 to 31 ] ) . A complete description of the included review s is available from the authors on request . Figure 1 . Flow diagram of inclusion and exclusion criteria of systematic review s. Figure 2 . Number of systematic review s of prognosis studies identified over time . Quality Items One hundred fifty-three review s provided adequate detail to allow extraction of quality items . Eight hundred eighty-two distinct quality items were extracted from the review s. Most review s developed their own set of quality items , with only a few applying criteria from previous review s. Most quality items Objective : To describe associations between unintended weight loss ( UWL ) and characteristics of nutritional status . Design : A comparative cross-sectional assessment study at 11 sites in Europe . The target population was a stratified r and om sample of 4,455 recipients of home care ( 405 in each r and om sample from 11 urban areas ) aged 65 years and older . Measurements : the  Resident Assessment Instrument for Home Care , version 2.0 . Epidemiological and medical characteristics of clients and service utilisation were recorded in a st and ardized , comparative manner . UWL was defined as information of 5 % or more weight loss in the last 30 days ( or 10 % or more in the last 180 days ) . Results : The final sample consisted of 4,010 persons ; 74 % were female . The mean ages were 80.9 ± 7.5 years ( males ) and 82.8 ± 7.3 years ( females ) . No associations were found between single diagnoses and UWL , except for cancer . Cancer patients were excluded from further analyses . Persons with a Cognitive Performance Scale value ( CPS ) > 3 ( impaired ) had increased risk of UWL ( OR = 2.0 ) compared with those scoring ≤ 3 ( less impaired ) . Only in the oldest group did we find a significant association between UWL and reduction in ADL and IADL functions , comparing those who scored 3 or less with those who scored more than 3 ( disabled ) . A binary logistic regression model explained 26 % of UWL : less than one meal/day , reduced appetite , malnutrition , reduced social activity , experiencing a flare-up of a recurrent or chronic problem , and hospitalisation were important indicators . Conclusion : We recommend a regular comprehensive assessment in home care to identify clients with potential risk factors for weight loss and malnutrition , in particular those discharged from hospital , and those with physical dependency or cognitive problems . This study may provide incentives to create tailored preventive strategies Purpose Undernutrition is a prevalent problem in older , community-dwelling individuals . Aim of this study was to determine the effects of a dietetic treatment in older , undernourished , community-dwelling individuals . Methods A parallel r and omized controlled trial was performed in 146 non-institutionalized , undernourished individuals aged ≥65 years in primary care . Participants were r and omly assigned to the intervention ( referral to and treatment by a trained dietitian ) or control group ( no referral )  . Body weight , physical performance , h and grip strength , energy intake , protein intake and fat-free mass were assessed at baseline , after 3 months and after 6 months . Results All r and omized participants ( n = 146 ) were included in the intention-to-treat generalized estimating equations analysis ( 72 in intervention and 74 in control group ) . No treatment effect was found on the primary outcomes body weight ( β = 0.49 kg , 95 % CI : −0.15–1.12 ) , physical performance ( β = 0.15 points , 95 % CI : −0.33–0.64 ) and h and grip strength ( β = 0.49 kg , 95 % CI : −0.62–1.60 ) . Furthermore , no treatment effect was found for the secondary outcomes . Predefined subgroup analyses showed a treatment effect on body weight in physically active participants ( β = 1.25 kg , 95 % CI : 0.70–2.11 ) and not in inactive participants ( β = −0.20 kg , 95 % CI : −1.16–0.75 ) . Conclusions After 6 months , a dietetic treatment by trained dietitians does not lead to increases in body weight and physical functioning in older , undernourished , community-dwelling individuals Objectives To assess the association between Body Mass Index ( BMI ) and cause-specific mortality  in older adults and to assess which BMI was associated with lowest mortality . Design Prospect i ve study . Setting European towns . Participants 1,980 older adults , aged 70–75 years from the SENECA ( Survey in Europe on Nutrition and the Elderly : a concerted action ) study . Measurements  BMI  , examined in 1988/1989 , and mortality rates and causes of death during 10 years of follow-up . Results Cox proportional hazards model including both BMI and BMI 2 , accounting for sex , smoking status , educational level and age at baseline showed that BMI was associated with all-cause mortality ( p<0.01 ) , cardiovascular mortality ( p<0.01 ) and mortality from other causes ( p<0.01 ) , but not with cancer or respiratory mortality ( p>0.3 ) . The lowest all-cause mortality risk was found at 27.1 ( 95%CI 24.1 , 29.3 ) kg/m2 , and this risk was increased with statistical significance when higher than 31.4 kg/m2 and lower than 21.1 kg/m2 . The lowest cardiovascular mortality risk was found at 25.6 ( 95%CI 17.1 , 28.4 ) kg/m2 , and was increased with statistical significance when higher than 30.9 kg/m2 . Conclusion In this study , BMI was associated with all-cause mortality risk  in older people . This risk was mostly driven by an increased cardiovascular mortality risk , as no association was found for mortality risk from cancer or respiratory disease . Our results indicate that the WHO cut-off point of 25 kg/m2 for overweight might be too low in old age , but more studies are needed to define specific cut-off points Objective : To determine dietary intake and eating patterns of older persons in Israel and to identify factors associated with low intake . Design : A cross-sectional study . Setting : Community-dwelling participants living in the Beer-Sheva area were interviewed at home , using a 24 h food question naire with additional questions regarding health and eating habits . Dietary intake was compared between people aged 65–74 and 75 y and older . Subjects : A total of 377 people over the age of 65 224 aged 65–74 and 153>75 , were r and omly selected from the Negev population . Results :  Dietary intake of energy , fat , carbohydrates , vitamins E , C and B1 were significantly lower for people aged 75 and older compared with people aged 65–74 .  Low energy intake was associated with lower subjective health status for men ( P<0.01 ) , poor appetite ( P<0.01 ) and more gastrointestinal problems ( P<0.05 ) for women and lower snack consumption ( P<0.01 ) for both genders . In a multivariate model , low energy intake was associated with low appetite and higher use of medication for both sexes and with frequency of eating alone and not consuming snacks for men . Conclusion :  Dietary intake  is lower among individuals older than 75 than in 65–74 y old . Risk factors for low intake include poor appetite and health status , gastrointestinal problems , and eating alone .  Snacking enhanced dietary intake and should be encouraged in this group . Sponsorship : Goldman Fund for Ben-Gurion University of the Negev BACKGROUND Although weight change in older persons has proven prognostic significance , it is not known whether monthly weights obtained by the clinical staff in long-term care institutions are reliable enough to be useful in identifying at-risk residents . The objective of this study was to determine whether an association exists between mortality risk and the intraresident variation in weight in long-term care institutions . METHODS For this study , 900 nursing home residents with a recently identified nutritional problem from 96 long-term care facilities in 8 states were r and omly selected . At study entry , nutritional , health status , and demographic data were extracted from the nursing home chart or the Minimum Data Set . Weights obtained by the nursing home staff were recorded at baseline and during each of the subsequent 6 months . Cox proportional hazards regression analysis was used to assess relationships between weight parameters and mortality risk during the 7 months of observation . RESULTS During the study , 435 ( 48 % ) participants had at least 1 monthly weight that differed from the previous month 's weight by > or = 5 % ; 163 ( 18 % ) participants had this magnitude of a 1-month weight change more than once . By controlling for the linear trend ( i.e. , slope ) of each residents ' weight change between the first to the last weight , the average month-to-month residual variability in the resident 's weights was calculated . This residual variability or " average r and om fluctuation " in weight from 1 month to the next was > or = 2 % in 229 ( 25 % ) participants and > or =3 % in 82 ( 9 % ) participants . Despite the large r and om fluctuation in the residents ' weights , weight loss was an important prognostic indicator . Those who lost > or = 5 % in any month had a 10-fold increased risk for death compared with those who gained weight ( adjusted relative risk , 10.6 ; 95 % confidence interval , 3.2 to 35.5 ) . The average r and om fluctuation in weight was associated with an increased risk for death only at the upper 10th percentile for the population . CONCLUSIONS Many nutritionally compromised elderly nursing home residents experience significant bidirectional fluctuations in their weight from month to month . How much of this variability is due to measurement error is not known . However , a weight loss of > or = 5 % in any month has important prognostic implication AIM The aim of this study was to characterise the trajectory and to identify determinants of nutritional health over time in a sample of older hospitalised patients , using the Generalized Estimating Equation . BACKGROUND Nutritional health deteriorates and may fluctuate over time during and post-hospitalisation . To develop a target intervention it is essential that we first have a clear picture of how the nutrition changes and examine the determinants of nutritional health during and post-hospitalisation . DESIGN A prospect i ve cohort study was conducted on 306 older hospitalised patients aged 65 years and older . METHODS Subjects were recruited from five surgical and medical wards at a tertiary medical center in northern Taiwan and assessed at four points in time : within 48 hours after admission , before discharge and 3 - 6 months post-discharge . RESULTS Nutritional health fluctuated significantly over time . The curve dropped during hospitalisation , returned at three months and rose slightly at six months post hospitalisation . After controlling for length of stay and surgical treatment , patients showed decreased cognitive capacity , worsening oral health , increased use of medications , increased functional limitations and raised depressive symptoms , all of which affects their nutritional health over time . The extent of functional status impacting on nutrition varies at different points in time while the predictability of other determinants remained stable . CONCLUSION The trajectory of nutritional health is a reflection of the patients ' cognitive status , oral health , medication taken , functional status and depressive symptoms . The findings of our study should provide guidance in the development of intervention for the nutritional health of older patients during inpatient as well as transitional care . RELEVANCE TO CLINICAL PRACTICE Multi-faceted packages of interventions targeting a range of determinants for managing undernutrition and subsequent decline during and post-hospitalisation need to be tested OBJECTIVE To examine the prevalence of undernutrition in community-dwelling older individuals ( ≥65 y ) using data from various setting s. METHODS A cross-sectional observational study was performed to examine the prevalence of undernutrition in three sample s ( all ≥65 y ) : 1 ) 1267 community-dwelling individuals participating in a large prospect i ve population -based study , the Longitudinal Aging Study Amsterdam ( LASA ) in 1998/99 ; 2 ) 814 patients receiving home care in 2009/10 ; and 3 ) 1878 patients from general practice s during the annual influenza vaccination in 2009/10 .  Undernutrition was assessed by the Short Nutritional Assessment Question naire 65 + . RESULTS  Mean age was 77.3 y ( SD 6.7 ) in the LASA sample , 81.6 y ( SD 7.4 ) in the home care sample , and 75.3 y ( SD 6.5 ) in the general practice sample .  The prevalence of undernutrition was highest in the home care sample ( 35 % ) , followed by the general practice ( 12 % ) and LASA ( 11 % ) sample s. The prevalence of undernutrition increased significantly with age in the general practice and LASA sample s. Gender differences were observed in the general practice and home care sample s ; women were more likely to be undernourished in the general practice sample and men were more likely to be undernourished in the home care sample . CONCLUSION The prevalence of undernutrition in Dutch community-dwelling older individuals was relatively high , especially in home care patients The purpose of this analysis was to determine the longitudinal relation between physical activity and the trajectory of weight change in an older cohort ( > or = 65 years ) living in New Haven , Connecticut , who participated in the Established Population s for the Epidemiologic Study of the Elderly between 1982 and 1994 ( n=2,812 ) . The authors hypothesized that body weight would decline over the follow-up and that physical activity would play an important role in minimizing weight loss over time . Physical activity and other covariables were self-reported at baseline , while body weight was self-reported annually over 12 years . Multivariable r and om effects regression demonstrated a curvilinear trajectory of weight loss per year with an accelerated loss at older ages . Baseline body weight was 155 ( st and ard deviation , 30 ) pounds ( 70 ( st and ard deviation , 14 ) kg ) for those who survived the entire follow-up and was 153 ( st and ard deviation , 32 ) pounds ( 70 ( st and ard deviation , 15 ) kg ) for those who did not . Each 1-unit increase in baseline total activity score minimized this aging-related weight loss , but this relation was most pronounced among those with chronic disease who did not survive the entire follow-up period ( n=973 ; 0.15 pounds ( 0.07 kg ) per year ) . These data suggest that , among frail older people , even modest levels of physical activity can attenuate the rate of aging- and disease-related weight loss Summary Hip fracture patients can benefit from nutritional supplementation during their recovery . Up to now , cost-effectiveness evaluation of nutritional intervention in these patients has not been performed . Costs of nutritional intervention are relatively low as compared with medical costs . Cost-effectiveness evaluation shows that nutritional intervention is likely to be cost-effective . Introduction Previous research on the effect of nutritional intervention on clinical outcome in hip fracture patients yielded contradictory results . Cost-effectiveness of nutritional intervention in these patients remains unknown . The aim of this study was to evaluate cost-effectiveness of nutritional intervention in elderly subjects after hip fracture from a societal perspective . Methods Open-label , multi-centre r and omized controlled trial investigating cost-effectiveness of intensive nutritional intervention comprising regular dietetic counseling and oral nutritional supplementation for 3 months postoperatively . Patients allocated to the control group received care as usual .  Costs , weight and quality of life were measured at baseline and at 3 and 6 months postoperatively . Incremental cost-effectiveness ratios ( ICERs ) were calculated for weight at 3 months and quality adjusted life years ( QALYs ) at 6 months postoperatively . Results Of 152 patients enrolled , 73 were r and omized to the intervention group and 79 to the control group .  Mean costs of the nutritional intervention was 613 Euro . Total costs and subcategories of costs were not significantly different between both groups . Based on bootstrapping of ICERs , the nutritional intervention was likely to be cost-effective for weight as outcome over the 3-month intervention period , regardless of nutritional status at baseline . With QALYs as outcome , the probability for the nutritional intervention being cost-effective was relatively low , except in subjects aged below 75 years . Conclusion Intensive nutritional intervention in elderly hip fracture patients is likely to be cost-effective for weight but not for QALYs . Future cost-effectiveness studies should incorporate outcome measures appropriate for elderly patients , such as functional limitations and other relevant outcome parameters for elderly OBJECTIVES To determine the association between periodontal disease and weight loss in an elderly cohort . DESIGN A longitudinal design was used with participants from the Health , Aging and Body Composition ( Health ABC ) cohort study to determine the association between periodontal disease status and weight loss of at least 5 % of baseline body weight over a period of 2 years . SETTING Participants were examined in research clinics in Pittsburgh , Pennsylvania , and Memphis , Tennessee . PARTICIPANTS A r and omly selected subset of 1,053 individuals from the Health ABC examination , aged 65 and older , ambulatory and community-dwelling at baseline . MEASUREMENTS Periodontal disease was measured as mean pocket depth and attachment loss , extent ( percentage ) of pockets with at least 6 mm probing depth , extent of bleeding on probing , and tissue inflammation . RESULTS In logistic regression models adjusting for variables that may explain weight loss , extent of periodontal pockets with at least 6 mm probing depth showed a significant association with weight loss ( odds ratio=1.53 , 95 % confidence interval=1.32 - 1.77 ) . CONCLUSION Periodontal disease may be causally related to weight loss in the elderly and thus may increase risk of morbidity and mortality BACKGROUND & AIMS Strategies to treat malnutrition lack practicability in the hospital setting . The present study aim ed at developing and evaluating a routinely manageable concept for an improved nutritional care of malnourished in-hospital patients . METHODS A r and omized controlled intervention study was conducted . 132 risk patients defined by Nutritional Risk Screening 2002 , were r and omized to individualised nutrition support  ( intervention group [ n = 66 ] ) or  st and ard hospital care ( control group [ n = 66 ] ) . Body weight , plasma vitamin levels , quality of life , complications , antibiotic therapies , readmissions and mortality were assessed . RESULTS Nutrition interventions led to higher intakes ( mean [ st and ard deviation ] ) in energy ( 1553 [ 341 ] kcal vs. 1115 [ 381 ] kcal , p < 0.001 ) and protein ( 65.4 [ 16.4 ] g vs. 43.9 [ 17.2 ] g , p < 0.001 ) . Intervention patients ( n = 66 ) kept their body weight in comparison to control patients ( n = 66 ; 0.0 [ 2.9 ] kg vs. -1.4 [ 3.2 ] kg , p = 0.008 ) . Positive effects on plasma ascorbic acid level ( 46.7 [ 26.7 ] μmol/l vs. 34.1 [ 24.2 ] μmol/l , p = 0.010 ) , SF-36 function summary scale ( 37 [ 11 ] % vs. 32 [ 9 ] % , p = 0.030 ) , number of complications ( 4/66 vs. 13/66 , p = 0.035 ) , antibiotic therapies ( 1/66 vs. 8/66 , p = 0.033 ) and readmissions ( 17/64 vs. 28/61 , p = 0.027 ) were recorded . CONCLUSIONS Malnourished patients profit from nutrition support regarding nutrition status and quality of life . They have fewer complications , need fewer antibiotics and are less often re-hospitalised OBJECTIVES Hyperinflation began in early 1992 in the former Soviet Union . This paper describes factors associated with nutritional status that year among elderly pensioners . METHODS Approximately 300 pensioners were selected r and omly in each of eight cities . Surveys of diet , weight , health status , and social and economic conditions were done between June and December 1992 . This paper reports on 2281 completed question naires . RESULTS Half the pensioners reported that they had lost 5 or more kilograms in the prior 6 months ; 57 % did not have enough money to buy food , and 39 % needed medicines they could not afford . Forty percent consumed less than a half kilogram of meat , 50 % consumed less than a half kilogram of fruit , a third consumed less than a liter of milk , and a third consumed less than 2 kg of bread per week . Weight loss was strongly associated with not having enough money to buy food , and inability to afford medication , and consumption of fewer than three meals a day . Concurrent with these conditions , there was a large increase in mortality in Russia . CONCLUSIONS The results of these surveys suggest that many elderly pensioners were experiencing severe nutritional deprivation in the latter half of 1992 BACKGROUND & AIM Effects of combined nutritional treatment of patients at risk of protein-energy malnutrition ( PEM ) discharged from a geriatric service were evaluated . METHODS Patients ( n=108 , age 85+/-6 years ) at risk of malnutrition according to the short form of the mini nutritional assessment were r and omly allocated to dietary counseling , including liquid and multivitamin supplementation , i.e. intervention ( I , n=51 ) and to controls ( C , n=57 ) . Body weight , biochemical indices ( e.g. insulin-like growth factor I ( IGF-I ) ) , Katz activities of daily living ( ADL ) index , mini mental status examination ( MMSE ) and quality of life ( QoL ) by SF-36 were assessed at the start of the study and after 4 months . Statistical analyses were performed on " intention-to-treat " and on " treated-as- protocol " bases . RESULTS Fifty-four patients , 29 in the I-group ( 86+/-7 years , 66 % females ) and 25 in the C-group ( 85+/-7 years , 72 % females ) completed the study according to the protocol . Both modes of analysis revealed a significant positive effect of the combined nutritional intervention on weight maintenance . Treated-as- protocol analyses showed that Katz ADL index improved in the I-group ( p<0.001 ; p<0.05 between the groups ) . Serum IGF-I levels increased in the I-group ( p<0.001 ) , but were unchanged in the C-group ( p=0.07 between the groups ) . QoL was assessed to be low and had not changed after nutritional treatment . CONCLUSIONS Combined nutritional intervention prevented weight loss and improved ADL functions in discharged geriatric patients at risk of malnutrition BACKGROUND & AIMS Malnutrition and poor intake during hospitalisation are common in older medical patients . Better underst and ing of patient-specific factors associated with poor intake may inform nutritional interventions . The aim of this study was to measure the proportion of older medical patients with inadequate nutritional intake , and identify patient-related factors associated with this outcome . METHODS Prospect i ve cohort study enrolling consecutive consenting medical in patients aged 65 years or older . Primary outcome was  energy intake less than resting energy expenditure  estimated using weight-based equations .  Energy intake was calculated for a single day using direct observation of plate waste . Explanatory variables included age , gender , number of co-morbidities , number of medications , diagnosis , usual residence , nutritional status , functional and cognitive impairment , depressive symptoms , poor appetite , poor dentition , and dysphagia . RESULTS Of 134 participants ( mean age 80 years , 51 % female ) , only 41 % met estimated resting energy requirements . Mean energy intake was 1220 kcal/day ( SD 440 ) , or 18.1 kcal/kg/day . Factors associated with inadequate energy intake in multivariate analysis were poor appetite , higher BMI , diagnosis of infection or cancer , delirium and need for assistance with feeding . CONCLUSIONS Inadequate nutritional intake is common , and patient factors contributing to poor intake should be considered in design ing nutritional interventions OBJECTIVE To describe the prevalence of nutritional risk factors among elderly residents in a rural Hispanic and non-Hispanic white population . DESIGN A geographically based survey of community-dwelling elderly adults . SUBJECTS/ SETTING From July 1993 to July 1995 , all Hispanic persons older than 65 years and an age-stratified , r and om sample of 69 % of non-Hispanic white persons , from 2 Colorado counties , were invited to participate in a study of functional impairment and disability ( 81 % responded ) . After exclusion of 184 respondents who required a surrogate respondent and 8 with missing diet data , the study consisted of 1,006 subjects .  Interviews included questions similar to the Nutrition screening Initiative checklist , a 21-item food frequency question naire , and anthropometric measures . STATISTICAL ANALYSES PERFORMED Gender- and ethnicity-specific , age-adjusted prevalence for each risk factor was estimated by use of logistic regression . RESULTS Hispanic participants were more likely than non-Hispanic whites to report inadequate intake of vegetables , problems with teeth or dentures that limited the kinds and amounts of food eaten , difficulty preparing meals , and lack of money needed to buy food . Hispanic women reported nutritional risk factors more often than Hispanic men , although anthropometric markers indicated that Hispanic men may be at higher risk of nutritional deficiency . APPLICATIONS/ CONCLUSIONS Hispanic men and women had a higher prevalence of  nutritional risk factors  than non-Hispanic whites . Intervention programs targeting rural , elderly Hispanics should aim to ensure that basic nutrition needs ( access to food , help preparing meals , and adequate dental care ) are being met . Community programs to increase activity levels and consumption of nutrient-dense foods are recommended Background : Malnutrition in chronic obstructive pulmonary disease ( COPD ) is associated with a poor prognosis , yet evidence to support the role of dietary counselling and food fortification is lacking . A study was undertaken to assess the impact of dietary counselling and food fortification on outcome in out patients with COPD who are at risk of malnutrition . Methods : A r and omised controlled unblinded trial was performed in 59 out patients with COPD ( 6 months intervention and 6 months follow-up ) . The intervention group received dietary counselling and advice on food fortification and the controls received a dietary advice leaflet . Outcome measures were nutritional status , respiratory and skeletal muscle strength , respiratory function , perceived dyspnoea , activities of daily living ( ADL ) and quality of life . Results : The intervention group consumed more energy ( difference 194 kcal/day ; p = 0.02 ) and protein ( difference 11.8 g/day ; p<0.001 ) than controls . The intervention group gained weight during the intervention period and maintained weight during follow-up ; the controls lost weight throughout the study . Significant differences were observed between the groups in St George ’s Respiratory Question naire total score ( difference 10.1 ; p = 0.02 ) , Short Form-36 health change score ( difference 19.2 ; p = 0.029 ) and Medical Research Council dyspnoea score ( difference 1.0 ; p = 0.03 ) ; the difference in ADL score approached statistical significance ( difference 1.5 ; p = 0.06 ) . No differences were observed between groups in respiratory function or skeletal and respiratory muscle strength . Improvements in some variables persisted for 6 months beyond the intervention period . Conclusion : Dietary counselling and food fortification result ed in weight gain and improvements in outcome in nutritionally at-risk out patients with COPD , both during and beyond the intervention period Undernutrition may be an important modifiable risk factor for poor clinical outcomes in older individuals . To achieve earlier detection or prevention of undernutrition , more information is needed about risk factors for the development of undernutrition in community-dwelling older individuals . The objective was to identify early determinants of incident undernutrition in a prospect i ve population -based study . Baseline data ( 1992 - 3 ) on socio-economic , psychological , medical , functional , lifestyle and social factors of 1120 participants aged 65 - 85 years of the Longitudinal Aging Study Amsterdam were used . Undernutrition , defined as a BMI < 20 kg/m2 or self-reported involuntary weight loss ≥ 5 % in the last 6 months , was assessed every 3 years during a 9-year follow-up period . Cox proportional-hazards regression analysis was used to investigate the association between early determinants at baseline and incident undernutrition . In 9 years , 156 participants ( 13·9 % ) developed undernutrition . In univariate analyses , female sex , depressive symptoms , anxiety symptoms , multiple chronic diseases , high medication use ( women ) , poor appetite , no alcohol use v. light alcohol use , loneliness , not having a partner , limitations in performing normal activities due to a health problem , low physical performance ( participants aged < 75 years ) and reporting difficulties walking stairs ( participants aged < 75 years ) were statistically significantly associated with incident undernutrition . In a multivariate model , poor appetite and reporting difficulties walking stairs ( participants aged < 75 years ) remained early determinants . The results of the present study can be used to identify subgroups of older individuals with increased risk of undernutrition and to identify modifiable determinants for the purpose of prevention of undernutrition AIMS AND OBJECTIVES To prospect ively investigate and describe the prevalence and incidence of malnutrition among home-living older people , related to demographic and medical factors , self-perceived health and health-related quality of life . Another aim was to find predictors for developing risk of malnutrition . BACKGROUND Risk factors for malnutrition have previously been identified as diseases , several medications , low functional status , symptoms of depression and inadequate nutrient intake . Most studies are cross-sectionally performed at hospitals or in nursing care setting s. DESIGN A prospect i ve study with a sample of 579 home-living older people , r and omly selected from a local national register . Examinations were performed at baseline and yearly follow-ups two to four times . METHOD Question naires vali date d and tested for reliability , to detect risk of malnutrition  ( Mini Nutritional Assessment ) , symptoms of depression ( Geriatric Depression Scale-20 ) , cognitive function (  Mini Mental State Examination ) , health-related quality of life ( Nottingham Health Profile ) , well-being ( Philadelphia Geriatric Center Multilevel Assessment Instrument ) self-perceived health , demographic factors , anthropometry and biochemical examinations . Predictors were search ed for through multiple logistic regression analysis with the MNA as dependent factor . RESULTS The prevalence of risk for malnutrition was 14.5 % , according to the MNA . Two risk factors for malnutrition were lower h and grip strength and lower self-perceived health . The incidence of risk for malnutrition at follow-ups was between 7.6 % and 16.2 % . Predictors for developing malnutrition were higher age , lower self-perceived health and more symptoms of depression .  Men with symptoms of depression had a higher risk of developing malnutrition . CONCLUSION Lower self-perceived health had the highest power to predict risk for malnutrition , with increased number of depression symptoms and higher age as second and third predictors . RELEVANCE TO CLINICAL PRACTICE A regular and combined assessment using the Mini Nutrition Assessment , Geriatric Depression Scale-20 and self-perceived health as a base for identifying people in need , is one way to prevent the development of malnutrition Objective : Poor nutrition is a common complication of strokes severe enough to require inpatient rehabilitation . We therefore tested whether intensive nutritional supplements given to undernourished patients from the time of their admission to a specialized stroke rehabilitation service would improve patient outcomes . Methods : R and omized , prospect i ve , double-blind , single center study comparing intensive nutritional supplementation to routine nutritional supplementation in 116 undernourished patients admitted to a stroke service . The analysis included the 90 % of patients who were not lost to follow-up due to acute or subacute hospitalization ( n = 102 ; 51 in each group ) . The nutritional supplements are commercially available and Food and Drug Administration approved . The primary outcome variable was change in total score on the Functional Independence Measure ( FIM ) . The secondary outcome measurements included the FIM motor and cognitive subscores , length of stay ( taken from day of admission ) , 2-minute and 6-minute timed walk tests measured at admission and on discharge , and discharge disposition ( home/not home ) . Results : Patients receiving intensive nutritional supplementation improved more than those on st and ard nutritional supplements on measures of motor function ( total FIM , FIM motor subscore , 2-minute and 6-minute timed walk tests , all significant at p < 0.002 ) . They did not , however , improve on measures of cognition ( FIM cognition score ) . A higher proportion of patients who received the intensive nutritional supplementation went home compared to those on st and ard supplementation ( p = 0.05 ) . Conclusion : Intensive nutritional supplementation , using readily available commercial preparations , improves motor recovery in previously undernourished patients receiving intensive in-patient rehabilitation after stroke . GLOSSARY : F-M = Fugl-Myer ; FIM = Functional Independence Measure ; FOOD = Feed or Ordinary Diet ; LOS = length of stay ; NIHSS = NIH Stroke Scale BACKGROUND Older people are vulnerable to malnutrition , which leads to negative outcomes . This study evaluates the effectiveness of nutritional supplementation in malnourished elderly patients after hospital discharge . METHODS Hospital-admitted malnourished elderly patients ( ≥ 60 years ) were r and omized to receive either nutritional supplementation ( energy and protein enriched diet , oral nutritional support , calcium-vitamin D supplement , telephone counseling by a dietitian ) for 3 months postdischarge or usual care . Outcomes were functional limitations , physical performance , physical activities , body weight , fat-free mass , and h and grip strength . Measurements were performed at hospital admission ( baseline ) and at 3 months after discharge . Data were analyzed according to the intention-to-treat principle . FINDINGS A total of 210 patients were included , 105 in each group . Body weight increased more in the intervention group than in the control group ; this was significant for the highest body weight category ( mean difference 3.4 kg , 95 % CI 0.2 - 6.6 ) . Functional limitations decreased more ( mean difference -0.5 ( 95 % CI -1.0 - 0.1 ) in the intervention group than in the control group . When excluding patients who had already received nutritional support before the start of the study , this reached significance . No significant differences could be demonstrated for physical performance , physical activities , fat-free mass , or h and grip strength . INTERPRETATION Three months of oral nutritional support to malnourished elderly decreased functional limitations and increased body weight . It can be question ed if a follow-up of only 3 months was not too short to detect differences on physical performance and physical activities as well OBJECTIVES To determine whether the oral nutritional supplementation of undernourished older people upon discharge from hospital improves muscle function and reduces disability . DESIGN R and omized controlled trial . SETTING Community-based study in two centers in Scotl and . PARTICIPANTS Two hundred fifty-three people . INTERVENTION R and omization to oral nutritional supplementation ( 600 kcal/d ) or control supplement of 200 kcal/d . MEASUREMENTS Primary outcome ( 20-point activity of daily living Barthel Index ) and secondary outcomes ( h and grip strength , Sit-to-St and test , and Euroquol ) were measured at baseline ( after discharge from the hospital and before supplement was commenced ) and 8 and 16 weeks and accelerometry-measured physical activity levels at baseline and 16 weeks . Falls were recorded prospect ively . RESULTS Mean age was 82 . There was no significant difference in change in Barthel score between supplement and control groups ( adjusted mean difference=0.28 , 95 % confidence interval (CI)=-0.28 - 0.84 ) . H and grip strength improved more in the supplemented group ( adjusted mean difference=1.52 kg , 95 % CI=0.50 - 2.55 ; P=.004 ) . The supplemented group exhibited modestly greater vector movement ( overall activity ) than controls ( P=.02 ) . There were no significant between-group differences in Sit-to-St and test , health-related quality of life , or falls . Adherence was 38.2 % in the nutritional supplement group and 50.0 % in the control supplement group . Weight did not increase in the nutritional supplement group as a whole , but on-treatment analysis adjusting for adherence showed a mean weight gain of 1.17 kg ( 95 % CI=0.07 - 2.27 ; P=.04 ) more than in controls . CONCLUSION Oral nutritional supplementation  of undernourished older people upon hospital discharge did not reduce disability , despite improving h and grip strength and modestly increasing objective ly measured physical activity levels . Lack of an effect of the nutritional supplement used in this study may have been due to low adherence , suggesting that different approaches to nutritional supplementation need to be tested in this population BACKGROUND Malnutrition is a common problem among older people and associated with reduced functional and cognitive ability . Furthermore , malnutrition among people living in special housing , i.e. in nursing homes or sheltered accommodation , appears to be more common than among those living in regular housing , i.e. in their own homes . However , it is still unclear if the relationship between malnutrition and impaired cognitive ability is connected to living arrangement , i.e. if the relationship is stronger among those who live alone compared to those who cohabit in regular housing . OBJECTIVES The purpose with the present study was to describe the relationship between nutritional status and cognitive ability among people 60 years of age and above in Sweden , with a focus on housing and living arrangement .  DESIGN Population -based cohort study . SETTING AND PARTICIPANTS The study focused on people living in regular or in special housing and comprised 1,402 r and omly selected individuals ( 60 - 96 years of age ) who lived in one municipality in south-eastern Sweden and participated in SNAC-B ( the Swedish study on Aging and Care - Blekinge ) , 2001 - 2003 . METHODS Data regarding demography , nutrition and functional and cognitive ability were collected through question naires , medical examinations and structured interviews . RESULTS The relationship was the strongest between cognitive ability and nutritional status among those living in special housing . Regardless of housing and living arrangement , older people with a moderate or severe cognitive impairment risked ( OR 2.59 - 16.00 ) being malnourished , irrespective of functional ability . CONCLUSION This study highlights that those with a moderate and severe cognitive impairment suffer a risk of developing malnutrition , irrespective of living and housing arrangement . The findings suggest that nurses in the social service and health care system need to consider changes in weight and nutritional intake as well as the individual needs of older people with cognitive impairment to avoid malnutrition
Protein-energy malnutrition is associated with numerous poor health outcomes , including high health care costs , mortality rates and poor physical functioning in older adults .
This systematic literature review aims to identify and provide an evidence based overview of potential determinants of protein-energy malnutrition in community-dwelling older adults .