A cluster randomised feasibility trial evaluating nutritional interventions in the treatment of malnutrition in care home adult residents Influence of Raised Plasma Osmolality on Clinical Outcome After Acute Stroke Malnutrition in hip fracture patients: an intervention study. Weight loss, exercise, or both and physical function in obese older adults. Nutrition support (tube feeding) as a rehabilitation intervention. Validation of multi-frequency bioelectrical impedance analysis in detecting changes in fluid balance of geriatric patients. Complications and mortality after percutaneous endoscopic gastrostomy in geriatrics: a prospective multicenter observational trial. Comprehensive care improves health outcomes among elderly Taiwanese patients with hip fracture. Subcutaneous fluids in elderly hospital patients with cognitive impairment. Oral nutritional supplements in a randomised trial are more effective than dietary advice at improving quality of life in malnourished care home residents. Survival in malnourished older patients receiving post-discharge nutritional support; long-term results of a randomized controlled trial Is dietetic treatment for undernutrition in older individuals in primary care cost-effective? Gastrointestinal tolerance and plasma status of carotenoids, EPA and DHA with a fiber-enriched tube feed in hospitalized patients initiated on tube nutrition: Randomized controlled trial. Cost-effectiveness of a disease-specific oral nutritional support for pressure ulcer healing. Biological variation and diagnostic accuracy of dehydration assessment markers. AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY COMPREHENSIVE CLINICAL PRACTICE GUIDELINES FOR MEDICAL CARE OF PATIENTS WITH OBESITY. Improved performance in activities of daily living and mobility after a multidisciplinary postoperative rehabilitation in older people with femoral neck fracture: a randomized controlled trial with 1-year follow-up. Community Weight Loss to Combat Obesity and Disability in At-Risk Older Adults Randomized clinical trial of nutritional supplementation shows little effect on functional status among free-living frail elderly. The effects of exercise and protein-energy supplements on body composition and muscle function in frail elderly individuals: a long-term controlled randomised study. Is this elderly patient dehydrated? Diagnostic accuracy of hydration assessment using physical signs, urine, and saliva markers. Follow-up home visits with registered dietitians have a positive effect on the functional and nutritional status of geriatric medical patients after discharge: a randomized controlled trial Exercise and dietary weight loss in overweight and obese older adults with knee osteoarthritis: the Arthritis, Diet, and Activity Promotion Trial. Effect of family style mealtimes on quality of life, physical performance, and body weight of nursing home residents: cluster randomised controlled trial Accuracy of prediction equations for serum osmolarity in frail older people with and without diabetes1234 Effects of a dietetic treatment in older, undernourished, community-dwelling individuals in primary care: a randomized controlled trial Individualized nutritional intervention during and after hospitalization: the nutrition intervention study clinical trial. Dysphagia in elderly nursing home residents with severe cognitive impairment can be attenuated by cervical spine mobilization. Effect of moderate intensity resistance training during weight loss on body composition and physical performance in overweight older adults Hydration and outcome in older patients admitted to hospital (The HOOP prospective cohort study) Effects of two models of nutritional intervention on homebound older adults at nutritional risk. Nutritional Supplementation Decreases Hip Fracture-related Complications Health, wellbeing and nutritional status of older people living in UK care homes: an exploratory evaluation of changes in food and drink provision Does looped nasogastric tube feeding improve nutritional delivery for patients with dysphagia after acute stroke? A randomised controlled trial. Effects of dietary supplements on depressive symptoms in older patients: a randomised double-blind placebo-controlled trial. Is it possible to increase weight and maintain the protein status of debilitated elderly residents of nursing homes? Cost-effectiveness of an interdisciplinary intervention in geriatric inpatients to prevent malnutrition. Mini Nutritional Assessment predicts gait status and mortality 6 months after hip fracture. The Effect of Caffeinated, Non-Caffeinated, Caloric and Non-Caloric Beverages on Hydration Effect of timing and method of enteral tube feeding for dysphagic stroke patients (FOOD): a multicentre randomised controlled trial. Is looped nasogastric tube feeding more effective than conventional nasogastric tube feeding for dysphagia in acute stroke? A multidisciplinary, multifactorial intervention program reduces postoperative falls and injuries after femoral neck fracture Using dietetic assistants to improve the outcome of hip fracture: a randomised controlled trial of nutritional support in an acute trauma ward. Functional recovery of older people with hip fracture: does malnutrition make a difference? Clinical benefits of oral nutritional supplementation for elderly hip fracture patients: a single blind randomised controlled trial. Subcutaneous dextrose for rehydration of elderly patients – an evidence-based review Nursing intervention to promote functional feeding. Whey protein, amino acids, and vitamin D supplementation with physical activity increases fat-free mass and strength, functionality, and quality of life and decreases inflammation in sarcopenic elderly. Postoperative delirium in old patients with femoral neck fracture: a randomized intervention study Evaluation of nutritional status and its relationship with functional status in older citizens with diabetes mellitus using the mini nutritional assessment (MNA) tool--a preliminary investigation. Short-term individual nutritional care as part of routine clinical setting improves outcome and quality of life in malnourished medical patients. Outcomes of percutaneous endoscopic gastrostomy among older adults in a community setting. Short-term oral nutritional intervention with protein and vitamin D decreases falls in malnourished older adults. Comprehensive and subacute care interventions improve health-related quality of life for older patients after surgery for hip fracture: a randomised controlled trial. A nutritional formula enriched with arginine, zinc, and antioxidants for the healing of pressure ulcers: a randomized trial. Insufficient fluid and energy intake in hospitalised patients with hip fracture. A prospective randomised study of 80 patients. Quality of life in long-term home enteral nutrition patients. Effects of a physical and nutritional intervention program for frail elderly people over age 75. A randomized controlled pilot treatment trial Readmission and mortality in malnourished, older, hospitalized adults treated with a specialized oral nutritional supplement: A randomized clinical trial. Nutritional supplementation and dietary advice in geriatric patients at risk of malnutrition. Factors contributing to dehydration in nursing homes: inadequate staffing and lack of professional supervision. A prospective, randomized clinical study of adjunctive peripheral parenteral nutrition in adult subacute care patients. Stroke rehabilitation patients, practice, and outcomes: is earlier and more aggressive therapy better? Effect of dietary oat and soy fiber on bowel function and clinical tolerance in a tube feeding dependent population. Effects of nutritional supplements on muscle mass and activities of daily living in elderly rehabilitation patients with decreased muscle mass: A randomized controlled trial Water-loss (intracellular) dehydration assessed using urinary tests: how well do they work? Diagnostic accuracy in older people. Effects of high-intensity progressive resistance training and targeted multidisciplinary treatment of frailty on mortality and nursing home admissions after hip fracture: a randomized controlled trial. Bowel function of long-term tube-fed patients consuming formulae with and without dietary fiber. Oral nutritional support in malnourished elderly decreases functional limitations with no extra costs. Nutritional supplementation and resistance training in nutritionally at risk older adults following lower limb fracture: a randomized controlled trial Nutritional counseling improves quality of life and nutrient intake in hospitalized undernourished patients. The BRIGHT Trial: what are the factors associated with nutrition risk? Prospective validation of the modified mini nutritional assessment short-forms in the community, nursing home, and rehabilitation setting. Increased fluid intake does not augment capacity to lay down new collagen in nursing home residents at risk for pressure ulcers: a randomized, controlled clinical trial. Comparison of subcutaneous and intravenous rehydration in geriatric patients: a randomized trial. Energy and protein intakes of acute stroke patients. Percutaneous endoscopic gastrostomy; evidence of different prognosis in various patient subgroups. Comprehensive care improves physical recovery of hip-fractured elderly Taiwanese patients with poor nutritional status. Enhanced interdisciplinary care improves self-care ability and decreases emergency department visits for older Taiwanese patients over 2 years after hip-fracture surgery: A randomised controlled trial. Long-term enteral feeding of aged demented nursing home patients. Use of parenteral nutrition in hospitals in the North of England. Post-discharge nutritional support in malnourished elderly individuals improves functional limitations. Diet and exercise interventions reduce intrahepatic fat content and improve insulin sensitivity in obese older adults. Should oral nutritional supplementation be given to undernourished older people upon hospital discharge? A controlled trial. Reduction in diarrhea incidence by soluble fiber in patients receiving total or supplemental enteral nutrition. Nutritional status of elderly patients during recovery from chest infection and the role of nutritional supplementation assessed by a prospective randomized single-blind trial. Increased energy density of the home-delivered lunch meal improves 24-hour nutrient intakes in older adults. Fiber-Fortifiled Feedings in Immobile Patients Multidisciplinary nutritional support for undernutrition in nursing home and home-care: A cluster randomized controlled trial. Individual, nutritional support prevents undernutrition, increases muscle strength and improves QoL among elderly at nutritional risk hospitalized for acute stroke: a randomized, controlled trial. The nasal loop provides an alternative to percutaneous endoscopic gastrostomy in high-risk dysphagic stroke patients. Enteral Long-Term Nutrition via Percutaneous Endoscopic Gastrostomy (PEG) in 210 Patients A Four-Year Prospective Study Physical and social functional abilities seem to be maintained by a multifaceted randomized controlled nutritional intervention among old (>65 years) Danish nursing home residents. Urine colour as an index of hydration in critically ill patients Effects of interventions on trajectories of health-related quality of life among older patients with hip fracture: a prospective randomized controlled trial Exercise training and nutritional supplementation for physical frailty in very elderly people. Tight calorie control in geriatric patients following hip fracture decreases complications: a randomized, controlled study. Effects of intensive diet and exercise on knee joint loads, inflammation, and clinical outcomes among overweight and obese adults with knee osteoarthritis: the IDEA randomized clinical trial. Effect of Caloric Restriction or Aerobic Exercise Training on Peak Oxygen Consumption and Quality of Life in Obese Older Patients With Heart Failure With Preserved Ejection Fraction: A Randomized Clinical Trial. Elevated Serum Osmolality and Total Water Deficit Indicate Impaired Hydration Status in Residents of Long-Term Care Facilities Regardless of Low or High Body Mass Index. Impact of restrictive diets on the risk of undernutrition in a free-living elderly population. Exercise attenuates the weight-loss-induced reduction in muscle mass in frail obese older adults. Multifaceted nutritional intervention among nursing-home residents has a positive influence on nutrition and function.
Background Protein energy malnutrition ( PEM ) predisposes individuals to disease , delays recovery from illness and reduces quality of life . Care home residents in the United Kingdom are especially vulnerable , with an estimated 30 to 42 % at risk . Evidence for nutritional interventions to address PEM in the care home setting is lacking . Widely used techniques include food-based intervention and /or the use of prescribed oral nutritional supplements . To define outcomes and optimise the design for an adequately powered definitive trial to compare the efficacy of established nutritional interventions in this setting , a cluster r and omised feasibility trial with a 6-month intervention was undertaken . Methods Care home residents with or at risk of malnutrition were identified across six UK care home sites from September to December 2013 . Homes were cluster r and omised to st and ard care ( SC ) , food-based intervention ( FB ) or oral nutritional supplement intervention ( ONS ) , for 6 months . Key outcomes were trial feasibility and the acceptability of design , allocated interventions and outcome assessment s. Anthropometry , dietary intake , healthcare re source usage and participant-reported outcome measures were assessed at baseline and at 3 and 6 months . Results All six care homes approached were recruited and retained . Of the 110 residents at risk of malnutrition , 85 % entered the trial , and 68 % completed the 6-month intervention . Pre-specified success criteria for feasibility were met for recruitment and retention , intervention acceptability ( resident compliance ≥60 % ) and measurement of weight , body mass index ( BMI ) , mid-upper arm circumference and dietary intake ( data completeness > 80 % ) . Measurement of h and grip strength and triceps skinfold thickness was not found to be feasible in this population . The 95 % confidence interval ( CI ) data suggested sensitivity to change in dietary intake for weight , BMI and energy intake between baseline and 3 months when each intervention ( FB and ONS ) was compared with SC . Conclusions A definitive trial comparing the efficacy of nutritional support interventions in increasing weight and BMI in malnourished care home residents can be conducted . However , whilst the design was feasible , this trial has highlighted the lack of clinical ly and patient-relevant outcome measures that are appropriate for use in this setting for both research and clinical practice . In particular , this trial identified a need for a more simple measure of functional status , which considers the limitations of functional tests in the care home population .Trial registration Current Controlled Trials IS RCT N38047922 , Date assigned : 22 April 2014 Background and Purpose Abnormal physiological parameters after acute stroke may induce early neurological deterioration . Studies of the effect of dehydration on stroke outcome are limited . We examined the association of raised plasma osmolality on stroke outcome at 3 months and the change of plasma osmolality with hydration during the first week after stroke . Methods Acute stroke patients had their plasma osmolality measured at admission and at days 1 , 3 , and 7 . Maximum plasma osmolality and the area under curve ( AUC ) were also calculated during the first week . Patients were stratified according to how they were hydrated : orally , intravenously , or both . Outcome included survival at 3 months after stroke . Logistic regression was performed to examine the association between raised plasma osmolality ( > 296 mOsm/kg ) and survival , adjusting for stroke severity . Linear regression was performed to examine the pattern of plasma osmolality across hydration groups . Results One hundred sixty-seven patients were included . Mean admission ( 300 mOsm/kg , SD 11.4 ) , maximum ( 308.1 mOsm/kg , SD 17.1 ) , and AUC ( 298.3 mOsm/kg , SD 11.7 ) plasma osmolality were significantly higher in those who died compared with survivors ( 293.1 mOsm/kg [ SD 8.2 ] , 297.7 mOsm/kg [ SD 8.7 ] , and 291.7 mOsm/kg [ SD 8.1 ] , respectively;P < 0.0001 ) . Admission plasma osmolality > 296 mOsm/kg was significantly associated with mortality ( OR 2.4 , 95 % CI 1.0 to 5.9 ) . In patients hydrated intravenously , there was no significant fall in plasma osmolality compared with patients hydrated orally ( P = 0.68 ) . Conclusions Raised plasma osmolality on admission is associated with stroke mortality , after correcting for case mix . Correction of dehydration after stroke requires a more systematic approach . Trials are required to determine whether correcting dehydration after stroke improves outcome AIMS To investigate whether a nutritional intervention in older women and men with femoral neck fracture had an effect on postoperative complications during hospitalization and on nutritional status at a four-month follow-up . METHODS The design was a r and omized controlled trial . The present study sample consisted of 157 patients aged 70 years and above with femoral neck fracture . The nutritional intervention included , among other things , a nutritional journal to detect nutrition deficiencies and protein-enriched meals for at least four days postoperatively . Further , at least two nutritional and protein drinks were served each day during the whole hospitalization and other factors that would influence the patient 's nutrition were also considered and dealt with . Postoperative complications were registered and patients were assessed using the Mini Nutritional Assessment ( MNA ) scale , including body mass index ( BMI ) , on admission and at a four-month follow-up . RESULTS Malnutrition was common and low MNA scores were associated with postoperative complications such as delirium and decubitus ulcers . There were significantly fewer days of delirium in the intervention group , seven patients in the intervention group developed decubitus ulcers vs. 14 patients in the control group and the total length of hospitalization was shorter . There were no detectable significant improvements regarding nutritional parameters between the intervention and the control group at the four-month follow-up but men improved their mean BMI , body weight and MNA scores in both the intervention and the control groups while women deteriorated in both groups . CONCLUSIONS Malnutrition was common among older people with hip fractures admitted to hospital . The nutritional intervention might have contributed to the patients suffering fewer days with delirium , fewer decubitus ulcers and shorter hospitalization but did not improve the long-term nutritional status , at least not in women . RELEVANCE TO CLINICAL PRACTICE This nutritional intervention , which was included in a multifactorial multidisciplinary intervention , is inexpensive and relatively easy to implement . It has significant effects on complications but no long-term effect on nutritional parameters , at least not in women BACKGROUND Obesity exacerbates the age-related decline in physical function and causes frailty in older adults ; however , the appropriate treatment for obese older adults is controversial . METHODS In this 1-year , r and omized , controlled trial , we evaluated the independent and combined effects of weight loss and exercise in 107 adults who were 65 years of age or older and obese . Participants were r and omly assigned to a control group , a weight-management ( diet ) group , an exercise group , or a weight-management-plus-exercise ( diet-exercise ) group . The primary outcome was the change in score on the modified Physical Performance Test . Secondary outcomes included other measures of frailty , body composition , bone mineral density , specific physical functions , and quality of life . RESULTS A total of 93 participants ( 87 % ) completed the study . In the intention-to-treat analysis , the score on the Physical Performance Test , in which higher scores indicate better physical status , increased more in the diet-exercise group than in the diet group or the exercise group ( increases from baseline of 21 % vs. 12 % and 15 % , respectively ) ; the scores in all three of those groups increased more than the scores in the control group ( in which the score increased by 1 % ) ( P<0.001 for the between-group differences ) . Moreover , the peak oxygen consumption improved more in the diet-exercise group than in the diet group or the exercise group ( increases of 17 % vs. 10 % and 8 % , respectively ; P<0.001 ) ; the score on the Functional Status Question naire , in which higher scores indicate better physical function , increased more in the diet-exercise group than in the diet group ( increase of 10 % vs. 4 % , P<0.001 ) . Body weight decreased by 10 % in the diet group and by 9 % in the diet-exercise group , but did not decrease in the exercise group or the control group ( P<0.001 ) . Lean body mass and bone mineral density at the hip decreased less in the diet-exercise group than in the diet group ( reductions of 3 % and 1 % , respectively , in the diet-exercise group vs. reductions of 5 % and 3 % , respectively , in the diet group ; P<0.05 for both comparisons ) . Strength , balance , and gait improved consistently in the diet-exercise group ( P<0.05 for all comparisons ) . Adverse events included a small number of exercise-associated musculoskeletal injuries . CONCLUSIONS These findings suggest that a combination of weight loss and exercise provides greater improvement in physical function than either intervention alone . ( Funded by the National Institutes of Health ; Clinical Trials.gov number , NCT00146107 . ) UNLABELLED James R , Gines D , Menlove A , Horn SD , Gassaway J , Smout RJ . Nutrition support ( tube feeding ) as a rehabilitation intervention . OBJECTIVE To describe site variation in use of enteral feeding and its association with stroke rehabilitation outcomes , controlling for a variety of confounding variables . DESIGN Prospect i ve observational cohort study . SETTING Six inpatient rehabilitation facilities in the United States . PARTICIPANTS Patients ( N=919 ) from the Post-Stroke Rehabilitation Outcomes Project data base with moderate or severe stroke who were discharged to home , community , or skilled nursing facility . INTERVENTIONS Not applicable . MAIN OUTCOME MEASURES Change in total , motor , and cognitive FIM instrument scores and change in severity of illness . RESULTS Monitoring of nutritional status and the frequency of tube-feeding interventions for patients with moderate and severe stroke varied significantly among sites . Patients with tube feeding had higher severity of illness and lower functioning on admission compared with patients who did not receive tube feeding . However , when we controlled for severity of illness , admission FIM score , and other important covariates , we found that patients with severe strokes who were tube fed for more than 25 % of their stay had greater increases in total , motor , and cognitive FIM scores and greater improvement in severity of illness by discharge . CONCLUSIONS Nutrition support ( tube feeding ) is an effective therapy in rehabilitation service for patients with severe strokes and is associated with greater motor and cognitive improvements , even in patients with the most severe strokes OBJECTIVES Multi-Frequency Bioelectrical Impedance Analysis ( MFBIA ) is a quick , simple , and inexpensive method to assess body fluid compartments . This study aim ed at determining the validity of MFBIA in detecting clinical ly relevant changes of fluid balance in geriatric patients . DESIGN A prospect i ve , observational study . SETTING The 22-bed Geriatric Department of the University Hospital Nijmegen . PARTICIPANTS Hospitalized patients were eligible if they did not have a pacemaker , were not suffering from terminal illnesses , and did not have psychogeriatric diseases likely to interfere with capacity to consent or comply . During a 16-months period , 218 patients were admitted , of whom 78 patients were eligible and 53 consented to participate . MEASUREMENTS Each subject 's fluid balance was diagnosed twice a week as dehydrated , overhydrated , or euvolemic , based on st and ardized physical examination , laboratory tests , and weight evaluation . Changes in fluid balance were quantified by measuring total body water ( TBW ) and extracellular fluid ( ECF ) applying deuterium- and bromide-dilution techniques . Impedance at 1 , 5 , 50 , and 100 kHz and body weight were measured daily . Sensitivity and Guyatt 's responsiveness indexes of MFBIA in detecting dehydration and overhydration were determined . RESULTS In total , 1071 MFBIA measurements were performed , during which 14 transitions from dehydration to euvolemia and 13 transitions from overhydration to euvolemia were monitored . Rehydration of dehydrated patients caused an increase in TBW and ECF of 3.4 + /- 1.8 L and 1.9 + /- 1.9 L , respectively , which result ed in significant decreases in impedance of 133 + /- 67 omega at 1 kHz and 93 + /- 61 omega at 100 kHz ( P = .001 ) . Treatment of overhydrated patients caused a TBW and ECF loss of 3.8 + /- 4.2 L and 3.1 + /- 3.8 L , respectively , which result ed in significant increases in impedance of 104 + /- 72 omega at 1 kHz and 81 + /- 68 omega at 100 kHz ( P < .001 ) . Sensitivity of a single MFBIA in diagnosing dehydration and overhydration was 14 % and 17 % , respectively . Responsiveness indexes of weighing and MFBIA for dehydration and overhydration were similar at all frequencies and greater than one . CONCLUSION The sensitivity of a single impedance measurement in detecting dehydration and overhydration was low . However , responsiveness of serial measurements to intra-individual changes in fluid balance was good . Therefore , this noninvasive technique may be used in clinical practice to improve monitoring fluid balance in geriatric patients , especially when daily weighing is difficult BACKGROUND Generally , the high short-term mortality after  percutaneous endoscopic gastrostomy ( PEG ) in geriatric patients is attributed to the severity of their underlying diseases . However , the procedure-related mortality in this group is unknown . METHODS This prospect i ve multicenter observational study gathered information about 197 geriatric patients treated with PEG insertion , including the indication for PEG insertion and the prevalence of postprocedure complications and analyzed how these factors related to mortality . RESULTS Dysphagia ( 64 % ) and insufficient food intake ( 76 % ) were the most frequent indications for PEG insertion .  Severe complications after PEG insertion occurred in 9.6 % of patients . Mortality was 9.6 % in hospital , as well as 18.4 % at 1 month . Six months after PEG placement , with 81 patients lost to follow-up , mortality was 51.9 % . Hospital mortality was significantly higher in patients with severe complications caused by PEG insertion ( 47.4 % vs 5.6 % ; P < .001 ) . A regression analysis that corrected for confounding factors revealed that severe complications in general ( HR 6.9 ; 95 % CI : 2.6 - 18.1 ; P < .001 ) , peritonitis ( HR 33.1 ; 95 % CI : 3.7 - 293.2 ; P = .002 ) , and severe wound infections ( HR 6.9 ; 95 % CI : 1.9 - 24.9 ; P = .003 ) were each independently associated with hospital mortality . Considering the prevalence of procedure-related complications and their association with early mortality after PEG insertion , the procedure-related mortality rate in geriatric patients was at least 2 % in this study . CONCLUSION Although the prevalence of complications after PEG in this study of multimorbid geriatric patients is within the expected range , the procedure-related mortality is higher than expected BACKGROUND Few studies have investigated the effects of care models that combine interdisciplinary care with nutrition consultation , depression management , and fall prevention in older persons with hip fracture . The purpose of this study was to compare the effects of a comprehensive care program with those of interdisciplinary care and usual care for elderly patients with hip fracture . METHODS A r and omized experimental trial was used to explore outcomes for 299 elderly patients with hip fracture receiving three treatment care models : interdisciplinary care ( n = 101 ) , comprehensive care ( n = 99 ) , and usual care ( n = 99 ) .  Interdisciplinary care included geriatric consultation , continuous rehabilitation , and discharge planning with post-hospital services . Comprehensive care consisted of interdisciplinary care plus nutrition consultation , depression management , and fall prevention . Usual care included only in-hospital rehabilitation without geriatric consultation , in-home rehabilitation , and home environmental assessment . RESULTS Participants in the comprehensive care group had better self-care ability ( odds ratio , OR = 3.19 , p < .01 ) and less risk of depression ( OR = 0.48 , p < .01 ) than those who received usual care . The comprehensive care group had less risk of depression ( OR = 0.51 , p < .05 ) and of malnutrition ( OR = 0.48 , p < .05 ) than the interdisciplinary care group during the first year following discharge . Older persons with hip fracture benefitted more from the comprehensive care program than from interdisciplinary care and usual care . CONCLUSIONS Older persons with hip fracture benefitted more from comprehensive care including interdisciplinary care and nutrition consultation , depression management , and fall prevention than simply interdisciplinary care Sixty patients ( mean age 80 years ) with cognitive impairment who required parenteral fluids for at least 48 h were r and omized to receive either intravenous ( i.v . ) or subcutaneous ( s.c . ) fluids . There was no significant difference in the mean volume of fluid prescribed over 48 h in the two groups ( s.c . 3.3 litres vs. i.v . 3.6 litres ) or in the proportion of prescribed fluids actually administered ( s.c . 0.82 vs. i.v . 0.76 ) . After adjusting for baseline differences , there was no difference between serum urea or creatinine levels in the two groups at 48 h. Agitation related to the infusion was reported in 11 ( 37 % ) patients receiving s.c . fluids and 24 ( 80 % ) patients receiving i.v . fluids ( p < 0.005 ) . The cost of the cannulae used during the study was 6.80 pounds for the s.c . group and 28.70 pounds for the i.v . group . Local oedema was noted in 2 patients in the s.c . group and led to re-siting of the infusion in 1 patient . No other complication was noted . These results suggest that s.c . fluid therapy is the treatment of choice in nonurgent situations for confused patients who require parenteral fluids BACKGROUND & AIMS Few trials have explored the effect of nutrition support on quality of life ( QoL ) . This study examined the effects of oral nutritional supplements ( ONS ) vs dietary advice on QoL in malnourished care home residents . METHODS 104 malnourished , care home residents ( medium + high risk ) , identified using the Malnutrition Universal Screening Tool ( ' MUST ' ) , ( mean age 88.5 ± 7.9y ) were r and omised to receive either oral nutritional supplements ( ONS ) ( n = 53 ) or dietary advice ( n = 51 ) for 12 weeks . Dietary intake was measured using 24 h dietary recall , and QoL assessed using EuroQol ( EQ-5D ) , including time trade off ( TTO ) ( range -0.59 to 1 ) and visual analogue scale ( VAS ) ( score 0 to 100 ) for self-perceived health . RESULTS QoL ( adjusted for baseline QOL , malnutrition risk , type of care received ( nursing or residential ) ) was significantly higher in the ONS than the dietary advice group ( intention to treat analysis at week 12 ; n = 104 ) . EQ-5D TTO scores ( mean ± SE ) were 0.50 ± 0.04 vs 0.36 ± 0.05 ( P = 0.005 ) , VAS rescaled scores were 0.54 + 0.03 vs 0.046 + 0.03 ( P = 0.006 ) and VAS scores were 61.3 ± 4.5 vs 54.6 ± 6.3 ( P = 0.533 ) for ONS vs dietary advice respectively . Total energy , protein and the majority of micronutrient intakes were significantly greater in the ONS group , with energy intake being 423 kcal greater in the ONS than the dietary advice group at week 12 . CONCLUSIONS This study in malnourished care home residents indicates that ONS can improve QoL and nutritional intake more effectively than dietary advice alone . CLINICAL TRIAL REGISTRY This trial was registered with clinical trials.gov on 10th August 2007 . Clinical trials identifier is NCT00515125http://www . clinical trials.gov/ct2/show/NCT00515125?term=nutrition+support&rank=60 Background Previous analyses have shown that a post-discharge individualized nutritional intervention had positive effects on body weight , lean body mass , functional limitations and fall incidents in malnourished older patients . However , the impact of this intervention on survival has not yet been studied Objective The objective of this r and omized controlled study was to examine the effect of a post-discharge individualized nutritional intervention on survival in malnourished older patients . Methods Malnourished older patients , aged ≥ 60 years , were r and omized during hospitalization to a three-months post-discharge nutritional intervention group ( protein and energy enriched diet , oral nutritional supplements , vitamin D3/calcium supplement and telephone counseling by a dietitian ) or to a usual care regimen ( control group ) . Survival data were collected 4 years after enrollment . Survival analyses were performed using intention-to-treat analysis by Log-rank tests and Cox regression adjusted for confounders . Results The study population consisted of 94 men ( 45 % ) and 116 women with a mean age of 74.5 ( SD 9.5 ) years . There were no statistically significant differences in baseline characteristics . Survival data was available in 208 out of 210 patients . After 1 and 4 years of follow-up , survival rates were respectively 66 % and 29 % in the intervention group ( n=104 ) and 73 % and 30 % in the control group ( n=104 ) . There were no statistically significant differences in survival between the two groups 1 year ( HR= 0.933 , 95 % CI=0.675 - 1.289 ) and 4 years after enrollment ( HR=0.928 , 95 % CI=0.671 - 1.283 ) . Conclusion The current study failed to show an effect of a three-months post-discharge multi-component nutritional intervention in malnourished older patients  on long-term survival , despite the positive effects on short-term outcome such as functional limitations and falls OBJECTIVES Undernutrition in older age is associated with adverse clinical outcomes and high health care costs . This study aim ed to evaluate the cost-effectiveness of a dietetic treatment in primary care compared with usual care in older , undernourished , community-dwelling individuals . DESIGN A parallel r and omized controlled trial . SETTING Primary care . PARTICIPANTS A total of 146 undernourished , independently living older ( ≥65 years ) individuals . INTERVENTION Dietetic treatment . MEASUREMENTS Main outcomes were change in kilogram body weight compared with baseline and quality -adjusted life years ( QALYs ) after 6 months . Costs were measured from a societal perspective . The main analysis was performed according to the intention-to-treat principle . Multiple imputation was used to impute missing data and bootstrapping was used to estimate uncertainty surrounding cost differences and incremental cost-effectiveness ratios . Cost-effectiveness planes and cost-effectiveness acceptability curves were estimated . RESULTS The participants were r and omized to receive either dietetic treatment ( n = 72 ) or usual care ( n = 74 ) . After 6 months , no statistically significant differences were found between the dietetic treatment and usual care group in body weight change ( mean difference 0.78 kg , 95 % CI -0.26 - 1.82 ) , QALYs ( mean difference 0.001 , 95 % CI -0.04 - 0.04 ) and total costs ( mean difference € 1645 , 95 % CI -525 - 3547 ) . The incremental cost-utility ratio ( ICUR ) for QALYs was not interpretable . The incremental cost-effectiveness ratio ( ICER ) for body weight gain was 2111 . The probability that dietetic treatment is cost-effective compared with usual care was 0.78 for a ceiling ratio of € 5000 for body weight and 0.06 for a ceiling ratio of € 20.000 for QALY . CONCLUSION In this study , dietetic treatment in older , undernourished , community-dwelling individuals was not cost-effective compared with usual care BACKGROUND & AIMS During the first days of tube feeding ( TF ) gastrointestinal ( GI ) complications are common and administration of sufficient nutrition is a challenge . Not all st and ard nutritionally complete formulas contain dietary fiber , fish oil or carotenoids , key dietary nutrients for health and wellbeing . The aim of this study was to investigate the effects of a fiber , fish oil and carotenoid enriched TF formula on diarrhea , constipation and nutrient bioavailability . METHODS A multi-center r and omized , double-blind , controlled , parallel trial compared the effects of a dietary fiber , fish oil and carotenoid-enriched TF formula ( test ) with an isocaloric non-enriched formula ( control ) in 51 patients requiring initiation of TF .  Incidence of diarrhea and constipation ( based on stool frequency and consistency ) was recorded daily . Plasma status of EPA , DHA and carotenoids was measured after 7 days . RESULTS The incidence of diarrhea was lower in patients receiving the test formula compared with the control group ( 19 % vs. 48 % , p = 0.034 ) . EPA and DHA status ( % of total plasma phospholipids ) was higher after 7 days in test compared with control group ( EPA : p = 0.002 , DHA : p = 0.082 ) . Plasma carotenoid levels were higher after 7 days in the test group compared with control group ( lutein : p = 0.024 , α-carotene : p = 0.005 , lycopene : p = 0.020 , β-carotene : p = 0.054 ) . CONCLUSIONS This study suggests that the nutrient-enriched TF formula tested might have a positive effect on GI tolerance with less diarrhea incidence and significantly improved EPA , DHA and carotenoid plasma levels during the initiation of TF in hospitalized patients who are at risk of diarrhea and low nutrient status . CLINICAL TRIAL REGISTRATION This trial was registered at trialregister.nl ; registration number 2924 BACKGROUND & AIMS The Oligo Element Sore Trial has shown that supplementation with a disease-specific nutritional formula enriched with arginine , zinc , and antioxidants improves  pressure ulcer ( PU ) healing in malnourished patients compared to an isocaloric-isonitrogenous support . However , the use of such a nutritional formula needs to be supported also by a cost-effectiveness evaluation . METHODS This economic evaluation - from a local healthcare system perspective - was conducted alongside a multicenter , r and omized , controlled trial following a piggy-back approach . The primary efficacy endpoint was the percentage of change in PU area at 8 weeks . The cost analysis focused on : the difference in direct medical costs of local PU care between groups and incremental cost-effectiveness ratio ( ICER ) of nutritional therapy related to significant study endpoints ( percentage of change in PU area and ≥40 % reduction in PU area at 8 weeks ) . RESULTS Although the experimental formula was more expensive ( mean difference : 39.4 Euros ; P < 0.001 ) , its use result ed in money saving with respect to both non-nutritional PU care activities ( difference , -113.7 Euros ; P = 0.001 ) and costs of local PU care ( difference , -74.3 Euros ; P = 0.013 ) . Therefore , given its efficacy it proved to be a cost-effective intervention . The robustness of these results was confirmed by the sensitivity analyses . CONCLUSION The use of a disease-specific oral nutritional formula not only results in better healing of PUs , but also reduces the costs of local PU care from a local healthcare system perspective BACKGROUND Well-recognized markers for static ( one time ) or dynamic ( monitoring over time ) dehydration assessment have not been rigorously tested for their usefulness in clinical , military , and sports medicine communities . OBJECTIVE This study evaluated the components of biological variation and the accuracy of potential markers in plasma , urine , saliva , and body mass ( B(m ) ) for static and dynamic dehydration assessment . DESIGN We studied 18 healthy volunteers ( 13 men and 5 women ) while carefully controlling hydration and numerous preanalytic factors . Biological variation was determined over 3 consecutive days by using published methods . Atypical values based on statistical deviations from a homeostatic set point were examined . Measured deviations in body fluid were produced by using a separate , prospect i ve dehydration experiment and evaluated by receiver operating characteristic ( ROC ) analysis to quantify diagnostic accuracy . RESULTS All dehydration markers displayed substantial individuality and one-half of the dehydration markers displayed marked heterogeneity of intraindividual variation . Decision levels for all dehydration markers were within one SD of the ROC criterion values , and most levels were nearly identical to the prospect i ve group means after volunteers were dehydrated by 1.8 - 7.0 % of B(m ) . However , only plasma osmolality ( P(osm ) ) showed statistical promise for use in the static dehydration assessment . A diagnostic decision level of 301 plusmn 5 mmol/kg was proposed . Reference change values of 9 mmol/kg ( P(osm ) ) , 0.010 [ urine specific gravity ( U(sg ) ) ] , and 2.5 % change in B(m ) were also statistically valid for dynamic dehydration assessment at the 95 % probability level . CONCLUSIONS P(osm ) is the only useful marker for static dehydration assessment . P(osm ) , U(sg ) , and B(m ) are valid markers in the setting of dynamic dehydration assessment OBJECTIVE Development of these guidelines is m and ated by the American Association of Clinical Endocrinologists ( AACE ) Board of Directors and the American College of Endocrinology ( ACE ) Board of Trustees and adheres to published AACE protocol s for the st and ardized production of clinical practice guidelines ( CPGs ) . METHODS Recommendations are based on diligent review of clinical evidence with transparent incorporation of subjective factors . RESULTS There are 9 broad clinical questions with 123 recommendation numbers that include 160 specific statements ( 85 [ 53.1 % ] strong [ Grade A ] ; 48 [ 30.0 % ] intermediate [ Grade B ] , and 11 [ 6.9 % ] weak [ Grade C ] , with 16 [ 10.0 % ] based on expert opinion [ Grade D ] ) that build a comprehensive medical care plan for obesity . There were 133 ( 83.1 % ) statements based on strong ( best evidence level [ BEL ] 1 = 79 [ 49.4 % ] ) or intermediate ( BEL 2 = 54 [ 33.7 % ] ) levels of scientific substantiation . There were 34 ( 23.6 % ) evidence -based recommendation grade s ( Grade s A-C = 144 ) that were adjusted based on subjective factors . Among the 1,790 reference citations used in this CPG , 524 ( 29.3 % ) were based on strong ( evidence level [ EL ] 1 ) , 605 ( 33.8 % ) were based on intermediate ( EL 2 ) , and 308 ( 17.2 % ) were based on weak ( EL 3 ) scientific studies , with 353 ( 19.7 % ) based on review s and opinions ( EL 4 ) . CONCLUSION The final recommendations recognize that obesity is a complex , adiposity-based chronic disease , where management targets both weight-related complications and adiposity to improve overall health and quality of life . The detailed evidence -based recommendations allow for nuanced clinical decision-making that addresses real-world medical care of patients with obesity , including screening , diagnosis , evaluation , selection of therapy , treatment goals , and individualization of care . The goal is to facilitate high- quality care of patients with obesity and provide a rational , scientific approach to management that optimizes health outcomes and safety . ABBREVIATIONS A1C = hemoglobin A1c AACE = American Association of Clinical Endocrinologists ACE = American College of Endocrinology ACSM = American College of Sports Medicine ADA = American Diabetes Association ADAPT = Arthritis , Diet , and Activity Promotion Trial ADHD = attention-deficit hyperactivity disorder AHA = American Heart Association AHEAD = Action for Health in Diabetes AHI = apnea-hypopnea index ALT = alanine aminotransferase AMA = American Medical Association ARB = angiotensin receptor blocker ART = assisted reproductive technology AUC = area under the curve BDI = Beck Depression Inventory BED = binge eating disorder BEL = best evidence level BLOOM = Behavioral Modification and Lorcaserin for Overweight and Obesity Management BLOSSOM = Behavioral Modification and Lorcaserin Second Study for Obesity Management BMI = body mass index BP = blood pressure C-SSRS = Columbia Suicidality Severity Rating Scale CAD = coronary artery disease CARDIA = Coronary Artery Risk Development in Young Adults CBT = cognitive behavioral therapy CCO = Consensus Conference on Obesity CHF = congestive heart failure CHO = carbohydrate CI = confidence interval COR-I = Contrave Obesity Research I CPG = clinical practice guideline CV = cardiovascular CVD = cardiovascular disease DASH = Dietary Approaches to Stop Hypertension DBP = diastolic blood pressure DEXA = dual-energy X-ray absorptiometry DPP = Diabetes Prevention Program DSE = diabetes support and education EL = evidence level ED  = erectile dysfunction  ER = extended release EWL = excess weight loss FDA = Food and Drug Administration FDG = 18F-fluorodeoxyglucose GABA = gamma-aminobutyric acid GERD = gastroesophageal reflux disease GI = gastrointestinal GLP-1 = glucagon-like peptide 1 HADS = Hospital Anxiety and Depression Scale HDL-c = high-density lipoprotein cholesterol HR = hazard ratio HTN = hypertension HUNT = Nord-Trøndelag Health Study ICSI = intracytoplasmic sperm injection IFG = impaired fasting glucose IGT = impaired glucose tolerance ILI = intensive lifestyle intervention IVF = in vitro fertilization LAGB = laparoscopic adjustable gastric b and ing LDL-c = low-density lipoprotein cholesterol LES = lower esophageal sphincter LSG = laparoscopic sleeve gastrectomy LV = left ventricle LVH = left ventricular hypertrophy LVBG = laparoscopic vertical b and ed gastroplasty MACE = major adverse cardiovascular events MAOI = monoamine oxidase inhibitor MI = myocardial infa rct ion MN RCT = meta- analysis of non-r and omized prospect i ve or case-controlled trials MRI = magnetic resonance imaging MUFA = monounsaturated fatty acid NAFLD = nonalcoholic fatty liver disease NASH = nonalcoholic steatohepatitis NES = night eating syndrome NHANES = National Health and Nutrition Examination Surveys NHLBI = National Heart , Lung , and Blood Institute NHS = Nurses ' Health Study NICE = National Institute for Health and Care Excellence OA = osteoarthritis OGTT = oral glucose tolerance test OR = odds ratio OSA = obstructive sleep apnea PHQ-9 = Patient Health Question naire PCOS = polycystic ovary syndrome PCP = primary care physician POMC = pro-opiomelanocortin POWER = Practice -Based Opportunities for Weight Reduction PPI = proton pump inhibitor PRIDE = Program to Reduce Incontinence by Diet and Exercise PSA = prostate specific antigen QOL = quality of life RA = receptor agonist RCT = r and omized controlled trial ROC = receiver operator characteristic RR = relative risk RYGB = Roux-en-Y gastric bypass  SAD = sagittal abdominal diameter SBP = systolic blood pressure SCOUT = Sibutramine Cardiovascular Outcome Trial SG = sleeve gastrectomy SHBG = sex hormonebinding globulin SIEDY = Structured Interview on Erectile Dysfunction SNRI = serotonin-norepinephrine reuptake inhibitors SOS = Swedish Obese Subjects SS = surveillance study SSRI = selective serotonin reuptake inhibitors STORM = Sibutramine Trial on Obesity Reduction and Maintenance TCA = tricyclic antidepressant TONE = Trial of Nonpharmacologic Intervention in the Elderly TOS = The Obesity Society T2DM = type 2 diabetes mellitus UKPDS = United Kingdom Prospect i ve Diabetes Study U.S = United States VAT = visceral adipose tissue VLDL = very low-density lipoprotein WC = waist circumference WHO = World Health Organization WHR = waist-hip ratio WHtR = waist-to-height ratio WMD = weighted mean difference WOMAC = Western Ontario and McMaster Universities osteoarthritis index XENDOS = XEnical in the Prevention of Diabetes in Obese Subjects OBJECTIVE To investigate the short- and long-term effects of a multidisciplinary postoperative rehabilitation programme in patients with femoral neck fracture . DESIGN AND SUBJECTS A r and omized controlled trial in patients ( n = 199 ) with femoral neck fracture , aged > or= 70 years . METHODS The primary outcomes were : living conditions , walking ability and activities of daily living performance on discharge , 4 and 12 months postoperatively . The intervention consisted of staff education , individualized care planning and rehabilitation , active prevention , detection and treatment of postoperative complications . The staff worked in teams to apply comprehensive geriatric assessment , management and rehabilitation . A geriatric team assessed those in the intervention group 4 months postoperatively , in order to detect and treat any complications . The control group followed conventional postoperative routines . RESULTS Despite shorter hospitalization , significantly more people from the intervention group had regained independence in personal activities of daily living performance at the 4- and 12-month follow-ups ; odds ratios ( 95 % confidence interval ( CI ) ) 2.51 ( 1.00 - 6.30 ) and 3.49 ( 1.31 - 9.23 ) , respectively . More patients in the intervention group had also regained the ability to walk independently indoors without walking aids by the end of the study period , odds ratio ( 95 % confidence interval ) 3.01 ( 1.18 - 7.61 ) . CONCLUSION A multidisciplinary postoperative intervention programme enhances activities of daily living performance and mobility after hip fracture , from both a short-term and long-term perspective Background Among older , overweight , and obese adults with either cardiovascular disease or the metabolic syndrome , reduced mobility and loss of leg strength are important risk factors for morbidity , disability , and mortality . It is unclear whether community-based approaches to weight loss may be an effective solution to this public health challenge . Methods An 18-month three-site , r and omized controlled trial conducted by YMCA staff , with blinded assessors , enrolled 249 older , overweight , and obese adults with either cardiovascular disease or metabolic syndrome with r and omization to three interventions : weight loss alone ( WL ) , weight loss + aerobic training ( WL + AT ) , and weight loss + resistance training ( WT + RT ) . The dual primary outcomes were 400-m walk time in seconds and knee extensor strength in Newton meters . Results All groups lost weight from baseline : average baseline adjusted change of -6.1 % ( 95 % confidence interval [ CI ] : -7.5 to -4.7 ) for WL only , -8.6 % ( 95 % CI : -10.0 to -7.2 ) for WL + AT , and -9.7 % ( 95 % CI : -11.1 to -8.4 ) for WL + RT . Combined , the two physical activity + WL training groups had greater improvement in walk time than WL alone ( mean difference 16.9 seconds [ 95 % CI : 9.7 to 24.0 ] , p < .0001 ) . Baseline adjusted change in knee extensor strength was no greater with WL + RT than WL + AT ( mean difference -3.6 Nm [ 95 % CI : -7.5 to 0.3 ] , p = .07 ) . Conclusions At risk , older , overweight and obese adults can achieve clinical ly significant reductions in body weight with community-based weight loss programs . The change in percent weight loss and improvements in mobility are significantly enhanced when either RT or AT is combined with dietary WL Nutritional deficiencies , frequently observed among the frail elderly , have been associated with increased morbidity and dependency . A r and omized clinical trial was conducted to assess the impact of nutritional supplementation on the functional status of frail elderly living at home . Subjects ( n = 50 ) over age 60 ( mean 78 y ) requiring community services and at elevated risk of undernutrition ( excessive weight loss or body mass index < 24 kg/m2 ) were r and omized to a high energy nutrient dense supplement provided by a dietitian or a control group receiving visits only . Outcome measures , including changes in h and grip strength , general well-being score , perception of health and number of falls , were measured by an investigator who was unaware of treatment assignment . After 12 wk , weight gain was greater in the supplemented group ( 2.1 + /- 2.3 vs. 0.6 + /- 1.6 kg ; P < 0.01 ) . Despite adequate statistical power , no functional measures differed except that the number of falls was lower among treated subjects vs. controls ( 0 % vs. 21 % ; P = 0.05 ) . Frail elderly can gain weight through oral supplementation , indicating the reversibility of weight loss in this group , but changes in functional status indicators may require a longer period of supplementation Fighting against inactivity and inadequate nutritional intake are of utmost importance in the elderly . To our knowledge , the few studies which have been performed were conducted for only a short period and the results do not permit formal conclusions to be drawn . We therefore tried to fill this gap in our knowledge by determining whether an intervention combining an acceptable progressive exercise programme and nutritional supplements would be feasible for a long-term period in the very frail elderly , and would bring about concomitant benefits in body composition and muscle power . Accordingly , this exercise and nutritional combination was assessed in the frail elderly in a 9-month r and omised trial with a factorial design . Fifty-seven elderly volunteers over 72 years , from sixteen retirement homes in Lyon , France participated in the study .  Dietary supplements were compared with placebo , and physical exercise was compared with memory training . Main outcome measures were fat-free mass ( FFM ) and muscle power . FFM was determined by labelled water , and muscle power was measured by a leg-extensor machine . At 9 months , the compliance was 63 % for exercise sessions , and 54 % for nutritional supplements . In patients with dietary supplements , muscle power increased by 57 % at 3 months ( P=0.03 ) , and showed only a tendency at 9 months ; although FFM increased by 2.7 % at 9 months , the difference was not significant ( P=0.10 ) . Exercise did not improve muscle power at 9 months , but improved functional tests ( five-time-chair rise , P=0.01 ) . BMI increased with supplements ( + 3.65 % ) , but decreased with placebo ( -0.5 % ) at 9 months ( P=0.007 ) . A long-term combined intervention is feasible in frail elderly individuals with a good rate of compliance . Nutritional supplements and exercise may improve muscle function . Despite no significant results on FFM , due to the limited number of volunteers , combined intervention should be suggested to counteract muscle weakness in the frail elderly OBJECTIVES Dehydration in older adults contributes to increased morbidity and mortality during hospitalization . As such , early diagnosis of dehydration may improve patient outcome and reduce the burden on healthcare . This prospect i ve study investigated the diagnostic accuracy of routinely used physical signs , and noninvasive markers of hydration in urine and saliva . DESIGN Prospect i ve diagnostic accuracy study . SETTING Hospital acute medical care unit and emergency department . PARTICIPANTS One hundred thirty older adults [ 59 males , 71 females , mean ( st and ard deviation ) age = 78 ( 9 ) years ] . MEASUREMENTS Participants with any primary diagnosis underwent a  hydration assessment  within 30 minutes of admittance to hospital . Hydration assessment comprised 7 physical signs of dehydration [ tachycardia ( > 100 bpm ) , low systolic blood pressure ( < 100 mm Hg ) , dry mucous membrane , dry axilla , poor skin turgor , sunken eyes , and long capillary refill time ( > 2 seconds ) ] , urine color , urine specific gravity , saliva flow rate , and saliva osmolality . Plasma osmolality and the blood urea nitrogen to creatinine ratio were assessed as reference st and ards of hydration with 21 % of participants classified with water-loss dehydration ( plasma osmolality > 295 mOsm/kg ) , 19 % classified with water- and -solute-loss dehydration ( blood urea nitrogen to creatinine ratio > 20 ) , and 60 % classified as euhydrated . RESULTS All physical signs showed poor sensitivity ( 0%-44 % ) for detecting either form of dehydration , with only low systolic blood pressure demonstrating potential utility for aiding the diagnosis of water- and -solute-loss dehydration [ diagnostic odds ratio ( OR ) = 14.7 ] . Neither urine color , urine specific gravity , nor saliva flow rate could discriminate hydration status ( area under the receiver operating characteristic curve = 0.49 - 0.57 , P > .05 ) . In contrast , saliva osmolality demonstrated moderate diagnostic accuracy ( area under the receiver operating characteristic curve = 0.76 , P < .001 ) to distinguish both dehydration types ( 70 % sensitivity , 68 % specificity , OR = 5.0 ( 95 % confidence interval 1.7 - 15.1 ) for water-loss dehydration , and 78 % sensitivity , 72 % specificity , OR = 8.9 ( 95 % confidence interval 2.5 - 30.7 ) for water- and -solute-loss dehydration ) . CONCLUSIONS With the exception of low systolic blood pressure , which could aid in the specific diagnosis of water- and -solute-loss dehydration , physical signs and urine markers show little utility to determine if an elderly patient is dehydrated . Saliva osmolality demonstrated superior diagnostic accuracy compared with physical signs and urine markers , and may have utility for the assessment of both water-loss and water- and -solute-loss dehydration in older individuals . It is particularly noteworthy that saliva osmolality was able to detect water- and -solute-loss dehydration , for which a measurement of plasma osmolality would have no diagnostic utility Objective : To assess the additional benefits of individualized nutritional counselling by a registered dietitian in geriatric patients ’ home after discharge from hospital , in relation to risk of re-admissions , functional status , nutritional status , use of social services and mortality . Design : Twelve-week single-blind r and omized controlled study . Setting and subjects : Geriatric medical patients ( 65 + years ) at nutritional risk . Interventions : Participants were r and omly allocated to receive a visit in their homes , either three individualized nutritional counselling by a registered dietitian complemented with three follow-up visits by general practitioners or three follow-up visits by general practitioners alone . Main measures : Primary outcome was risk of re-admissions . Secondary outcomes were functional status ( h and grip strength , chair st and , mobility , disability and tiredness in daily activities , rehabilitation capacity ) , nutritional status ( weight , BMI , energy and protein intake ) , need of social services ( home care , home nursing , meals-on-wheels ) and mortality . Results : One hundred and fifty-two patients were included ; 132 ( 87 % ) completed the first and 124 ( 82 % ) the second data collection after 12 weeks . Ten per cent of the participants had three contacts with their general practitioner , while compliance with the dietetic intervention was almost 100 % . Odds ratio for re-admission and mortality after 26 weeks was 1.62 ( 95 % confidence interval ( CI ) 0.85 to 3.10 ) and 0.60 ( 95 % CI 0.17 to 2.13 ) . The intervention had a positive effect on functional status ( i.e. mobility , P = 0.029 ) , and nutritional status ( i.e. weight , P = 0.035 ; energy intake , P < 0.001 ; protein intake , P = 0.001 ) and the use of meals-on wheels was reduced ( P = 0.084 ) . Conclusion : Follow-up home visits with registered dietitians have a positive effect on the functional and nutritional status of geriatric medical patients after discharge OBJECTIVE The Arthritis , Diet , and Activity Promotion Trial ( ADAPT ) was a r and omized , single-blind clinical trial lasting 18 months that was design ed to determine whether long-term exercise and dietary weight loss are more effective , either separately or in combination , than usual care in improving physical function , pain , and mobility in older overweight and obese adults with knee osteoarthritis ( OA ) . METHODS Three hundred sixteen community-dwelling overweight and obese adults ages 60 years and older , with a body mass index of > or = 28 kg/m(2 ) , knee pain , radiographic evidence of knee OA , and self-reported physical disability , were r and omized into healthy lifestyle ( control ) , diet only , exercise only , and diet plus exercise groups . The primary outcome was self-reported physical function as measured with the Western Ontario and McMaster Universities Osteoarthritis Index ( WOMAC ) . Secondary outcomes included weight loss , 6-minute walk distance , stair-climb time , WOMAC pain and stiffness scores , and joint space width . RESULTS Of the 316 r and omized participants , 252 ( 80 % ) completed the study .  Adherence was as follows : for healthy lifestyle , 73 % ; for diet only , 72 % ; for exercise only , 60 % ; and for diet plus exercise , 64 % . In the diet plus exercise group , significant improvements in self-reported physical function ( P < 0.05 ) , 6-minute walk distance ( P < 0.05 ) , stair-climb time ( P < 0.05 ) , and knee pain ( P < 0.05 ) relative to the healthy lifestyle group were observed . In the exercise group , a significant improvement in the 6-minute walk distance ( P < 0.05 ) was observed . The diet-only group was not significantly different from the healthy lifestyle group for any of the functional or mobility measures . The weight-loss groups lost significantly ( P < 0.05 ) more body weight ( for diet , 4.9 % ; for diet plus exercise , 5.7 % ) than did the healthy lifestyle group ( 1.2 % ) . Finally , changes in joint space width were not different between the groups . CONCLUSION The combination of modest weight loss plus moderate exercise provides better overall improvements in self-reported measures of function and pain and in performance measures of mobility in older overweight and obese adults with knee OA compared with either intervention alone Abstract Objective To assess the effect of family style mealtimes on quality of life , physical performance , and body weight of nursing home residents without dementia . Design Cluster r and omised trial . Setting Five Dutch nursing homes . Participants 178 residents ( mean age 77 years ) . Two wards in each home were r and omised to intervention ( 95 participants ) or control groups ( 83 ) . Intervention During six months the intervention group took their meals family style and the control group received the usual individual pre-plated service . Main outcome measures Quality of life ( perceived safety ; autonomy ; and sensory , physical , and psychosocial functioning ) , gross and fine motor function , and body weight . Results The difference in change between the groups was significant for overall quality of life ( 6.1 units , 95 % confidence interval 2.1 to 10.3 ) , fine motor function ( 1.8 units , 0.6 to 3.0 ) , and body weight ( 1.5 kg , 0.6 to 2.4 ) . Conclusion Family style mealtimes maintain quality of life , physical performance , and body weight of nursing home residents without dementia . Trial registration Clinical trials Background : Serum osmolality is an accurate indicator of hydration status in older adults . Glucose , urea , and electrolyte concentrations are used to calculate serum osmolarity , which is an indirect estimate of serum osmolality , but which serum osmolarity equations best predict serum osmolality in the elderly is unclear . Objective : We assessed the agreement of measured serum osmolality with calculated serum osmolarity equations in older people . Design : Serum osmolality was measured by using freezing point depression in a cross-sectional study .  Plasma glucose , urea , and electrolytes were analyzed and entered into 38 serum osmolarity-prediction equations . The Bl and -Altman method was used to evaluate the agreement and differential bias between measured osmolality and calculated osmolarity . The sensitivity and specificity of the most-promising equations were examined against serum osmolality ( reference st and ard ) . Results : A total of 186 people living in UK residential care took part in the Dehydration Recognition In our Elders study ( 66 % women ; mean ± SD age : 85.8 ± 7.9 y ; with a range of cognitive and physical impairments ) and were included in analyses . Forty-six percent of participants had impending or current dehydration ( serum osmolality ≥295 mmol/kg ) . Participants with diabetes ( n = 33 ; 18 % ) had higher glucose ( P < 0.001 ) and serum osmolality ( P < 0.01 ) . Of 38 predictive equations used to calculate osmolarity , 4 equations showed reasonable agreement with measured osmolality . One [ calculated osmolarity = 1.86 × ( Na+ + K+ ) + 1.15 × glucose + urea + 14 ; all in mmol/L ] was characterized by narrower limits of agreement and the capacity to predict serum osmolality within 2 % in > 80 % of participants , regardless of diabetes or hydration status . The equation 's sensitivity ( 79 % ) and specificity ( 89 % ) for impending dehydration ( ≥295 mmol/kg ) and current dehydration ( > 300 mmol/kg ) ( 69 % and 93 % , respectively ) were reasonable . Conclusions : The assessment of a panel of equations for the prediction of serum osmolarity led to identification of one formula with a greater diagnostic performance . This equation may be used to predict hydration status in frail older people ( as a first-stage screening ) or to estimate hydration status in population studies . This trial was registered at the Research Register for Social Care ( http://www . research register.org.uk ) as 122273 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 test the hypothesis that individualized nutritional treatment during and after discharge from acute hospitalization will reduce mortality and improve nutritional outcomes . DESIGN R and omized , controlled trial . SETTING Internal medicine departments . PARTICIPANTS Two hundred fifty-nine hospitalized adults aged 65 and older at nutritional risk were recruited and r and omized according to hospitalization ward into one intervention and two control groups during hospitalization . INTERVENTION Group 1 ( intervention group ) received individualized nutritional treatment from a dietitian in the hospital and three home visits after discharge . Group 2 received one meeting with a dietitian in the hospital . Group 3 received st and ard care . Groups 2 and 3 were combined into a single group that served as the control group in the analysis . MEASUREMENTS Mortality , health status , nutritional outcomes , blood tests , cognition , emotional , and functional parameters were assessed at baseline and after 6 months . All participants were contacted monthly . RESULTS The overall dropout rate was 25.8 % . After 6 months , rise in Mini Nutritional Assessment score , adjusted for education and hospitalization ward , was significantly higher in the intervention group than in the control groups ( 3.01 ± 2.65 vs 1.81 ± 2.97 , P = .004 ) mainly on the subjective assessment part ( 0.34 ± 0.86 vs. -0.04 ± 0.87 , P=.004 ) . The only laboratory parameter for which a difference was observed between the groups was albumin ; 9.7 % of the intervention group had serum albumin levels of less than 3.5 g/dL , versus 22.9 % of the control group ( P = .03 ) . Mortality was significantly lower in the intervention group ( 3.8 % ) than in the control group ( 11.6 % , P = .046 ) . CONCLUSION Lower mortality and moderate improvement in nutritional status were found in patients receiving individualized nutritional treatment during and after acute hospitalization OBJECTIVE To investigate the feasibility of cervical spine mobilization in elderly dementia patients with dysphagia , and its effect on swallowing capacity . METHODS Fifteen nursing home residents ( 9 women , 6 men , age range 77 - 98 years ) with severe dementia ( median Mini Mental State Examination score=8/30 , percentile (P)25 - 75=4 - 13 ) and known dysphagia participated in a r and omized controlled trial with cross-over design . Cervical spine mobilization was administered by trained physiotherapists . Control sessions consisted of socializing visits .  Feasibility ( attendance , hostility , complications ) and maximal swallowing volume ( water bolus 1 - 20 ml ) were assessed following one session and one week ( 3 sessions ) of treatment and control . RESULTS Ninety percent of cervical spine mobilization sessions were completed successfully ( 3 sessions could not be carried out due to the patient 's hostility and 2 due to illness ) and no complications were observed . Swallowing capacity improved significantly after cervical spine mobilization ( from 3 ml ( P25 - 75=1 - 10 ) to 5 ml ( P25 - 75=3 - 15 ) after one session p=0.01 and to 10 ml ( P25 - 75=5 - 20 ) ( + 230 % ) after one week treatment p=0.03 ) compared with control ( no significant changes , difference in evolution after one session between treatment and control , p=0.03 ) . CONCLUSION Cervical spine mobilization is feasible and can improve swallowing capacity in cognitively impaired residents in nursing homes . Given the acute improvements following treatment , it is probably best provided before meals The impact of resistance training has not been thoroughly examined in overweight older adults undergoing weight loss . Subjects ( n = 27 ) were overweight and obese ( BMI 31.7 ± 3.6 kg/m2 ) older ( age 67 ± 4 years ) adults and were r and omized into either a 10-week Dietary Approaches to Stop Hypertension for weight loss diet ( DASH , n = 12 ) or DASH plus moderate intensity resistance training ( DASH-RT , n = 15 ) . Outcomes included weight loss , total body and mid-thigh composition , muscle and physical function . There were no significant weight loss differences between the DASH-RT and DASH groups ( −3.6 ± 0.8 vs. −2.0 ± 0.9 % , p = 0.137 ) . The DASH-RT group had a greater reduction in body fat than the DASH group ( −4.1 ± 0.9 vs. −0.2 ± 1.0 kg , p = 0.005 ) . The DASH-RT group had greater changes in lean mass ( + 0.8 ± 0.4 vs. −1.4 ± 0.4 kg , p = 0.002 ) and strength ( + 60 ± 18 vs. −5 ± 9 N , p = 0.008 ) than the DASH group . There were favorable changes in mid-thigh composition variables in the DASH-RT group that were different than the lack of changes observed in the DASH group , except for intermuscular adipose tissue . Both groups experienced decreases in 400-m walk times showed ( DASH −36 ± 11 s , DASH-RT −40 ± 7 s ) with no differences between groups . Moderate intensity resistance training  during weight loss appears to improve fat mass and thigh composition , but weight loss only does not . However , global measures of physical functioning may improve with a weight loss-only program Background : older adults are susceptible to dehydration due to age-related pathophysiological changes . We aim ed to investigate the prevalence of  hyperosmolar dehydration ( HD ) in hospitalised older adults , aged ≥65 years , admitted as an emergency and to assess the impact on short-term and long-term outcome . Methods : this prospect i ve cohort study was performed on older adult participants who were admitted acutely to a large UK teaching hospital . Data collected included the Charlson comorbidity index ( CCI ) , national early warning score ( NEWS ) , Canadian Study of Health and Aging ( CSHA ) clinical frailty scale and Nutrition Risk Screening Tool ( NRS ) 2002 . Admission bloods were used to measure  serum osmolality . HD was defined as serum osmolality > 300 mOsmol/kg . Participants who were still in hospital 48 h after admission were review ed , and the same measurements were repeated . Results : a total of 200 participants were recruited at admission to hospital , 37 % of whom were dehydrated . Of those dehydrated , 62 % were still dehydrated when review ed at 48 h after admission . Overall , 7 % of the participants died in hospital , 79 % of whom were dehydrated at admission ( P = 0.001 ) . Cox regression analysis adjusted for age , gender , CCI , NEWS , CSHA and NRS demonstrated that participants dehydrated at admission were 6 times more likely to die in hospital than those euhydrated , hazards ratio ( HR ) 6.04 ( 1.64–22.25 ) ; P = 0.007 . Conclusions : HD is common in hospitalised older adults and is associated with poor outcome . Coordinated efforts are necessary to develop comprehensive hydration assessment tools to implement and monitor a real change in culture and attitude towards hydration in hospitalised older adults OBJECTIVE To test the feasibility of two models of home meal delivery with Meals-on-Wheels ( MOW ) applicants who were identified as being malnourished or " at-risk " as determined by the vali date d Mini Nutritional Assessment ( MNA ) . DESIGN A 6-month , prospect i ve comparative study of two nutrition intervention models with data collection at baseline , 3 months , and 6 months . R and omized treatment assignment was followed , with a few exceptions linked to particular client circumstances . SUBJECTS A total of 203 older adults ( age range = 60 to 90 years ) newly applying for homebound meal service were enrolled . At baseline , the body mass index ( BMI ) was 26.3+/-7.2 ( mean+/-SD ) in the " Traditional " MOW model ( 101 subjects including 30 malnourished ) , and the BMI was 27.6+/-9.0 in the " New " MOW model ( 102 subjects including 26 malnourished ) ( P = ns ) . INTERVENTION Study participants received either the Traditional MOW program of five hot meals per week , meeting 33 % of the Daily Reference Intake ( DRI ) or the restorative , comprehensive New MOW program of three meals and two snacks per day , 7 days a week , meeting 100 % of the DRI . Assessment s were conducted in the home of the participants . Main outcome measures The MNA was used to evaluate nutritional risk and status of participants at baseline , 3 months , and 6 months . St and ardized functional impairment scales , Activities of Daily Living ( ADL ) , and Instrumental Activities of Daily Living ( IADL ) evaluated limitations in activities of daily living and life management skills . Statistical analysis Comparisons between treatment groups were calculated with t tests or Wilcoxon rank-sum tests when appropriate . Comparisons among time periods between treatment groups were conducted with repeated measures analysis of variance . A general linear model was used to evaluate the relationship between change in functional status and BMI , controlling for sex . RESULTS The New MOW group gained significantly more weight between baseline and 3 months than did the Traditional MOW group ( 2.78 lb vs -1.46 lb , respectively , P = .0120 ) and again between baseline and 6 months ( 4.30 lb vs -1.72 lb , respectively , P = .0004 ) . MNA improved faster in the New MOW group . Functional change appeared to be related more to BMI and age than to treatment intervention . The malnourished participants in both groups took longer to affect positive change in nutrition measurements , with the New MOW group showing the most improvement over the 6-month measurement period . Both delivery models were well accepted . CONCLUSIONS Applicants for home meal delivery have varying nutrition needs . By addressing nutritional risk , interventions can be targeted to meet these needs . A new , restorative , comprehensive meal program improved nutritional status and decreased nutritional risk and can possibly impact independence and functionality Protein energy malnutrition is an important determinant of clinical outcome in older patients after hip fracture , but the effectiveness of nutritional support programs in routine clinical practice is controversial . We performed a prospect i ve , r and omized , controlled clinical trial to determine if nutritional supplementation decreased fracture-related complications in a selection of otherwise healthy patients with hip fractures . Patients were r and omized to intervention or control groups . The control group ( n = 40 ) was given ordinary hospital food and beverage . The intervention group ( n = 40 ) also was administered a 1000 kcal daily intravenous supplement for 3 days , followed by a 400 kcal oral nutritional supplement for 7 days . We recorded daily fluid and energy intake during the first 10 days of hospitalization and fracture-related complications up to 4 months . The total fluid and energy intake in the intervention group neared optimal levels . The control group received 54 % and 64 % of optimal energy and fluid intake , respectively . The risk of fracture- related complications was greater in the control group ( 70 % ) than in the intervention group ( 15 % ) . Four patients in the control group died within 120 days postoperatively . The comprehensive balanced nutrition supplement result ed in lower complication rates and mortality at 120 days postoperatively . Level of Evidence : Therapeutic Level I. See the Guidelines for Authors for a complete description of levels of evidence Background Food and drink are important determinants of physical and social health in care home residents . This study explored whether a pragmatic methodology including routinely collected data was feasible in UK care homes , to describe the health , wellbeing and nutritional status of care home residents and assess effects of changed provision of food and drink at three care homes on residents '  falls ( primary outcome ) , anaemia , weight , dehydration , cognitive status , depression , lipids and satisfaction with food and drink provision . Methods We measured health , wellbeing and nutritional status of 120 of 213 residents of six care homes in Norfolk , UK . An intervention comprising improved dining atmosphere , greater food choice , extended restaurant hours , and readily available snacks and drinks machines was implemented in three care homes . Three control homes maintained their previous system . Outcomes were assessed in the year before and the year after the changes . Results Use of routinely collected data was partially successful , but loss to follow up and levels of missing data were high , limiting power to identify trends in the data .This was a frail older population ( mean age 87 , 71 % female ) with multiple varied health problems . During the first year 60 % of residents had one or more falls , 40 % a wound care visit , and 40 % a urinary tract infection . 45 % were on diuretics , 24 % antidepressants , and 43 % on psychotropic medication . There was a slight increase in falls from year 1 to year 2 in the intervention homes , and a much bigger increase in control homes , leading to a statistically non-significant 24 % relative reduction in residents ' rate of falls in intervention homes compared with control homes ( adjusted rate ratio 0.76 , 95 % CI 0.57 to 1.02 , p = 0.06 ) . Conclusions Care home residents are frail and experience multiple health risks . This intervention to improve food and drink provision was well received by residents , but effects on health indicators ( despite the relative reduction in falls rate ) were inconclusive , partly due to problems with routine data collection and loss to follow up . Further research with more homes is needed to underst and which , if any , components of the intervention may be successful . Trial registration Trial registration : IS RCT N86057119 BACKGROUND nasogastric tube ( NGT ) feeding is commonly used after stroke , but its effectiveness is limited by frequent dislodgement . OBJECTIVE the objective of the study was to evaluate looped NGT feeding in acute stroke patients with dysphagia . METHODS this was a r and omised controlled trial of 104 patients with acute stroke fed by NGT in three UK stroke units .  NGT was secured using either a nasal loop ( n = 51 ) or a conventional adhesive dressing ( n = 53 ) . The main outcome measure was the proportion of prescribed feed and fluids delivered via NGT in 2 weeks post-r and omisation . Secondary outcomes were frequency of NGT insertions , treatment failure , tolerability , adverse events and costs at 2 weeks ; mortality ; length of hospital stay ; residential status ; and Barthel Index at 3 months . RESULTS participants assigned to looped NGT feeding received a mean 17 % ( 95 % confidence interval 5 - 28 % ) more volume of feed and fluids , required fewer NGTs ( median 1 vs 4 ) , and had fewer electrolyte abnormalities than controls . There was more minor nasal trauma in the loop group . There were no differences in outcomes at 3 months . Looped NGT feeding cost 88 pounds sterling more per patient over 2 weeks than controls . CONCLUSION looped NGT feeding improves delivery of feed and fluids and reduces NGT reinsertion with little additional cost BACKGROUND & AIMS The effect of nutritional supplements on mental health in older patients has received little attention so far . The aims of this trial were therefore to test the effect of nutritional support on older patient 's depressive symptoms and cognitive function . METHODS In this prospect i ve , double-blind , placebo-controlled study , we r and omly assigned 225 hospitalised acutely ill older patients to receive either normal hospital diet plus 400 mL oral nutritional supplements ( 106 subjects ) or normal hospital diet plus a placebo ( 119 subjects ) daily for 6 weeks . The composition of the supplement was such as to provide 995 kcal for energy and 100 % of the Reference Nutrient Intakes for a healthy old person for vitamins and minerals . Outcome measures were 6 weeks and 6 months changes in nutritional status , depressive symptoms and cognitive state . RESULTS R and omisation to the supplement group led to a significant increase in red-cell folate and plasma vitamin B12 concentrations , in contrast to a decrease seen in the placebo group . There were significant differences in symptoms of depression scores in the supplement group compared with the placebo group at 6 months ( p = 0.021 for between groups difference ) . The effect of supplement was seen in all patient groups including those with no symptoms of depression , mild depression and those with severe depression ( p = 0.007 ) . There was no evidence of a difference in cognitive function scores at 6 months . CONCLUSION Oral nutritional supplementation of hospitalised acutely ill older patients led to a statistically significant benefit on depressive symptoms BACKGROUND The care of elderly persons in chronic care nursing wards is generally complicated by nutritional problems such as weight loss and worsening protein status . An inability or refusal of the patient to consume enough food often necessitates the use of expensive commercial formulas for nutritional support . The purpose of this study was to determine whether the use of an in-house ( high-protein , milk-based ) low-cost formula with added minerals and vitamins for total nutritional support would be effective in maintaining weight and protein status of patients in the long term . METHODS Participants were recruited from five nursing care units of a single geriatric facility . All residents who required formula feeding  were followed prospect ively . The formula was provided either as a pudding or a milkshake for oral feeding or as a liquid for tube feeding and served as the sole source of nutrition . Data were collected regarding the participants ' weight ( monthly ) , serum albumin level ( periodically ) , and the manner of formula administration ( oral , nasogastric , or gastrostomy tube ) . RESULTS One hundred forty-three participants who received this formula were followed for a maximum period of 6 years . Mean weight increased by 5 kg during the first year and remained stable thereafter . Those participants who died within 6 months had no increase in weight . The long-term mean serum albumin level of all participants was an acceptable 4 g/dL. CONCLUSION The long-term use of an inexpensive in-house formula for total nutritional support increased weight and maintained serum albumin levels in most of the chronically ill elderly nursing care patients who participated in the study BACKGROUND In order to reduce protein-energy malnutrition in older people during hospitalisation an early interdisciplinary intervention is needed . We developed a protocol which includes screening for malnutrition , dysphagia and dehydration on admission , followed by immediate interventions . OBJECTIVE To assess effectiveness of the protocol on nutritional status , hospital-acquired infections and pressure sores , and to evaluate the protocol s economical feasibility . DESIGN Prospect i ve , controlled study . SETTING The inpatient geriatric service of a university hospital ( UMC Nijmegen ) and a geriatric ward of a non-academic teaching hospital ( Rijnstate Hospital , Arnhem ) . SUBJECTS 298 older patients ( > 60 years ) . METHODS One of the geriatric wards applied the protocol ( N=140 ) while the other provided st and ard care ( N=158 ) . All non-terminally ill patients admitted for more than two days were included .  Body mass was measured on admittance and discharge and hospital-acquired infections and pressure sores were scored and costs related to nutrition , infections and length of hospital stay were assessed . RESULTS There was a 0.8 kg loss ( SEM 0.3 kg ) in average weight in the st and ard care group and a 0.9 kg gain ( SEM 0.2 kg ) in the intervention group ( p<0.001 ) . The number of hospital acquired infections was significantly lower in the intervention group ( 33/140 versus 58/158 , p=0.01 ) but no significant difference in number of patients with pressure sores ( 23/140 versus 33/158 ) was found . Costs were not significantly different : 7516 versus 7908 Euro/patient for intervention versus controls , respectively . CONCLUSION An early interdisciplinary intervention approach can be effective in reducing protein-energy malnutrition and related hospital-acquired infections and appears to be economically feasible The aim of the present study was to evaluate the Mini Nutritional Assessment ( MNA ) , the Nutritional Risk Screening ( NRS ) 2002 and the American Society of Anesthesiologists Physical Status Score ( ASA ) as predictors of gait status and mortality 6 months after hip fracture . A total of eighty-eight consecutive patients over the age of 65 years with hip fracture admitted to an orthopaedic unit were prospect ively evaluated . Within the first 72 h of admission , each patient 's characteristics were recorded , and the MNA , the NRS 2002 and the ASA were performed . Gait status and mortality were evaluated 6 months after hip fracture . Of the total patients , two were excluded because of pathological fractures . The remaining eighty-six patients ( aged 80·2 ( sd 7·3 ) years ) were studied . Among these patients 76·7 % were female , 69·8 % walked with or without support and 12·8 % died 6 months after the fracture . In a multivariate analysis , only the MNA was associated with gait status 6 months after hip fracture ( OR 0·773 , 95 % CI 0·663 , 0·901 ; P= 0·001 ) . In the Cox regression model , only the MNA was associated with mortality 6 months after hip fracture ( hazard ratio 0·869 , 95 % CI 0·757 , 0·998 ; P= 0·04 ) . In conclusion , the MNA best predicts gait status and mortality 6 months after hip fracture . These results suggest that the MNA should be included in the clinical stratification of patients with hip fracture to identify and treat malnutrition in order to improve the outcomes Objective : To examine the effect of various combinations of beverages on hydration status in healthy free-living adult males . Methods : In a counterbalanced , crossover manner , 18 healthy adult males ages 24 to 39 , on four separate occasions , consumed water or water plus varying combinations of beverages . Clinical guidelines were used to determine the fluid allowance for each subject . The beverages were carbonated , caffeinated caloric and non-caloric colas and coffee . Ten of the 18 subjects consumed water and carbonated , non-caffeinated , citrus soft drink during a fifth trial . Body weight , urine and blood assays were measured before and after each treatment . Results : Slight body weight loss was observed on all treatments , with an average of 0.30 % for all treatments . No differences ( p>0.05 ) among treatments were found for body weight changes or any of the biochemical assays . Biochemical assays conducted on first voids and 24-hour urines included electrolytes , creatine , osmolality and specific gravity . Blood sample s were analyzed for hemoglobin , hematocrit , electrolytes , osmolality , urea nitrogen , creatinine and protein . Conclusions : This preliminary study found no significant differences in the effect of various combinations of beverages on hydration status of healthy adult males . Advising people to disregard caffeinated beverages as part of the daily fluid intake is not substantiated by the results of this study . The across-treatment weight loss observed , when combined with data on fluid-disease relationships , suggests that optimal fluid intake may be higher than common recommendations . Further research is needed to confirm these results and to explore optimal fluid intake for healthy individuals BACKGROUND Undernutrition is common in patients admitted with stroke . We aim ed to establish whether the timing and route of enteral tube feeding after stroke affected patients ' outcomes at 6 months . METHODS The FOOD trials consist of three pragmatic multicentre r and omised controlled trials , two of which included dysphagic stroke patients . In one trial , patients enrolled within 7 days of admission were r and omly allocated to early enteral tube feeding or no tube feeding for more than 7 days ( early versus avoid ) . In the other , patients were allocated percutaneous endoscopic gastrostomy ( PEG ) or nasogastric feeding . The primary outcome was death or poor outcome at 6 months . Analysis was by intention to treat . FINDINGS Between Nov 1 , 1996 , and July 31 , 2003 , 859 patients were enrolled by 83 hospitals in 15 countries into the early versus avoid trial . Early tube feeding was associated with an absolute reduction in risk of death of 5.8 % ( 95 % CI -0.8 to 12.5 , p=0.09 ) and a reduction in death or poor outcome of 1.2 % ( -4.2 to 6.6 , p=0.7 ) . In the PEG versus nasogastric tube trial , 321 patients were enrolled by 47 hospitals in 11 countries . PEG feeding was associated with an absolute increase in risk of death of 1.0 % ( -10.0 to 11.9 , p=0.9 ) and an increased risk of death or poor outcome of 7.8 % ( 0.0 to 15.5 , p=0.05 ) . INTERPRETATION Early tube feeding might reduce case fatality , but at the expense of increasing the proportion surviving with poor outcome . Our data do not support a policy of early initiation of PEG feeding in dysphagic stroke patients Background Dysphagia occurs in up to 50 % of patients admitted to hospital with acute strokes with up to 27 % remaining by seven days . Up to 8 % continue to have swallowing problems six months after their stroke with 1.7 % still requiring enteral feeding . Nasogastric tubes ( NGT ) are the most commonly used method for providing enteral nutrition in early stroke , however they are easily and frequently removed leading to inadequate nutrition , early PEG ( Percutaneous Endoscopic Gastrostomy ) insertion or ab and oning of feeding attempts . Looped nasogastric tube feeding may improve the delivery of nutrition to such patients . Methods Three centre , two arm r and omised controlled trial , with 50 participants in each arm comparing loop ( the intervention ) versus conventional nasogastric tube feeding . The primary outcome measure is proportion of intended feed delivered in the first 2 weeks . The study is design ed to show a mean increase of feed delivery of 16 % in the intervention group as compared with the control group , with 90 % power at a 5 % significance level . Secondary outcomes are treatment failures , mean volume of feed received , adverse events , cost-effectiveness , number of chest x-rays , number of nasogastric tubes and tolerability . Trial Registration IS RCT N Number : IS RCT Introduction This study evaluates whether a postoperative multidisciplinary , intervention program , including systematic assessment and treatment of fall risk factors , active prevention , detection , and treatment of postoperative complications , could reduce inpatient falls and fall-related injuries after a femoral neck fracture . Methods A r and omized , controlled trial at the orthopedic and geriatric departments at Umeå University Hospital , Sweden , included 199 patients with femoral neck fracture , aged ≥70 years . Results Twelve patients fell 18 times in the intervention group compared with 26 patients suffering 60 falls in the control group . Only one patient with dementia fell in the intervention group compared with 11 in the control group . The crude postoperative fall incidence rate was 6.29/1,000 days in the intervention group vs 16.28/1,000 days in the control group . The incidence rate ratio was 0.38 [ 95 % confidence interval ( CI ) : 0.20 – 0.76 , p = 0.006 ] for the total sample and 0.07 ( 95 % CI : 0.01–0.57 , p=0.013 ) among patients with dementia . There were no new fractures in the intervention group but four in the control group . Conclusion A team applying comprehensive geriatric assessment and rehabilitation , including prevention , detection , and treatment of fall risk factors , can successfully prevent inpatient falls and injuries , even in patients with dementia OBJECTIVE To examine how improved attention to nutritional status and dietary intake , achieved through the employment of dietetic assistants ( DAs ) , will affect postoperative clinical outcome among elderly women with hip fracture . DESIGN Open prospect i ve r and omised controlled trial , comparing conventional nursing care with the additional nutritional support provided by DA . SETTING Thirty-eight bedded acute trauma ward in a teaching hospital . PARTICIPANTS All but 11 of 344 consecutive admissions with acute nonpathological hip fracture were approached . Three hundred and eighteen ( 93 % ) agreed to inclusion . Sixteen were ineligible as they were immediately transferred to another acute ward , were managed conservatively or died preoperatively . PRIMARY OUTCOME MEASURE Postoperative mortality in the acute trauma unit . SECONDARY OUTCOME MEASURES Postoperative mortality at 4 months after fracture , length of stay , energy intake and nutritional status . RESULTS DA-supported participants were less likely to die in the acute ward ( 4.1 versus 10.1 % , P = 0.048 ) . This effect was still apparent at 4 month follow-up ( 13.1 versus 22.9 % , P = 0.036 ) . DA-supported subjects had significantly better mean daily energy intake ( 1,105 kcal versus 756 kcal/24 h , 95 % CI 259 - 440 kcal/24 h , P<0.001 ) , significantly smaller reduction in mid-arm circumference during their inpatient stay ( 0.39 cm , P = 0.002 ) and nonsignificantly favourable results for other anthropometric and laboratory measurements . CONCLUSION Dietetic or nutrition assistants are being introduced in units across the UK . This , the largest ever study of nutritional support after hip fracture , shows that their employment significantly reduced patients ' risk of dying in the acute trauma unit ; an effect that persisted at 4 month follow-up AIM To report a study of the effects of protein-energy malnutrition on the functional recovery of older people with hip fracture who participated in an interdisciplinary intervention . BACKGROUND It is not clear whether protein-energy malnutrition is associated with worse functional outcomes or it affects the interdisciplinary intervention program on the functional recovery of older people with hip fracture . DESIGN A r and omized experimental design . METHODS Data were collected between 2002 - 2006 from older people with hip fracture ( N = 162 ) in Taiwan . The generalized estimating equations approach was used to evaluate the effect of malnutrition on the functional recovery of older people with hip fracture . RESULTS The majority of older patients with hip fracture were malnourished ( 48/80 , 60 % in the experimental group vs. 55/82 , 67 % in the control group ) prior to hospital discharge . The results of the generalized estimating equations analysis demonstrated that subjects suffering from protein-energy malnutrition prior to hospital discharge appeared to have significantly worse performance trajectories for their activities of daily living , instrumental activities of daily living , and recovery of walking ability compared with those without protein-energy malnutrition . In addition , it was found that the intervention is more effective on the performance of activities of daily living and recovery of walking ability in malnourished patients than in non-malnourished patients . CONCLUSION Healthcare providers should develop a nutritional assessment /management system in their interdisciplinary intervention program to improve the functional recovery of older people with hip fracture BACKGROUND malnutrition is an important risk factor for poor outcome in patients recovering after hip fracture surgery . This study aim ed to investigate the clinical , nutritional and rehabilitation effects of an oral nutritional supplementation ( ONS ) in an inpatient rehabilitation setting . METHODS this was an observer-blinded r and omised controlled trial of elderly post-surgical proximal femoral fracture patients . A ready-to-use oral liquid nutritional supplementation ( 18 - 24 g protein and 500 kcal per day ) in addition to hospital diet was compared with hospital diet only . Both groups received usual rehabilitation therapy and oral calcium and vitamin D supplements . Outcomes were compared at discharge from rehabilitation and after 4 weeks of discharge . The primary outcome parameters were the serum albumin level , the body mass index ( BMI ) , the functional independence measure ( FIM ) and the elderly mobility scale ( EMS ) . Secondary outcome parameters were frequency of complications , inpatient length of stay , mortality and acute hospital use within 6 months after discharge . RESULTS a total of 126 patients were recruited , 65 in the supplementation arm and 61 in the control arm . There was a significant difference in change in BMI with a decrease of 0.25 and 0.03 kg/m(2 ) in the ONS group and 0.72 and 0.49 kg/m(2 ) in the control group at hospital discharge and follow-up , respectively ( P = 0.012 ) . The length of stay in rehabilitation ward was shortened by 3.80 ( SE = 1.81 , P = 0.04 ) days favouring the ONS group . The total number of infection episodes was also reduced significantly . No difference was observed in the rate of change of the serum albumin level , the FIM and the EMS . CONCLUSION clinical and nutritional benefits were seen in this trial but rehabilitation benefits could not be demonstrated Background In the Rehabilitation and Aged Care Services Program at Southern Health in Victoria , saline hypodermoclysis is a relatively common method of rehydration . However , there were questions about the safety and effectiveness of subcutaneous infusion of other fluids and , in particular , dextrose solutions . This review aim ed to assess the safety and effectiveness of rehydration of elderly patients with subcutaneous 5 % dextrose solutions compared with intravenous 5 % dextrose solutions . Methods We search ed the Cochrane Library , Medline , IDIS , CINAHL , Current Contents , Pre medline , Australasian Medical Index , the Joanna Briggs Institute , the US National Guideline Clearinghouse and bibliographies of retrieved articles . Search ing was undertaken in July 2003 . Studies selected were primary studies ( or systematic review s of primary studies ) providing evidence as to the effectiveness and safety of subcutaneous infusion of dextrose solutions for rehydration of elderly patients . We included articles published in English in the last 10 years . Data were extracted by a single research er . Results From our search we identified 15 potentially relevant articles . We obtained the full text of these articles to determine their relevance . After application of the inclusion criteria , four articles remained for appraisal including one systematic review , two r and omised controlled trials and one cohort study . Conclusion The four studies appraised all provide evidence that appropriate volumes of subcutaneous dextrose infusions ( in the form of half-normal saline-glucose 5 % , 40 g/L dextrose and 30 mmol/L NaCl , or 5 % dextrose solution and 4 g/L NaCl , or two-thirds 5 % glucose and one-third normal saline ) can be used effectively for the treatment of dehydration , with similar rates of adverse effects to intravenous infusion . The evidence in this area is limited , and larger r and omised controlled trials using vali date d outcome measures would be useful to confirm these results Results of this study suggest that specific nursing protocol s can be design ed to promote functional feeding for demented elders in nursing homes while enhancing the mealtime environment for both the demented elders and their caregivers . By nurses altering the feeding environment ( context ) alone , subjects received more food and drink , refused less food and showed more self-feeding . Major findings were that subjects demonstrated increased independence by refusing food more often and initiating self-feeding more frequently BACKGROUND Interventions to attenuate the adverse effects of age-related loss of skeletal muscle and function include increased physical activity and nutritional supplementation . OBJECTIVE This study tested the hypothesis that nutritional supplementation with whey protein ( 22 g ) , essential amino acids ( 10.9 g , including 4 g leucine ) , and vitamin D [ 2.5 μg ( 100 IU ) ] concurrent with regular , controlled physical activity would increase fat-free mass , strength , physical function , and quality of life , and reduce the risk of malnutrition in sarcopenic elderly persons . DESIGN A total of 130 sarcopenic elderly people ( 53 men and 77 women ; mean age : 80.3 y ) participated in a 12-wk r and omized , double-blind , placebo-controlled  supplementation trial . All participants concurrently took part in a controlled physical activity program . We examined body composition with dual-energy X-ray absorptiometry , muscle strength with a h and grip dynamometer , and blood biochemical indexes of nutritional and health status , and evaluated global nutritional status , physical function , and quality of life before and after the 12 wk of intervention . RESULTS Compared with physical activity and placebo , supplementation plus physical activity  increased fat-free mass ( 1.7-kg gain , P < 0.001 ) , relative skeletal muscle mass ( P = 0.009 ) , and roid distribution of fat ( P = 0.021 ) , h and grip strength ( P = 0.001 ) , st and ardized summary scores for physical components ( P = 0.030 ) , activities of daily living ( P = 0.001 ) , mini nutritional assessment ( P = 0.003 ) , and insulin-like growth factor I ( P = 0.002 ) , and lowered C-reactive protein ( P = 0.038 ) . CONCLUSION Supplementation with whey protein , essential amino acids , and vitamin D , in conjunction with age-appropriate exercise , not only boosts fat-free mass and strength but also enhances other aspects that contribute to well-being in sarcopenic elderly . This trial was registered at clinical trials.gov as NCT02402608 Background and aims : Delirium is a common postoperative complication in elderly patients which has a serious impact on outcome in terms of morbidity and costs . We examined whether a postoperative multi-factorial intervention program can reduce delirium and improve outcome in patients with femoral neck fractures . Methods : One hundred and ninety-nine patients , aged 70 years and over ( mean age±SD , 82±6 , 74 % women ) , were r and omly assigned to  postoperative care in a specialized geriatric ward or a conventional orthopedic ward . The intervention consisted of staff education focusing on the assessment , prevention and treatment of delirium and associated complications . The staff worked as a team , applying comprehensive geriatric assessment , management and rehabilitation . Patients were assessed using the Mini Mental State Examination and the Organic Brain Syndrome Scale , and delirium was diagnosed according to DSM-IV criteria . Results : The number of days of postoperative delirium among intervention patients was fewer ( 5.0±7.1 days vs 10.2±13.3 days , p=0.009 ) compared with controls . A lower proportion of intervention patients were delirious postoperatively than controls ( 56/102 , 54.9 % vs 73/97 , 75.3 % , p=0.003 ) . Eighteen percent in the intervention ward and 52 % of controls were delirious after the seventh postoperative day ( p<0.001 ) . Intervention patients suffered from fewer complications , such as decubitus ulcers , urinary tract infections , nutritional complications , sleeping problems and falls , than controls . Total postoperative hospitalization was shorter in the intervention ward ( 28.0±17.9 days vs 38.0±40.6 days , p=0.028 ) . Conclusions : Patients with postoperative delirium can be successfully treated , result ing in fewer days of delirium , fewer other complications , and shorter length of hospitalization BACKGROUND Despite all that is known about diabetes mellitus , little is known about the nutritional status of older adults with this condition . OBJECTIVE To determine whether older people with diabetes mellitus are malnourished when compared with non-diabetic subjects , to evaluate the MNA in this group , and to assess the possible relationship between nutritional impairment and function . DESIGN A case controlled study . Community-dwelling volunteers were selected r and omly from 2 general practice registers . 35 people over the age of 65 , with diabetes mellitus , were age and sex matched with 35 control subjects without diabetes . The major outcome measures were : the MNA question naire , anthropometric measurements , serum albumin , transferrin , Barthel Index , Nottingham Extended ADL score and h and grip . RESULTS The diabetic group scored significantly lower on the MNA than the control group ( p < 0.01 ) , but this was mainly indicative of many of the diabetic subjects scoring within the at risk category of the tool . Those in the diabetic group also had significantly lower albumin scores ( P<0.05 ) when compared with the control group . Within the diabetic group , and in the study group as a whole , the MNA scores were significantly correlated with Barthel Index ( p<0.01 ) , Nottingham Extended ADL score ( p<0.01 ) and h and grip ( p<0.01 ) . CONCLUSION Community dwelling elderly subjects with diabetes may be at risk of malnutrition when compared with non-diabetic citizens . There is probably a causal relationship between malnutrition and functional decline in this group . Further research is needed , where the prevalence of malnutrition is higher , to fully evaluate the MNA in people with diabetes 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 OBJECTIVE Percutaneous endoscopic gastrostomy ( PEG ) has become the preferred method to provide enteral tube feeding to older adults who have difficulty eating , but the impact of PEG on patient outcomes is poorly understood . The objective of this study was to describe changes in nutrition , functional status , and health-related quality of life among older adults receiving PEG .  DESIGN A prospect i ve cohort study . SETTING A small community of approximately 60,000 residents served by two hospital systems . PARTICIPANTS One hundred fifty patients aged 60 and older receiving PEG from one of the four gastroenterologists practicing in the targeted community . MEASUREMENTS Patients were assessed at baseline and every 2 months for 1 year to obtain clinical characteristics , process of care data , physical and cognitive function , subjective health status , nutritional status , complications , and mortality . RESULTS Over a 14-month period , 150 patients received PEG tubes in the targeted community ; the mean age was 78.9 . The most frequent indications for the PEG were stroke ( 40.7 % ) , neurodegenerative disorders ( 34.7 % ) , and cancer ( 13.3 % ) . All measures of functional status , cognitive status , severity of illness , comorbidity , and quality of life demonstrated profound and life-threatening impairment ; 30-day mortality was 22 % and 1-year mortality was 50 % . Among patients surviving 60 days or more , at least 70 % had no significant improvement in functional , nutritional , or subjective health status . Serious complications were rare , but most patients experienced symptomatic problems that they attributed to the enteral tube feeding . CONCLUSIONS PEG tube feeding in severely and chronically ill older adults can be accomplished safely . However , there are important patient burdens associated with the PEG and there was limited evidence that the procedure improves functional , nutritional , or subjective health status in this cohort of older adults . The issues raised in this descriptive study provide impetus for a r and omized trial of PEG tube feeding compared with alternative methods of patient care for older adults with difficulty eating OBJECTIVES To evaluate the effects of a short-term nutritional intervention with protein and vitamin D on  falls in malnourished older adults .  DESIGN R and omized controlled trial . SETTING From hospital admission until 3 months after discharge . PARTICIPANTS Malnourished older adults ( ≥ 60 ) newly admitted to an acute hospital ( n = 210 ) . INTERVENTION Participants were r and omized to receive nutritional intervention ( energy- and protein-enriched diet , oral nutritional supplements , calcium-vitamin D supplement , telephone counseling by a dietitian ) for 3 months after discharge or usual care . MEASUREMENTS Number of participants who fell , fall incidents , serum 25-hydroxyvitamin D , and dietary intake . Measurements were performed on admission to hospital and 3 months after discharge . RESULTS Three months after discharge , 10 participants ( 10 % ) in the intervention group had fallen at least once , compared with 24 ( 23 % ) in the control group ( hazard ratio = 0.41 , 95 % confidence interval ( CI ) = 0.19 - 0.86 ) . There were 57 fall incidents ( 16 in the intervention group ; 41 in the control group ) . A significantly higher intake of energy ( 280 kcal , 95 % CI = 37 - 524 kcal ) and protein ( 11 g , 95 % CI = 1 - 25 g ) and significantly higher serum 25-hydroxyvitamin D levels ( 10.9 nmol/L , 95 % CI = 2.9 - 18.9 nmol/L ) were found in participants in the intervention group than in controls . CONCLUSION A short-term nutritional intervention consisting of oral nutritional supplements and calcium and vitamin D supplementation and supported by dietetic counseling in malnourished older adults decreases the number of patients who fall and fall incidents BACKGROUND Elderly patients with hip fracture have been found to benefit from subacute care interventions that usually comprise usual care with added geriatric intervention , early rehabilitation , and supported discharge . However , no studies were found on the effects of combining subacute care and health-maintenance interventions on health outcomes for elders with hip fracture . OBJECTIVES To compare the effects of an interdisciplinary comprehensive care programme with those of subacute care and usual care programmes on health-related quality of life ( HRQoL ) for elderly patients with hip fracture . DESIGN R and omised controlled trial . SETTING S A 3000-bed medical centre in northern Taiwan . PARTICIPANTS Patients with hip fracture ( N=299 ) were r and omised into three groups : subacute care ( n=101 ) , comprehensive care ( n=99 ) , and usual care ( n=99 ) . METHODS Subacute care included geriatric consultation , continuous rehabilitation , and discharge planning . Comprehensive care consisted of subacute care plus health-maintenance interventions to manage depressive symptoms , manage malnutrition , and prevent falls . Usual care included only 1 - 2 in-hospital rehabilitation sessions , discharge planning without environmental assessment , no geriatric consultation , and no in-home rehabilitation .  HRQoL was measured using the Medical Outcomes Study Short-Form 36 Taiwan version at 1 , 3 , 6 , and 12 months after discharge . RESULTS Participants in the comprehensive care group improved more in physical function , role physical , general health and mental health than those in the usual care group . The subacute care group had greater improvement in physical function , role physical , vitality , and social function than the usual care group . The intervention effects for both comprehensive and subacute care increased over time , specifically from 6 months after hip fracture onward , and reached a maximum at 12 months following discharge . CONCLUSIONS Both comprehensive care and subacute care programmes may improve health outcomes of elders with hip fracture . Our results may provide a reference for health care providers in countries using similar programmes with Chinese/Taiwanese immigrant population BACKGROUND Trials on specific nutritional supplements for the treatment of  pressure ulcers ( PUs ) have been small , inconsistent in their formulations , or unsuccessful in controlling for total supplement calorie or protein content . OBJECTIVE To evaluate whether supplementation with arginine , zinc , and antioxidants within a high-calorie , high-protein formula improves PU healing . DESIGN Multicenter , r and omized , controlled , blinded trial . ( Clinical Trials.gov : NCT01107197 ) . SETTING Long-term care and home care services . PATIENTS 200 adult malnourished patients with stage II , III , and IV PUs . INTERVENTIONS An energy-dense , protein-rich oral formula enriched with arginine , zinc , and antioxidants ( 400 mL/d ) or an equal volume of an isocaloric , isonitrogenous formula for 8 weeks . MEASUREMENTS The primary end point was the percentage of change in PU area at 8 weeks . Secondary end points included complete healing , reduction in the PU area of 40 % or greater , incidence of wound infections , the total number of dressings at 8 weeks , and the percentage of change in area at 4 weeks . RESULTS Supplementation with the enriched formula ( n = 101 ) result ed in a greater reduction in PU area ( mean reduction , 60.9 % [ 95 % CI , 54.3 % to 67.5 % ] ) than with the control formula ( n = 99 ) ( 45.2 % [ CI , 38.4 % to 52.0 % ] ) ( adjusted mean difference , 18.7 % [ CI , 5.7 % to 31.8 % ] ; P = 0.017 ) . A more frequent reduction in area of 40 % or greater at 8 weeks was also seen ( odds ratio , 1.98 [ CI , 1.12 to 3.48 ] ; P = 0.018 ) . No difference was found in terms of the other secondary end points . LIMITATION Participation was restricted to patients who were malnourished , were able to drink oral supplements , and were living in long-term care institutions or receiving home care services . CONCLUSION Among malnourished patients with PU , 8 weeks of supplementation with an oral nutritional formula enriched with arginine , zinc , and antioxidants improved PU healing . PRIMARY FUNDING SOURCE Azienda Ospedaliera Universitaria Maggiore della Carità AIMS Evaluate nutritional status and fluid and energy intake during the first ten days of hospitalisation in a selection of otherwise healthy patients with a hip fracture . METHODS A prospect i ve r and omised controlled study of 80 patients . Nutritional status was assessed at inclusion . The  energy and fluid intake  was recorded and calculated daily whilst hospitalised . All patients were given ordinary hospital food and beverage . In the treatment group ( n = 40 ) patients also received intraveneous supplementary nutrition ( 1000 kcal/day ) for three days followed by oral supplementary nutrition ( 400 kcal/day ) for seven days or until discharge . RESULTS One third of patients were classified as malnourished in both groups . The average daily fluid intake/patient was 1300 ml in the control group compared to 1856 ml in the treatment group ( P<0.0001 ) . The average daily energy intake/patient was 916 kcal in the control group compared to 1296 kcal in the treatment group ( P = 0.003 ) . The mean difference between actual and needed daily fluid intake was -739 ml in the control group and + 27 ml in the treatment group ( P<0.0001 ) . Corresponding numbers for energy intake was -783 kcal/day in the control group and -228 kcal/day in the treatment group ( P = 0.0003 ) . CONCLUSIONS Malnutrition is common even in a selection of healthy patients with hip fractures . During hospital stay the fluid and energy intake was considerably lower than that needed in the control group . Supplementary nutritional intake for ten days increased the total fluid and energy intake in the treatment group to near needed levels BACKGROUND AND AIMS Few data are available on the quality of life of home enteral nutrition ( HEN ) patients . This study was design ed to assess both the quality of life of long-term HEN patients and the evolution of quality of life after initiation of HEN . METHODS Quality of life-related parameters were analysed in 38 patients ( 24 M , 14F ) aged 56 + /- 5 years who had been on HEN for more than 2 months ( mean 25 + /- 5 months ) . Patients or close relatives were asked to answer a  subjective assessment question naire , and patients with normal consciousness ( n+ 24 ) answered the self-administered SF-36 and EuroQol question naires .  RESULTS Since the initiation of HEN , patients had spent 1.9 + /- 0.5 % of the time in the hospital , in 54 % of cases because of HEN-related complications . Analysis of the generic question naires revealed poorer quality of life parameters in comparison to a general population , although better results were sometimes observed in younger patients ( under 45 years ) , patients without cancer , and patients with more than one care-giver . Nevertheless , the patients ' subjective assessment of the changes in their quality of life since beginning HEN was generally good , with most patients reporting improved or stable mental and physical well-being . CONCLUSIONS Quality of life is poor in HEN patients , but subgroups of patients who score better in some quality of life dimensions can be identified . Most patients describe an improvement in their quality of life following the initiation of HEN that needs to be confirmed by a prospect i ve study Background and aims : There are few studies published that combine the interventions of physical training and nutrition . The aim of the present study was to describe the impact of a physical and nutritional intervention program for frail community-dwelling elderly people over the age of 75 . Methods : Ninety-six community-dwelling elderly people ( 58 women ) were r and omized to four different groups : i ) a physical training program ( aerobic , muscle strength , balance ) , ii ) a nutritional intervention program ( individually targeted advice and group sessions ) , iii ) a combination of these interventions , and iv ) a control group . At baseline subjects were screened for physical performance such as muscle strength , balance , mobility and activities of daily living , as well as nutritional aspects such as energy intake , body weight and fat-free mass . These measurements were repeated immediately after the intervention , which lasted for 12 weeks , and after another 6 months . Results : The intention-to-treat analysis indicated significant improvements in lower-extremity muscle strength in both training groups compared with the nutrition group at 1st follow-up . There were small significant changes for some of the balance measurements in the training group without nutrition treatment . The nutrition intervention did not show any significant results . Conclusions : This study shows the positive effect on lower-extremity muscle strength directly after the intervention . Balance training most probably needs to be more individualized in order to be effective for frail elderly people . Further studies are needed , with larger sample sizes , to investigate the effects of these types of interventions before any further conclusions can be drawn BACKGROUND Hospitalized , malnourished older adults have a high risk of readmission and mortality . OBJECTIVE Evaluation of a high-protein oral nutritional supplement ( HP-HMB ) containing beta-hydroxy-beta-methylbutyrate on postdischarge outcomes of nonelective readmission and mortality in malnourished , hospitalized older adults . DESIGN Multicenter , r and omized , placebo-controlled , double-blind trial . SETTING Inpatient and posthospital discharge . PATIENTS Older ( ≥65 years ) , malnourished ( Subjective Global Assessment [ SGA ] class B or C ) adults hospitalized for congestive heart failure , acute myocardial infa rct ion , pneumonia , or chronic obstructive pulmonary disease . INTERVENTIONS St and ard-of-care plus HP-HMB ( n = 328 ) or a placebo supplement ( n = 324 ) , 2 servings/day . MEASUREMENTS Primary composite endpoint was 90-day postdischarge incidence of death or nonelective readmission . Other endpoints included 30- and 60-day postdischarge incidence of death or readmission , length of stay ( LOS ) , SGA class , body weight , and activities of daily living ( ADL ) . RESULTS The primary composite endpoint was similar between HP-HMB ( 26.8 % ) and placebo ( 31.1 % ) . No between-group differences were observed for 90-day readmission rate , but 90-day mortality was significantly lower with HP-HMB relative to placebo ( 4.8 % vs. 9.7 % ; relative risk 0.49 , 95 % confidence interval [ CI ] , 0.27 to 0.90 ; p = 0.018 ) . The number-needed-to-treat to prevent 1 death was 20.3 ( 95 % CI : 10.9 , 121.4 ) . Compared with placebo , HP-HMB result ed in improved odds of better nutritional status ( SGA class , OR , 2.04 , 95 % CI : 1.28 , 3.25 , p = 0.009 ) at day 90 , and an increase in body weight at day 30 ( p = 0.035 ) . LOS and ADL were similar between treatments . LIMITATIONS Limited generalizability ; patients represent a selected hospitalized population . CONCLUSIONS Although no effects were observed for the primary composite endpoint , compared with placebo HP-HMB  decreased mortality and improved indices of nutritional status during the 90-day observation period . CLINICAL TRIAL REGISTRATION www . Clinical Trials.govNCT01626742 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 OBJECTIVE To investigate the factors that influenced fluid intake among nursing home residents who were not eating well . DESIGN A prospect i ve , descriptive , anthropological study . SETTING Two proprietary nursing homes with 105 and 138 beds , respectively . PARTICIPANTS Forty nursing home residents . MEASUREMENTS Participant observation , event analysis , bedside dysphagia screening , mental and functional status evaluation , assessment of level of family/advocate involvement , and chart review  were used to collect data . Data were gathered on the amount of liquid served and consumed over a 3- day period . Daily fluid intake was compared with three established st and ards : St and ard 1 ( 30 mL/kg body weight ) , St and ard 2 ( 1 mL/kcal/energy consumed ) , and St and ard 3 ( 100 mL/kg for the first 10 kg , 50 mL/kg for the next 10 kg , 15 mL/kg for the remaining kg ) . RESULTS The residents ' mean fluid intake was inadequate ; 39 of the 40 residents consumed less than 1500 mL/day . Using three established st and ards , we found that the fluid intake was inadequate for nearly all of the residents . The amount of fluid consumed with and between meals was low . Some residents took no fluids for extended periods of time , which result ed in their fluid intake being erratic and inadequate even when it was resumed . Clinical ( undiagnosed dysphagia , cognitive and functional impairment , lack of pain management ) , sociocultural ( lack of social support , inability to speak English , and lack of attention to individual beverage preferences ) , and institutional factors ( an inadequate number of knowledgeable staff and lack of supervision of certified nursing assistants by professional staff ) contributed to low fluid intake . During the data collection , 25 of the 40 residents had illnesses/conditions that may have been related to dehydration . CONCLUSIONS When staffing is inadequate and supervision is poor , residents with moderate to severe dysphagia , severe cognitive and functional impairment , aphasia or inability to speak English , and a lack of family or friends to assist them at mealtime are at great risk for dehydration . Adequate fluid intake can be achieved by simple interventions such as offering residents preferred liquids systematic ally and by having an adequate number of supervised staff help them to drink while properly positioned BACKGROUND A number of frail , older , undernourished patients can not maintain adequate oral intake to meet protein-calorie needs after an illness , even when high-density nutritional supplements are added . Tolerance to enteral nutrition by gastric tube is poor in this group of patients . Peripheral parenteral nutrition is an effective method of administering nutritional support to patients with mild to moderate nutritional deficiencies who are unable to receive enteral nutrition or for whom enteral nutrition alone can not meet energy needs . However , no data exists for the use of peripheral parenteral nutrition longer than two weeks and overall there are remarkably few studies on the efficacy of peripheral parenteral nutrition . METHODS A Phase 4 , single center , prospect i ve , r and omized , parallel group design clinical trial was conducted to evaluate long-term safety of peripheral parenteral nutrition in post-acute patients receiving inadequate enteral nutrition .  Nutritional status was measured by the Mini-Nutritional Assessment and functional status by the Functional Inventory Measure . Subjects received a mean duration for peripheral parenteral nutrition of 15.8 + /- 6.7 days ( range 8 - 23 ) . RESULTS The peripheral parenteral nutrition group demonstrated several trends towards improvement in prealbumin , CD4 cell count , and functional status compared to the untreated control group . Two patients in the peripheral parenteral nutrition group developed low- grade phlebitis ; however , this did not result in discontinuing intravenous therapy . No other adverse events occurred . This study demonstrates that peripheral parenteral nutrition is feasible and safe in postacute care . CONCLUSIONS We conclude that peripheral parenteral nutrition can be safely administered in post-acute setting s with a low rate of complications UNLABELLED Horn SD , DeJong G , Smout RJ , Gassaway J , James R , Conroy B. Stroke rehabilitation patients , practice , and outcomes : is earlier and more aggressive therapy better ? OBJECTIVE To examine associations of patient characteristics , rehabilitation therapies , neurotropic medications , nutritional support , and timing of initiation of rehabilitation with functional outcomes and discharge destination for inpatient stroke rehabilitation patients . DESIGN Prospect i ve observational cohort study . SETTING Five U.S. inpatient rehabilitation facilities . PARTICIPANTS Post-stroke rehabilitation patients ( N=830 ; age , > 18 y ) with moderate or severe strokes , from the Post-Stroke Rehabilitation Outcomes Project data base . INTERVENTIONS Not applicable . MAIN OUTCOME MEASURES Discharge total , motor , and cognitive FIM scores and discharge destination . RESULTS Controlling for patient differences , various activities and interventions were associated with better outcomes including earlier initiation of rehabilitation , more time spent per day in higher-level rehabilitation activities such as gait , upper-extremity control , and problem solving , use of newer psychiatric medications , and enteral feeding . Several findings part with conventional practice , such as starting gait training in the first 3 hours of physical therapy , even for low-level patients , was associated with better outcomes . CONCLUSIONS Specific therapy activities and interventions are associated with better outcomes . Earlier rehabilitation admission , higher-level activities early in the rehabilitation process , tube feeding , and newer medications are associated with better stroke rehabilitation outcomes OBJECTIVE The role of fiber in tube feeding products has not clearly been defined . While some studies suggest that fiber can increase stool weight and bowel transit time in acutely ill patients , there is less information in stable patients receiving chronic enteral nutritional support . DESIGN Using a crossover study design , we investigated the effect of 28.8 g/day of a 50 % soy and 50 % oat fiber combination in 10 medically stable residents of a chronic care facility . Subjects were r and omized to initially receive 10 days of either Isocal HN or Ultracal , which are identical in composition except Ultracal contains 14.4 g/L of fiber . After the first 10-day study , subjects underwent a washout followed by a second 10-day study using the other product . Fecal dye markers were used to identify appropriate collection times . RESULTS Fiber significantly increased the number of bowel movements per day ( 0.9 + /- 0.4 vs 0.5 + /- 0.2 , p < 0.05 ) and fecal weights ( 57 + /- 31 vs 32 + /- 25 g/day , p < 0.05 ) . Fiber also caused a significant increase in fecal nitrogen output ( 110 + /- 65 vs 75 + /- 74 mg/day , p < 0.05 ) and fecal energy ( 141 + /- 73 vs 76 + /- 62 kcal/day , p < 0.05 ) . Fiber did not affect fecal moisture , gastric emptying , or intestinal transit time . CONCLUSION We conclude that the addition of a combination of soy and oat fiber to tube feeding material is well tolerated , and promotes regular bowel movements without altering the rate of gastric emptying or intestinal transit time Objective To investigate the effects of nutritional intervention with resistance training on skeletal muscle mass in elderly patients with disabilities in a convalescent rehabilitation setting . Design A r and omized controlled trial . ( UMIN Clinical Trials Registry ID : UMIN000006238 ) . Setting A rehabilitation hospital . Participants 39 elderly patients with decreased skeletal muscle mass in an inpatient convalescence rehabilitation unit . Interventions A combination of resistance training plus nutritional supplementation ( R/N group ) or resistance training alone ( R group ) . The training and supplementation were conducted essentially from the patient ’s admission to discharge ( 2–6 months ) . Outcome Measures The patients were evaluated at the time of admission and at the end of the intervention for skeletal muscle mass ( calf circumference [ CC ] as a primary outcome , and arm circumference [ AC ] ) , h and grip strength ( HG ) , Mini-Nutritional Assessment -Short Form ( MNA ® -SF ) score , serum albumin level ( Alb ) , body mass index ( BMI ) , and activities of daily living ( ADL ) as represented by the Barthel Index ( BI ) score . Results Significant treatment effects were seen for CC , AC , BI , Alb in the R/N group compared to the R group . A mean treatment effect of 3.2 ( 95%CI : 2.0–4.4 ) was seen in CC , 1.4 ( 95%CI : 0.8–2.1 ) was seen in AC , 11.2 ( 95%CI : 0.5–21.8 ) was seen in BI , 0.3 ( 95%CI : 0.1–0.5 ) was seen in Alb . Conclusion The results of this study suggest that nutritional intervention added to resistance training during convalescent rehabilitation may improve skeletal muscle mass and activities of daily living BACKGROUND Water-loss dehydration ( hypertonic , hyperosmotic , or intracellular dehydration ) is due to insufficient fluid intake and is distinct from hypovolemia due to excess fluid losses . Water-loss dehydration is associated with poor health outcomes such as disability and mortality in older people . Urine specific gravity ( USG ) , urine color , and urine osmolality have been widely advocated for screening for dehydration in older adults . OBJECTIVE We assessed the diagnostic accuracy of urinary measures to screen for water-loss dehydration in older people . DESIGN This was a diagnostic accuracy study of people aged ≥65 y taking part in the DRIE ( Dehydration Recognition In our Elders ; living in long-term care ) or NU-AGE ( Dietary Strategies for Healthy Ageing in Europe ; living in the community ) studies . The reference st and ard was serum osmolality , and index tests included USG , urine color ,  urine osmolality  , urine cloudiness , additional dipstick measures , ability to provide a urine sample , and the volume of a r and om urine sample . Minimum useful diagnostic accuracy was set at sensitivity and specificity ≥70 % or a receiver operating characteristic plot area under the curve ≥0.70 . RESULTS DRIE participants ( women : 67 % ; mean age : 86 y ; n = 162 ) had more limited cognitive and functional abilities than did NU-AGE participants ( women : 64 % ; mean age : 70 y ; n = 151 ) . Nineteen percent of DRIE participants and 22 % of NU-AGE participants were dehydrated ( serum osmolality > 300 mOsm/kg ) . Neither USG nor any other potential urinary tests were usefully diagnostic for water-loss dehydration . CONCLUSIONS Although USG , urine color , and urinary osmolality have been widely advocated for screening for dehydration in older adults , we show , in the largest study to date to our knowledge , that their diagnostic accuracy is too low to be useful , and these measures should not be used to indicate hydration status in older people ( either alone or as part of a wider tranche of tests ) . There is a need to develop simple , inexpensive , and noninvasive tools for the assessment of dehydration in older people . The DRIE study was registered at www . research register.org.uk as 122273 . The NU-AGE trial was registered at clinicialtrials.gov as NCT01754012 RATIONALE Excess mortality and residual disability are common after hip fracture . HYPOTHESIS Twelve months of high-intensity weight-lifting exercise and targeted multidisciplinary interventions will result in lower mortality , nursing home admissions , and disability compared with usual care after hip fracture . DESIGN R and omized , controlled , parallel-group superiority study . SETTING Outpatient clinic PARTICIPANTS Patients ( n = 124 ) admitted to public hospital for surgical repair of hip fracture between 2003 and 2007 . INTERVENTION Twelve months of geriatrician-supervised high-intensity weight-lifting exercise and targeted treatment of balance , osteoporosis , nutrition , vitamin D/calcium , depression , cognition , vision , home safety , polypharmacy , hip protectors , self-efficacy , and social support . OUTCOMES Functional independence : mortality , nursing home admissions , basic and instrumental activities of daily living ( ADLs/IADLs ) , and assistive device utilization . RESULTS Risk of death was reduced by 81 % ( age-adjusted OR [ 95 % CI ] = 0.19 [ 0.04 - 0.91 ] ; P < .04 ) in the HIPFIT group ( n = 4 ) compared with usual care controls ( n = 8) . Nursing home admissions were reduced by 84 % ( age-adjusted OR [ 95 % CI ] = 0.16 [ 0.04 - 0.64 ] ; P < .01 ) in the experimental group ( n = 5 ) compared with controls ( n = 12 ) . Basic ADLs declined less ( P < .0001 ) and assistive device use was significantly lower at 12 months ( P = .02 ) in the intervention group compared with controls . The targeted improvements in upper body strength , nutrition , depressive symptoms , vision , balance , cognition , self-efficacy , and habitual activity level were all related to ADL improvements ( P < .0001-.02 ) , and improvements in basic ADLs , vision , and walking endurance were associated with reduced nursing home use ( P < .0001-.05 ) . CONCLUSION The HIPFIT intervention reduced mortality , nursing home admissions , and ADL dependency compared with usual care Diarrhea , constipation and subsequent laxative use are chronic problems in long-term enterally fed patients . We have conducted a double-blind r and omized crossover study to evaluate the effects of two enteral formulae ( Enrich , 12.8 g of dietary fiber per 1000 kcal and Ensure , fiber-free ) on stool frequency , fecal weight , laxative use , gastrointestinal tolerance and bowel function in chronic care tube-fed patients . Twenty-eight subjects ( 24 male , 4 female ) completed the study .  Mean daily number of stools and mean daily fecal wet weight in Enrich-fed patients were not significantly different from those of patients receiving Ensure . Ensure-fed patients required significantly more laxatives ( p = 0.02 ) than those receiving Enrich . There were 26 reports of diarrhea in the Ensure-fed group as compared to 6 in the Enrich-fed group , and this difference was significant ( p = 0.006 ) . Reporting rates for constipation were not significantly different in the two groups . At the end of the study , the bowel function of 57.1 % of patients receiving Enrich was improved when compared with that of 14.3 % of Ensure-fed patients , and this difference was significant ( p = 0.005 ) . These results suggest that the addition of dietary fiber to enteral formulae improves gastrointestinal tolerance and bowel function , and reduces laxative use in long-term enterally fed patients BACKGROUND & AIMS Older people are vulnerable to malnutrition which leads to increased health care costs . The aim of this study was to evaluate the cost-effectiveness of nutritional supplementation from a societal perspective . DESIGN This r and omized controlled trial included hospital admitted malnourished elderly ( ≥ 60 y ) patients . Patients in the intervention group received nutritional supplementation ( energy and protein enriched diet , oral nutritional support , calcium-vitamin D supplement , telephone counselling by a dietician ) until three months after discharge from hospital . Patients in the control group received usual care ( control ) . Primary outcomes were Quality Adjusted Life Years ( QALYs ) , physical activities and functional limitations . Measurements were performed at hospital admission and three months after discharge . Data were analyzed according to the intention-to-treat principle and multiple imputation was used to impute missing data . Incremental cost-effectiveness ratios were calculated and bootstrapping was applied to evaluate cost-effectiveness . Cost-effectiveness was expressed by cost-effectiveness planes and cost-effectiveness acceptability curves . RESULTS 210 patients were included , 105 in each group . After three months , no statistically significant differences in quality of life and physical activities were observed between groups . Functional limitations decreased significantly more in the intervention group ( mean difference -0.72 , 95 % CI-1.15 ; -0.28 ) . There were no differences in costs between groups . Cost-effectiveness for QALYs and physical activities could not be demonstrated . For functional limitations we found a 0.95 probability that the intervention is cost-effective in comparison with usual care for ceiling ratios > € 6500 . CONCLUSIONS A multi-component nutritional intervention to malnourished elderly patients for three months after hospital discharge leads to significant improvement in functional limitations and is neutral in costs . A follow-up of three months is probably too short to detect changes in QALYs or physical activities Objective : To describe the independent and combined effects of oral nutrition supplementation and resistance training on health outcomes in nutritionally at risk older adults following lower limb fracture . Design : R and omized controlled trial with 12-week masked outcome assessment . Setting : Teaching hospital . Participants : One hundred nutritionally at risk older adults hospitalized following a fall-related lower limb fracture . Intervention : Commenced seven days after injury . Consisted of daily multinutrient energy-dense oral supplement ( 6.3 kJ/mL ) individually prescribed for six weeks ( n = 25 ) , tri-weekly resistance training for 12 weeks ( n = 25 ) , combined treatment ( n = 24 ) or attention control plus usual care and general nutrition and exercise advice ( n = 26 ) . Measurements : Weight change , quadriceps strength , gait speed , quality of life and health care utilization at completion of the 12-week intervention . Results : At 12 weeks , all groups lost weight :  nutrition -6.2 % ( -8.4 , -4.0 ) ; resistance training -6.3 % ( -8.3 , -4.3 ) ; nutrition and resistance training -4.7 % ( -7.4 , -2.0 ) ; attention control -5.2 % ( -9.0 , -1.5 ) . Those receiving resistance training alone lost more weight than those receiving the combined treatment ( P = 0.029 ) . Significant weight loss was prevented if supplement was consumed for at least 35 days . Groups were no different at 12 weeks for any other outcome . Conclusion : Frail , undernourished older adults with a fall-related lower limb fracture experience clinical ly significant weight loss that is unable to be reversed with oral nutritional supplements . Those receiving a programme of resistance training without concurrent nutrition support are at increased risk of weight loss compared with those who receive a combined nutrition and resistance training intervention . In this high-risk patient group it is possible to prevent further decline in nutritional status using oral nutritional supplements if strategies are implemented to ensure prescription is adequate to meet energy requirements and levels of adherence are high OBJECTIVE Up to 60 % of hospitalized patients are undernourished . We studied the impact of nutritional therapy on quality of life and food intake . METHODS Undernourished patients were r and omized into two groups . The nutritional therapy group ( NT group ) received individual nutritional counseling and interventions , including oral nutritional supplements if appropriate , by a dietitian . The oral nutritional supplement group ( ONS group ) received oral nutritional supplements in addition to hospital meals without further instruction or counseling . Study duration was 10 to 15 d. At baseline and before discharge ( time point 1 ) we measured energy and protein intakes and quality of life . Quality of life was measured again 2 mo after discharge ( time point 2 ) . RESULTS Energy and protein intakes increased between baseline and time point 1 in both groups ( P=0.001 ) . The NT group ( n=18 ) met the energy requirements at time point 1 by 107 % and of protein by 94 % , the ONS group ( n=18 ) by 90 % and 88 % , respectively . Hospital meals alone did not cover the requirements . From baseline to time point 1 , quality of life increased in both groups . Quality of life increased further in the NT group from time point 1 to time point 2 ( P=0.016 ) , but not in the ONS group . CONCLUSION Both interventions caused a significant increase in energy and protein intakes and quality of life . In the NT group every patient received an efficacious individualized intervention . In contrast , the 7 of 18 patients in the ONS group who did not consume ONS had no intervention at all . Therefore , undernourished patients should be counseled individually by a dietitian OBJECTIVES To determine the nutrition risk status and factors associated with nutrition risk among older adults enrolled in the Brief Risk Identification Geriatric Health Tool ( BRIGHT Trial ) . DESIGN A cluster r and omised controlled trial . SETTING Three main centres in New Zeal and . PARTICIPANTS A total of 3,893 older adults were recruited from 60 general practice s in three of the District Health Board ( DHB ) regions aged 75 years and older ( or 65 years and older if Māori ) . MEASUREMENTS  Nutrition risk  was assessed using the  Australian Nutrition Screening Initiative ( ANSI ) . Vali date d question naires were used to establish quality of life ( WHOQOL-BREF ) , physical function ( the Nottingham Extended Activities of Daily Living ) and depressive symptoms ( 15 item Geriatric Depression Scale ) . Demographic , st and ard of living and health data were established . RESULTS Sixty two percent of participants were identified to be at moderate or high nutrition risk . The mean ANSI score was 4.9 ( range 0 - 21 , maximum 29 ) . Factors which independently predicted moderate or high nutrition risk were female gender , being Māori and other ethnicities versus European , not being married , taking multiple medications , having more depressive symptoms , cardiovascular disease and diabetes . Protective factors independently related to low nutrition risk were living with others , higher physical and social health related QOL and higher functional status . WHOQOL environmental and psychological factors were not associated with nutrition risk when other predictive factors were taken into account . CONCLUSION Nearly two thirds of participants were identified to be at higher nutrition risk . Women , living alone , taking multiple medications , with depressive symptoms , cardiovascular disease and ndiabetes were factors associated with higher nutrition risk . Those at low nutrition risk had a better functional status and physical and social health related QOL OBJECTIVES To vali date the modified Mini Nutritional Assessment ( MNA ) short-forms ( MNA-SFs ) with respect to agreement with full MNA classification in the target population s of the MNA . DESIGN Prospect i ve analysis . SETTING Community , nursing home , rehabilitation . PARTICIPANTS Six hundred fifty-seven individuals aged 65 and older ( 75.3 % female ; mean age 82.3 ± 7.4 ) . MEASUREMENTS Classification agreement between full MNA score and MNA-SF scores . RESULTS Agreement between the full MNA and classification using the MNA-SFs was 84.6 % when the MNA-SF using body mass index ( BMI ) was applied and 81.4 % when the MNA-SF using calf circumference ( CC ) was applied . The highest agreement of classification was found in the community setting ( 90.8 % and 90.4 % , respectively ) and the lowest in the rehabilitation setting ( 72.4 % and 71.4 % , respectively ) . Both MNA-SFs tended to underestimate nutritional status , but that was significant only for the MNA-SF with CC . CONCLUSION The modified MNA-SFs represent a valuable tool for rapid and reliable nutritional screening Prevention of pressure ulcers is fundamental to safe care of nursing home residents yet the role of hydration in pressure ulcer prevention has not been systematic ally examined . This r and omized clinical trial was undertaken to determine whether administration of supplemental fluid to nursing home residents at risk for pressure ulcers would enhance collagen deposition , increase estimated total body water , augment subcutaneous tissue oxygenation , and was safe . After a baseline period , 64 subjects were r and omized to receive the fluid volume prescribed or additional fluid ( prescribed plus 10 mL/kg ) for 5 days . Participants ' potential to heal as measured with hydroxyproline was low at baseline and did not increase significantly during treatment when additional fluid was systematic ally provided . Fluid intake increased significantly during treatment . Estimates of total body water and subcutaneous oxygen did not increase , indicating hydration was not improved . Supplemental fluid did not result in overhydration as measured by clinical parameters . Further work is needed to examine the relationship between fluid intake and hydration in nursing home residents as well as the role of hydration in pressure ulcer prevention OBJECTIVES To compare the acceptance , feasibility , and adverse effects of subcutaneous ( SC ) and intravenous ( IV ) rehydration in dehydrated geriatric patients and clinical changes exhibited by the patients . DESIGN A prospect i ve , r and omized , open clinical trial . SETTING Hospital geriatric wards during a period of 20 months . PARTICIPANTS Ninety-six patients with a mean age + /- st and ard deviation of 85.3 + /- 6.7 with signs of mild to moderate dehydration needing parenteral fluids . INTERVENTION Geriatric patients were r and omly allocated to receive SC or IV infusions of half-normal saline-glucose solutions as long as clinical ly necessary . MEASUREMENTS A st and ardized patient record form was used to document the observed adverse effects . Using a Likert-like scale based on the German school marks system with scores ranging from 1 = very good to 6 = very bad , patients were asked to score their discomfort ; nurses and doctors scored the feasibility of the intervention . Changes in laboratory and clinical findings ( including patients ' orientation and activities of daily living using the Barthel Index ) and adverse effects were recorded . RESULTS Forty-eight patients were r and omized into each group . Median duration of fluid administration was 6 days ( SC and IV , P = .33 ) . Median volume was 750 mL/day ( SC ) and 1,000 mL/day ( IV , P = .002 ) . In 13 patients , the therapy had to be changed from SC to IV ( SC/IV subgroup ) : 11 times because of the exigency of an IV drug application and twice because of poor resorption . In 17 patients , there was a change from IV to SC ( IV/SC subgroup ) , mainly because of impossibility of further peripheral IV punctures ( 8 times ) and permanent removal of the IV cannula ( 5 times ) . The patients of the IV/SC subgroup scored their discomfort significantly worse ( median 5.5 vs all other groups median 2 , P = .017 ) . This corresponded with the scoring of feasibility by the nurses ( IV/SC : median 4.25 vs all other groups median 2 , P = .009 ) and by the doctors ( IV/SC : median 4 vs all other groups : median 2 , P = .001 ) . Both methods of rehydration caused only few systemic adverse reactions ; acute cardiac failure occurred twice in the SC group versus four times in the IV group ( P = .68 ) and hyponatremia once in the SC group versus twice in the IV group ( P = 1.0 ) . Some patients experienced local side effects ( SC , n = 29 vs IV , n = 24 ; P = .41 ) , mainly to a mild extent ( SC , n = 25 vs IV , n = 24 ; P = 1.0 ) . Major local side effects ( large edema , phlebitis , cellulitis , erythema and strong pain ) occurred in nine SC and eight IV ( P = 1.0 ) patients . The clinical and laboratory changes during therapy were similar in both trial arms . CONCLUSIONS Rehydration by hypodermoclysis is equally well accepted by geriatric patients as the IV therapy and offers a similarly easy feasibility . Additionally , in confused patients and in those in whom IV punctures are difficult to achieve , it represents the far superior method . Both techniques are comparably safe and effective BACKGROUND Although protein-energy malnutrition has been cited as a frequent complication following stroke , there is very little data describing nutritional intake among hospitalized patients . OBJECTIVE To report : i ) the level of protein and energy intake , ii ) the adequacy of intake during the first 21 days of hospitalization and iii ) to examine the differences in nutritional intake associated with diet type ( regular texture , texture-modified and enteral feeding ) . DESIGN Prospect i ve observational study of an inception cohort . The  energy and protein intakes  of well-nourished patients with recent onset of first time stroke were assessed at admission to hospital and at days 7 , 11 , 14 and 21 . Adequacy of energy intake at each of these intervals was expressed as a percentage ( actual intake/energy requirement assessed by indirect calorimetry x 100 ) . Adequacy of protein intake was assessed in a similar manner , with 1 g/kg of actual or adjusted body weight used to estimate requirement . The nutritional intakes of patients receiving regular diets , dysphagia diets and enteral tube feedings were compared using one-way ANOVA . RESULTS The average energy intakes of the entire study group ranged from 19.4 - 22.3 Kcals/kg/day over five observation points , representing 80.3 - 90.9 % of measured requirements ; protein intake and ranged from 0.81 - 0.90 g/kg day yielding adequacy of intake of 81 - 90 % of requirement . There were significant differences in energy intakes and /or adequacy of intake of patients receiving different diet types at days 11 , 14 and 21 ( p < 0.05 ) and differences in protein intake and /or adequacy of protein intake at all intervals except admission ( p < 0.05 ) . Patients receiving enteral tube feedings consumed more calories and protein compared to those patients on regular or dysphagia diets . CONCLUSIONS On average , newly diagnosed , well-nourished , hospitalized patients consumed 80 - 91 % of their both their energy and protein requirements , in the early post stroke period BACKGROUND As there are no prospect i ve r and omised trials about percutaneous endoscopic gastrostomy ( PEG ) insertion , the medical staff and caregivers encounter great difficulty in deciding when and if to perform this procedure . OBJECTIVE To explore which variables are associated with increased mortality after  PEG insertion . DESIGN Prospect i ve observational study . SETTING Gastroenterological unit of a 500-bed community hospital . SUBJECTS All patients over the age of 50 years referred for PEG insertion between January 1992 and December 2002 . METHODS Patients were studied for their indication for PEG insertion  as well as their main medical problems , and demographic details and medical records were review ed yearly until mortality . RESULTS 674 patients were enrolled ( mean age 80.1 years , 42 % men ) . The median survival was worst in diabetic patients ( 128 days , P < 0.05 ) , patients referred from hospital ( 161 days , P < 0.01 ) and patients over the age of 80 years with dementia ( 171 days , P < 0.001 ) . The best median survival was found among demented patients under the age of 80 ( 467 days , P < 0.05 ) and women under the age of 80 referred from nursing homes ( 780 days , P < 0.01 ) . CONCLUSIONS The outcome after PEG insertion is variable , with survival of over a year in many of the patients . These data are important for the medical staff , the patients and their caregivers when deciding about PEG placement OBJECTIVES The effects of nutritional management among other intervention components have not been examined for hip-fractured elderly persons with poor nutritional status . Accordingly , this study explored the intervention effects of an in-home program using a comprehensive care model that included a nutrition-management component on recovery of hip-fractured older persons with poor nutritional status at hospital discharge . DESIGN A secondary analysis of data from a r and omized controlled trial with 24-month follow-up . SETTING A 3000-bed medical center in northern Taiwan . PARTICIPANTS Subjects were included only if they had " poor nutritional status " at hospital discharge , including those at risk for malnutrition or malnourished . The sub sample included 80 subjects with poor nutritional status in the comprehensive care group , 87 in the interdisciplinary care group , and 85 in the usual care group .  INTERVENTIONS The 3 care models were usual care , interdisciplinary care , and comprehensive care . Usual care provided no in-home care , interdisciplinary care provided 4 months of in-home rehabilitation , and comprehensive care included management of depressive symptoms , falls , and nutrition as well as 1 year of in-home rehabilitation . MEASUREMENTS Data were collected on nutritional status and physical functions , including range of motion , muscle power , proprioception , balance and functional independence , and analyzed using a generalized estimating equation approach . We also compared patients ' baseline characteristics : demographic characteristics , type of surgery , comorbidities , length of hospital stay , cognitive function , and depression . RESULTS Patients with poor nutritional status who received comprehensive care were 1.67 times ( 95 % confidence interval 1.06 - 2.61 ) more likely to recover their nutritional status than those who received interdisciplinary and usual care . Furthermore , the comprehensive care model improved the functional independence and balance of patients who recovered their nutritional status over the first year following discharge , but not of those who had not yet recovered . CONCLUSIONS An in-home program using the comprehensive care model with a nutritional component effectively improved the nutritional status of hip-fractured patients with poor nutrition . This comprehensive care intervention more effectively improved recovery of functional independence and balance for patients with recovered nutritional status BACKGROUND Little evidence is available on the longer-term effects ( beyond 12 months ) of intervention models consisting of hip fracture-specific care in conjunction with management of malnutrition , depression , and falls . OBJECTIVE To compare the relative effects of an interdisciplinary care , and a comprehensive care programme with those of usual care for elderly patients with a hip fracture on self-care ability , health care use , and mortality .  DESIGN R and omised experimental trial . SETTING A 3000-bed medical centre in northern Taiwan . PARTICIPANTS Patients with hip fracture aged 60 years or older ( N=299 ) . METHOD Patients were r and omly assigned to three groups : comprehensive care ( n=99 ) , interdisciplinary care ( n=101 ) , and usual care ( control ) ( n=99 ) . Usual care entailed only one or two in-hospital rehabilitation sessions . Interdisciplinary care included not only hospital rehabilitation , but also geriatric consultation , discharge planning , and 4-month in-home rehabilitation . Building upon interdisciplinary care , comprehensive care extended in-home rehabilitation to 12 months and added management of malnutrition and depressive symptoms , and fall prevention . Patients ' self-care ability was measured by activities of daily living and instrumental activities of daily living using the Chinese Barthel Index and Chinese version Instrumental Activities of Daily Living scale , respectively . Outcomes were assessed before discharge , and 1 , 3 , 6 , 12 , 18 , 24 months following hip fracture . Hierarchical linear models were used to analyse health outcomes and health care utilisation , including emergency department visit and hospital re-admission . RESULTS The comprehensive care group had better performance trajectories for both measures of activities of daily living and fewer emergency department visits than the usual care group , but no difference in hospital readmissions . The interdisciplinary care and usual care groups did not differ in trajectories of self-care ability and service utilisation . The three groups did not differ in mortality during the 2-year follow-up . CONCLUSION Comprehensive care , with enhanced rehabilitation , management of malnutrition and depressive symptoms , and fall prevention , improved self-care ability and decreased emergency department visits for elders up to 2 years after hip-fracture surgery , above and beyond the effects of usual care and interdisciplinary care The terminal phase of dementia is initiated by the inability to swallow . New techniques of enteral alimentation permit more effective , longer intubation . To assess the application of these new techniques to late-stage demented aged patients , all current intubations in a teaching nursing home were review ed . Of 52 feeding intubations , 26 had been in situ for more than 1 year . A r and omly selected comparison group of  nonintubated patients was also studied . Weight increased for 48 % of the intubated group versus 17 % of the nonintubated group ( P less than .01 ) . Aspiration pneumonia occurred more often in the intubated group ( 58 % ) than in the nonintubated group ( 17 % ) ( P less than .01 ) . Decubitus ulcers were also more common in the intubated group ( 21 % ) than in the nonintubated group ( 14 % ) . Restraints were used more in the intubated group ( 71 % ) than in the nonintubated group ( 56 % ) . These differences did not reach statistical significance . All of the intubated patients were severely demented  , with MMSE scores of zero . Seventy-one percent of the nonintubated group were demented , with MMSE scores of less than 23 . Prolongation of the terminal phase of dementia in the aged by tube feeding is now feasible . The implication s of this change in the life-span of demented nursing home patients need attention by families , nursing homes , and those who make public health policy BACKGROUND Parenteral nutrition ( PN ) is a costly technology used widely to provide nutrition to patients who have an inaccessible or nonfunctioning intestine . A prospect i ve survey was design ed to collect data on  PN for in patients to study the current use of PN , its complications and outcomes in the north of Engl and . The study objectives were to use the Northern Nutrition Network to collect data from all acute hospital in patients prospect ively receiving PN  , for 3 months and to provide evidence for current PN practice , and to establish whether this is in line with recognized published clinical guidelines . METHODS Using a paper-based collection tool information was recorded on aspects of PN including : total inpatient episodes , patient demographics , indications , duration , venous access used , complications , number returning to enteral feeding and mortality . The presence of a nutrition support team was also recorded . RESULTS Data on 193 patient PN episodes were recorded totalling 1708 patient days . The median age of the patients was 67 years . Of these , 158 ( 82 % ) were deemed to have a clear indication for PN using the indications cited in the NICE guidelines ( http://www.nice.org.uk ) . The median duration of PN  was 7 days ( range 1 - 93 ) . Thirty ( 16 % ) patients developed complications due to PN , 23 ( 12 % ) had catheter infections which were most common on medical wards . Thirty-nine ( 20 % ) patients died within 28 days of PN starting ; no deaths were attributable to PN . A total of 118 ( 61 % ) patients returned to full enteral feeding . Only three hospitals had nutrition support teams , which had no significant effect on outcomes . CONCLUSIONS Parenteral nutrition practice in the north of Engl and is generally in line with current guidelines , however , only three of 15 hospitals had nutrition support teams . Eighteen per cent of patients did not have a clearly documented indication for PN and 15 % developed a complication , most often a catheter-related infection 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 Both obesity and aging increase intrahepatic fat ( IHF ) content , which leads to nonalcoholic fatty liver disease ( NAFLD ) and metabolic abnormalities such as insulin resistance . We evaluated the effects of diet and diet in conjunction with exercise on IHF content and associated metabolic abnormalities in obese older adults . Eighteen obese ( BMI > or=30 kg/m(2 ) ) older ( > or=65 years old ) adults completed a 6-month clinical trial . Participants were r and omized to diet ( D group ; n = 9 ) or diet + exercise ( D+E group ; n = 9 ) . Primary outcome was IHF quantified by magnetic resonance spectroscopy ( MRS ) . Secondary outcomes included insulin sensitivity ( assessed by oral glucose tolerance ) , body composition ( assessed by dual-energy X-ray absorptiometry ) , physical function ( VO(2 peak ) and strength ) , glucose , lipids , and blood pressure ( BP ) . Body weight ( D : -9 + /- 1 % , D+E : -10 + /- 2 % , both P < 0.05 ) and fat mass ( D : -13 + /- 3 % , D+E -16 + /- 3 % , both P < 0.05 ) decreased in both groups but there was no difference between groups . IHF decreased to a similar extent in both groups ( D : -46 + /- 11 % , D+E : -45 + /- 8 % , both P < 0.05 ) , which was accompanied by comparable improvements in insulin sensitivity ( D : 66 + /- 25 % , D+E : 68 + /- 28 % , both P < 0.05 ) . The relative decreases in IHF correlated directly with relative increases in insulin sensitivity index ( ISI ) ( r = -0.52 ; P < 0.05 ) . Improvements in VO(2 peak ) , strength , plasma triglyceride ( TG ) , and low-density lipoprotein-cholesterol concentration , and diastolic BP occurred in the D+E group ( all P < 0.05 ) but not in the D group . Diet with or without exercise results in significant decreases in IHF content accompanied by considerable improvements in insulin sensitivity in obese older adults . The addition of exercise to diet therapy improves physical function and other obesity- and aging-related metabolic abnormalities 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 Gastrointestinal side effects , particularly diarrhea , are still the main reasons for discontinuation of enteral nutrition . Although the causes of diarrhea are diverse , the enteral nutrition solution is frequently suspected of playing a leading role in causing diarrhea . METHODS Our r and omized , prospect i ve , double-blind trial with 100 patients assessed the effects of feeding a st and ard diet ( Nutrodrip St and ard ) vs the same diet supplemented with 20 g of soluble fiber , containing partially hydrolyzed guar gum ( Sunfiber ) , per 1000 mL.  Thirty patients received total enteral nutrition postoperatively , and 70 patients received enteral supplementation . RESULTS The patients receiving total enteral nutrition with soluble fiber had decreased diarrhea but increased flatulence . In none of these patients did enteral feeding have to be discontinued because of gastrointestinal side effects , whereas in four patients who were on a st and ard diet , enteral feeding had to be interrupted because of diarrhea ( p < .05 ) . Similar observations were made in patients receiving enteral supplementation . In both groups , the incidence of diarrhea decreased significantly with the soluble fiber diet compared with the st and ard diet ( 6 vs 15 , p < .05 ) . CONCLUSIONS Enteral feeding with a formula supplemented with partially hydrolyzed guar gum reduces the incidence of diarrhea in patients receiving total enteral nutrition as well as in those receiving enteral supplementation , regardless of the cause of diarrhea . The increased hydrogen production and the significantly higher rate of flatulence are likely to result from fermentation of the soluble fiber in the colon , with concomitant production of short-chain fatty acids , which leads to increased absorption of short-chain fatty acids , sodium , and water by the colonocytes . This effect , together with the observed cholecystokinin-mediated decrease in colonic transit time with partially hydrolyzed guar gum , may explain the reduction in the incidence of diarrhea in this study We examined changes in the nutritional status of elderly patients with chest infection for a period of 3 months after discharge from hospital , including the effects of nutritional supplementation on well-being and functional status as well as on nutritional indices . Eighty-one subjects admitted to an acute medical ward aged 65 years and over with chest infection were recruited consecutively , and r and omized to receive supplement ( 500 ml of Ensure liquid daily ) for 1 month , or no supplement , on discharge . Assessment at baseline , 1 , 2 and 3 months included a question naire to determine health , mental and functional status , and anthropometric measurements . Biochemical nutritional status was assessed at baseline , 1 and 3 months , and  dietary intake  ( 24 h recall method ) at 1 and 3 months . During recovery , both supplement and non-supplement groups showed improvement in various measures of well-being and biochemical status . In addition , the former group showed improvement in more anthropometric measurements , in thiamine and pyridoxine status , while the non-supplement group showed a lower level of functional ability after 3 months . Various measures of well-being and biochemical status of the water-soluble vitamins were better in the supplement groups . We conclude that nutritional supplementation may have a role in helping elderly patients to recover from chest infections As food intake declines with aging , older adults develop energy and nutrient inadequacies . It is important to design practical approaches to combat insufficient dietary intakes to decrease risk for acute and chronic diseases , illness , and injury . Manipulating the energy density of meals has improved energy intakes in institutional setting s , but the effects on community-residing older adults who are at nutrition risk have not been investigated . The aim of this study was to determine whether enhancing the energy density of food items regularly served in a home-delivered meals program would increase lunch and 24-hour energy and nutrient intakes . In a r and omized crossover counterbalanced design , 45 older adult Older American Act Nutrition Program participants received a regular and enhanced version of a lunch meal on alternate weeks . The types of foods , portion sizes ( gram weight ) , and appearance of the lunch meal was held constant . Consumption of the enhanced meal increased average lunch energy intakes by 86 % ( P<0.001 ) and 24-hour energy intakes by 453 kcal ( from 1,423.1+/-62.2 to 1,876.2+/-78.3 kcal , P<0.001 ) . The 24-hour intakes of several key macronutrients and micronutrients also improved . These data suggest that altering the energy density of regularly served menu items is an effective strategy to improve dietary intakes of free-living older adults The purpose of this pilot study was to test methods to measure the effects of a fiber-fortified , enteral feeding ( Jevity ™ ) on the bowel habits of an immobile , tube-fed group of patients . Three experimental patients received fiber-fortified feedings for seven weeks , whereas four control patients received their usual enteral feeding . Measurements of the number of stools , the consistency of stools , the formula volume delivered , the daily water volume , the body temperature , the urinary output , and the bowel medications were made during three phases — a baseline , an adjustment , and a treatment period . Patients who receive the fiber-fortified enteral feedings had more stools and better consistency of stools than did those patients who did not receive the fiber-fortified formula . Results indicated that fiber-fortified feedings should be added gradually to immobile , tube-fed patients ' diets under close supervision . Although measuring the effects of a new feeding in immobile , tube-fed patients is labor-intensive , it can be accomplished successfully OBJECTIVE To assess the effect of multidisciplinary nutritional support for undernutrition in older adults in nursing home and home-care identified with the vali date d Eating Validation Scheme ( EVS ) . METHODS An 11 wk cluster r and omized trial with a home-care ( 3 clusters ) or nursing home ( 3 clusters ) setting as the unit of r and omization . Before starting the study , a train-the-trainer course was performed to educate the nutrition coordinators . In addition to the nutrition coordinator , the participants assigned to the intervention group strategy received multidisciplinary nutrition support . Focus was on treatment of the potentially modifiable nutritional risk factors identified with the EVS , by involving the physiotherapist , registered dietitian , and occupational therapist , as relevant and independent of the municipality 's ordinary assessment and referral system . Outcome parameters were quality of life ( by means of EuroQol-5D-3L ) , physical performance ( 30-seconds chair st and ) , nutritional status ( weight and h and -grip strength ) , oral care , fall incidents , hospital admissions , rehabilitation stay , moving to nursing homes ( participants from home-care ) , and mortality . RESULTS Respectively , 55 ( 46 from 2 home-care clusters ) and 40 ( 18 from 1 home-care cluster ) were identified with the EVS and comprised the intervention and control group . A difference after 11 wk in quality of life ( 0.758 [ 0.222 ] versus 0.534 [ 0.355 ] , P = 0.001 ) , 30-seconds chair st and ( 47 % versus 17 % improved , P = 0.005 ) and oral care ( 1.1 [ 0.3 ] versus 1.3 [ 0.5 ] , P = 0.021 ) was observed . There was a almost significant difference in mortality ( 2 % versus 13 % , P = 0.079 ) . CONCLUSIONS Multidisciplinary nutritional support in older adults in nursing home and home-care could have a positive effect on quality of life , muscle strength , and oral care BACKGROUND & AIMS Undernutrition after an acute stroke increases the risk of poor outcome . We wanted to examine the effect of individualized , nutritional support on weight loss and functional outcomes in stroke patients . METHODS Acute stroke patients at nutritional risk were r and omized to either individualized , nutritional care or routine care while in hospital . Patients in the intervention group received an individualized treatment plan aim ing to prevent weight loss . In accordance with routine care , the controls did not have such a treatment plan . Patients were review ed at follow-up after three months . Primary outcome measure was the percentage of patients with weight loss ≥5 % . Secondary outcomes measures were quality of life ( QoL ) , h and grip strength and length of hospital stay . This trial is registered with Clinical Trials.gov , number NCT00163007 . RESULTS At follow-up , 20.7 % of the intervention group ( n = 58 ) lost ≥5 % weight compared with 36.4 % in the control group ( n = 66 ) ( P = 0.055 ) . The intervention group had a significantly higher increase in QoL score ( P = 0.009 ) and in h and grip strength ( P = 0.002 ) . There was no difference in length of hospital stay . CONCLUSIONS Individualized , nutritional treatment strategy can prevent clinical ly significant weight loss and improve QoL in elderly acute stroke patients at nutritional risk INTRODUCTION In the management of dysphagic stroke patients , percutaneous endoscopic gastrostomies ( PEGs ) are frequently sited early due to the failure of nasogastric tube ( NGT ) feeding , with NGTs becoming displaced in over 58 % of cases . PEG insertion is a procedure with significant mortality and morbidity . We adapted a novel technique of securing NGTs ( a nasal loop ) which is non-invasive , allows successful NG feeding and may avoid the need for PEG placement . AIMS To show that nasal loops result in improved delivery of enteral nutrition . To compare the outcome and complication rate of nasal loop fed patients with those undergoing PEG feeding . METHODS A 6 month prospect i ve audit of dysphagic stroke patients who were referred for PEG . All patients who were referred with failed NG feeding within 28 days of presentation were offered a nasal loop .  Patients who were 28 days post-stroke had a PEG placed if appropriate . The daily feed intake was monitored before and after nasal loop placement . Complication rates and patient outcomes were documented at 2 week and 3 month follow-up . RESULTS Nasal loop group : 14 patients had a  nasal loop  for a median of 15 days . The median daily feed provided was 0 % before nasal loop and 100 % after . Four patients went on to recover normal swallowing , 4 patients died and 6 later proceeded to PEG . PEG group : Seven patients proceeded direct to PEG , 1 died and 6 were alive and PEG fed at 3 months . There were 6 complications from PEG insertion . No patients recovered normal swallowing . CONCLUSIONS Nasal loops are safe , well tolerated , and effective at delivering full enteral nutrition .  Nasal loops allow time for patients who may recover normal swallowing to do so , and thus avoid a PEG . Nasal loops avoid unnecessary PEG insertion in those with a poor prognosis who will not ultimately survive their initial stroke After PEG placement at the Medical Department ofthe University Hospital in Kiel , 210 patients ( mean age61.3 years ; 137 men , 73 women ) were prospect ivelyfollowed-up for 133 ± 181 days . Close-meshed evaluations of the development of nutritionalstatus , long-term outcome , complications , subjectiveacceptability , patient care after discharge from thehospital , survival , and nutritional long-term problems were performed . The PEG procedure ( duration 13.3 ± 4.2 min ) was carried out for neurological(42 % ) , ear-nose-throat ( 28 % ) , and internal medical (30%)indications . Procedure-related mortality was 0 % , while altogether 3.8 % severe and 20.0 % mildcomplications were observed . Body weight decreased by amean of 11.4 ± 1.5 kg in the three months before and increased by 3.5 ± 1.7 kg one year after PEGplacement with no significant differences betweenmalignant or benign underlying diseases . Individualsubjective acceptability was excellent in 83%,sufficient in 15 % , and poor in 2 % of patients only . One-year survival rate was 34.3 % . The various results of thepresent prospect i ve study demonstrate that long-termenteral feeding via PEG is a safe , effective , easy-to practice , and highly acceptable method withexcellent long-term results and distinct improvement ofnutritional status . Individual decisions for PEGplacement should be considered much earlier and morefrequently in appropriate patients The purpose was to test the hypothesis that a multifaceted 11 weeks r and omized controlled intervention would have a significant influence of functional abilities in old nursing home residents . Participants were 121 old ( > 65 years ) residents in seven Danish nursing homes . The intervention consisted of nutrition ( chocolate , homemade oral supplements ) , group exercise ( moderate intensity ) and oral care . Measurements taken were weight , body mass index ( BMI ) , energy and protein intake , and functional abilities ( activities of daily living = ADL , cognitive performance , and social engagement ) . The results showed that the nutrition and exercise were well accepted . After 11 weeks the change in % weight ( 1.3 vs. -0.6 % , p=0.005 ) , % BMI ( 0.4 vs. -0.2 % , p=0.003 ) , energy intake ( 0.7 vs. -0.3 MJ/day , p=0.084 ) and protein intake ( 5 vs. -2g/day , p=0.012 ) was higher in the intervention group than in the control group . Also , after 11 weeks , social and physical function had decreased in the control group but was unchanged in the intervention group . The difference between groups was significant in relation to social engagement ( p=0.009 ) . After the end of the intervention both groups had lost weight and physical function . Cognitive performance did not change , at any time . In conclusion , it seems possible to maintain social ( and physical ) functional abilities in old nursing home residents by means of a multifaceted intervention In order to test the hypothesis that urine colour can be used as an index of hydration in critically ill patients , we selected 40 intensive care and high‐dependency patients and correlated urine colour ( scored on an eight‐point scale ) with various indices of hydration : urine : plasma sodium , osmolality and urea ratios , urine output and central venous pressure . In addition , we compared the colour‐chart score with scores made by intensive care nurses ( without the benefit of a colour chart ) in order to test subjective assessment of urine colour . There were weak but statistically significant correlations between urine colour and urine output ( Spearman 's r = − 0.555 ) and between urine colour and urine : plasma sodium ratio ( Spearman 's r = − 0.459 ) . Subjective assessment of urine colour appeared to be reliable . Thus , although urine colour does vary with hydration in the critically ill , assessment of urine colour adds little to the overall assessment of hydration in this group of patients Background Health-related quality of life ( HRQoL ) has been used to assess subjects ’ prognosis and recovery following hip fracture . However , evidence is mixed regarding the effectiveness of interventions to improve HRQoL of elders with hip fracture . The purpose s of this study were to identify distinct HRQoL trajectories and to evaluate the effects of two care models on these trajectories over 12 months following hip-fracture surgery . Methods For this secondary analysis , data came from a r and omized controlled trial of subjects with hip fracture receiving three treatment care models : interdisciplinary care ( n = 97 ) , comprehensive care ( n = 91 ) , and usual care ( n = 93 ) .  Interdisciplinary care consisted of geriatric consultation , discharge planning , and 4 months of in-home rehabilitation . Comprehensive care consisted of interdisciplinary care plus management of malnutrition and depressive symptoms , fall prevention , and 12 months of in-home rehabilitation . Usual care included only in-hospital rehabilitation and occasional discharge planning , without geriatric consultation and in-home rehabilitation .  Mental and physical HRQoL were measured at 1 , 3 , 6 , and 12 months after discharge by the physical component summary scale ( PCS ) and mental component summary scale ( MCS ) , respectively , of the Medical Outcomes Study Short Form 36 , Taiwan version . Latent class growth modeling was used to identify PCS and MCS trajectories and to evaluate how they were affected by the interdisciplinary and comprehensive care models . Results We identified three quadratic PCS trajectories : poor PCS ( n = 103 , 36.6 % ) , moderate PCS ( n = 96 , 34.2 % ) , and good PCS ( n = 82 , 29.2 % ) . In contrast , we found three linear MCS trajectories : poor MCS ( n = 39 , 13.9 % ) , moderate MCS ( n = 84 , 29.9 % ) , and good MCS ( n = 158 , 56.2 % ) . Subjects in the comprehensive care and interdisciplinary care groups were more likely to experience a good PCS trajectory ( b = 0.99 , odds ratio [ OR ] = 2.69 , confidence interval [ CI ] = 7.24–1.00 , p = 0.049 , and b = 1.32 , OR = 3.75 , CI = 10.53–1.33 , p = 0.012 , respectively ) than those who received usual care . However , neither care model improved MCS . Conclusions The interdisciplinary and comprehensive care models improved recovery from hip fracture by increasing subjects ’ odds for following a trajectory of good physical functioning after hospitalization . Trial registration Clinical Trials.gov ( NCT01350557 BACKGROUND Although disuse of skeletal muscle and undernutrition are often cited as potentially reversible causes of frailty in elderly people , the efficacy of interventions targeted specifically at these deficits has not been carefully studied . METHODS We conducted a r and omized , placebo-controlled trial comparing progressive resistance exercise training , multinutrient supplementation , both interventions , and neither in 100 frail nursing home residents over a 10-week period . RESULTS The mean ( + /- SE ) age of the 63 women and 37 men enrolled in the study was 87.1 + /- 0.6 years ( range , 72 to 98 ) ; 94 percent of the subjects completed the study .  Muscle strength increased by 113 + /- 8 percent in the subjects who underwent exercise training , as compared with 3 + /- 9 percent in the nonexercising subjects ( P < 0.001 ) . Gait velocity increased by 11.8 + /- 3.8 percent in the exercisers but declined by 1.0 + /- 3.8 percent in the nonexercisers ( P = 0.02 ) . Stair-climbing power also improved in the exercisers as compared with the nonexercisers ( by 28.4 + /- 6.6 percent vs. 3.6 + /- 6.7 percent , P = 0.01 ) , as did the level of spontaneous physical activity . Cross-sectional thigh-muscle area increased by 2.7 + /- 1.8 percent in the exercisers but declined by 1.8 + /- 2.0 percent in the nonexercisers ( P = 0.11 ) . The nutritional supplement had no effect on any primary outcome measure . Total energy intake was significantly increased only in the exercising subjects who also received nutritional supplementation . CONCLUSIONS High-intensity resistance exercise training is a feasible and effective means of counteracting muscle weakness and physical frailty in very elderly people . In contrast , multi-nutrient supplementation without concomitant exercise does not reduce muscle weakness or physical frailty BACKGROUND & AIMS Optimizing nutritional intake has been recommended for geriatric patients undergoing hip-fracture surgery . Whether nutritional support guided by repeated measurements of resting energy requirements ( REE ) improves outcomes in these patients is not known . METHODS A r and omized , controlled , unblinded , prospect i ve , cohort study comparing provision of energy with a goal determined by repeated REE measurements using indirect calorimetry , with no intervention . Oral nutritional supplements were started 24 h after surgery and the amount adjusted to make up the difference between energy received from hospital food and measured energy expenditure . RESULTS 50 Geriatric patients were included in the study . Patients in the intervention group ( n = 22 ) received significantly higher daily energy intake than the control group ( n = 28 ) ( 1121.3 ± 299.0 vs. 777.1 ± 301.2 kcal , p = 0.001 ) . This was associated with a significantly less negative cumulative energy balance ( -1229.9 ± 1763 vs. -4975.5 ± 4368 kcal , p = 0.001 ) . A significant negative correlation was found between the cumulative energy balance and total complication rate ( r = -0.417 , p = 0.003 ) as well as for length of hospital stay ( r = -0.282 , p = 0.049 ) . CONCLUSION We have demonstrated that nutritional support actively supervised by a dietician and guided by repeated measurements of REE was achievable and improved outcomes in geriatric patients following surgery for hip fractures . Clinical trials.gov Identifier : NCT017354435 IMPORTANCE Knee osteoarthritis ( OA ) , a common cause of chronic pain and disability , has biomechanical and inflammatory origins and is exacerbated by obesity . OBJECTIVE To determine whether a ≥10 % reduction in body weight induced by diet , with or without exercise , would improve mechanistic and clinical outcomes more than exercise alone . DESIGN , SETTING , AND PARTICIPANTS Single-blind , 18-month , r and omized clinical trial at Wake Forest University between July 2006 and April 2011 . The diet and exercise interventions were center-based with options for the exercise groups to transition to a home-based program . Participants were 454 overweight and obese older community-dwelling adults ( age ≥55 years with body mass index of 27 - 41 ) with pain and radiographic knee OA . INTERVENTIONS Intensive diet-induced weight loss plus exercise , intensive diet-induced weight loss , or exercise . MAIN OUTCOMES AND MEASURES Mechanistic primary outcomes : knee joint compressive force and plasma IL-6 levels ; secondary clinical outcomes : self-reported pain ( range , 0 - 20 ) , function ( range , 0 - 68 ) , mobility , and health-related quality of life ( range , 0 - 100 ) . RESULTS Three hundred ninety-nine participants ( 88 % ) completed the study . Mean weight loss for diet + exercise participants was 10.6 kg ( 11.4 % ) ; for the diet group , 8.9 kg ( 9.5 % ) ; and for the exercise group , 1.8 kg ( 2.0 % ) . After 18 months , knee compressive forces were lower in diet participants ( mean , 2487 N ; 95 % CI , 2393 to 2581 ) compared with exercise participants ( 2687 N ; 95 % CI , 2590 to 2784 , pairwise difference [Δ](exercise vs diet ) = 200 N ; 95 % CI , 55 to 345 ; P = .007 ) . Concentrations of IL-6 were lower in diet + exercise ( 2.7 pg/mL ; 95 % CI , 2.5 to 3.0 ) and diet participants ( 2.7 pg/mL ; 95 % CI , 2.4 to 3.0 ) compared with exercise participants ( 3.1 pg/mL ; 95 % CI , 2.9 to 3.4 ; Δ(exercise vs diet + exercise ) = 0.39 pg/mL ; 95 % CI , -0.03 to 0.81 ; P = .007 ; Δ(exercise vs diet ) = 0.43 pg/mL ; 95 % CI , 0.01 to 0.85 , P = .006 ) . The diet + exercise group had less pain ( 3.6 ; 95 % CI , 3.2 to 4.1 ) and better function ( 14.1 ; 95 % CI , 12.6 to 15.6 ) than both the diet group ( 4.8 ; 95 % CI , 4.3 to 5.2 ) and exercise group ( 4.7 ; 95 % CI , 4.2 to 5.1 , Δ(exercise vs diet + exercise ) = 1.02 ; 95 % CI , 0.33 to 1.71 ; P(pain ) = .004 ; 18.4 ; 95 % CI , 16.9 to 19.9 ; Δ(exercise vs diet + exercise ) , 4.29 ; 95 % CI , 2.07 to 6.50 ; P(function ) < .001 ) . The diet + exercise group ( 44.7 ; 95 % CI , 43.4 to 46.0 ) also had better physical health-related quality of life scores than the exercise group ( 41.9 ; 95 % CI , 40.5 to 43.2 ; Δ(exercise vs diet + exercise ) = -2.81 ; 95 % CI , -4.76 to -0.86 ; P = .005 ) . CONCLUSIONS AND RELEVANCE Among overweight and obese adults with knee OA , after 18 months , participants in the diet + exercise and diet groups had more weight loss and greater reductions in IL-6 levels than those in the exercise group ; those in the diet group had greater reductions in knee compressive force than those in the exercise group . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00381290 IMPORTANCE More than 80 % of patients with heart failure with preserved ejection fraction ( HFPEF ) , the most common form of heart failure among older persons , are overweight or obese . Exercise intolerance is the primary symptom of chronic HFPEF and a major determinant of reduced quality of life ( QOL ) . OBJECTIVE To determine whether caloric restriction ( diet ) or aerobic exercise training ( exercise ) improves exercise capacity and QOL in obese older patients with HFPEF . DESIGN , SETTING , AND PARTICIPANTS R and omized , attention-controlled , 2 × 2 factorial trial conducted from February 2009 through November 2014 in an urban academic medical center . Of 577 initially screened participants , 100 older obese participants ( mean [ SD ] : age , 67 years [ 5 ] ; body mass index , 39.3 [ 5.6 ] ) with chronic , stable HFPEF were enrolled ( 366 excluded by inclusion and exclusion criteria , 31 for other reasons , and 80 declined participation ) . INTERVENTIONS Twenty weeks of diet , exercise , or both ; attention control consisted of telephone calls every 2 weeks . MAIN OUTCOMES AND MEASURES Exercise capacity measured as peak oxygen consumption ( V̇O2 , mL/kg/min ; co- primary outcome ) and QOL measured by the Minnesota Living with Heart Failure ( MLHF ) Question naire ( score range : 0 - 105 , higher scores indicate worse heart failure-related QOL ; co- primary outcome ) . RESULTS Of the 100 enrolled participants , 26 participants were r and omized to exercise ; 24 to diet ; 25 to exercise + diet ; 25 to control . Of these , 92 participants completed the trial . Exercise attendance was 84 % ( SD , 14 % ) and diet adherence was 99 % ( SD , 1 % ) . By main effects analysis , peak V̇O2 was increased significantly by both interventions : exercise , 1.2 mL/kg body mass/min ( 95 % CI , 0.7 to 1.7 ) , P < .001 ; diet , 1.3 mL/kg body mass/min ( 95 % CI , 0.8 to 1.8 ) , P < .001 . The combination of exercise + diet was additive ( complementary ) for peak V̇O2 ( joint effect , 2.5 mL/kg/min ) . There was no statistically significant change in MLHF total score  with exercise and with diet ( main effect : exercise , -1 unit [ 95 % CI , -8 to 5 ] , P = .70 ; diet , -6 units [ 95 % CI , -12 to 1 ] , P = .08 ) . The change in peak V̇O2 was positively correlated with the change in percent lean body mass ( r = 0.32 ; P = .003 ) and the change in thigh muscle : intermuscular fat ratio ( r = 0.27 ; P = .02 ) . There were no study -related serious adverse events . Body weight decreased by 7 % ( 7 kg [ SD , 1 ] ) in the diet group , 3 % ( 4 kg [ SD , 1 ] ) in the exercise group , 10 % ( 11 kg [ SD , 1 ] in the exercise + diet group , and 1 % ( 1 kg [ SD , 1 ] ) in the control group . CONCLUSIONS AND RELEVANCE Among obese older patients with clinical ly stable HFPEF , caloric restriction or aerobic exercise training increased peak V̇O2 , and the effects may be additive . Neither intervention had a significant effect on quality of life as measured by the MLHF Question naire . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00959660 BACKGROUND Dehydration is typically associated with underweight and malnutrition in long-term care ( LTC ) setting s. Evidence is lacking regarding the influence of the rising prevalence of overweight and obesity on risk factors , prevalence , and presentation of dehydration . OBJECTIVE The aim of this study was to objective ly assess hydration status and the adequacy of total water intake , and determine relationships between hydration status , total water intake , and body mass index ( BMI ) in LTC residents . DESIGN A cross-sectional analysis of baseline data was performed . PARTICIPANTS AND SETTING Baseline data from 247 subjects recruited from eight community-based LTC facilities participating in two r and omized trials comparing nutrient and cost-efficacy of between-meal snacks vs oral nutrition supplements ( ONS ) . MAIN OUTCOMES Hydration status was assessed by serum osmolality concentration and total water intakes were quantified by weighed food , beverage , water , and ONS intake . STATISTICAL ANALYSES Simple and multiple linear regression methods were applied . RESULTS Forty-nine ( 38.3 % ) subjects were dehydrated ( > 300 mOsm/kg ) and another 39 ( 30.5 % ) had impending dehydration ( 295 to 300 mOsm/kg ) . The variance in serum osmolality was significantly accounted for by blood urea nitrogen level , mental status score , and having diabetes ( R(2)=0.46 ; P<0.001 ) . Total water intake averaged 1,147.2±433.1 mL/day . Thus , 96 % to 100 % of subjects did not meet estimated requirements , with a deficit range of 700 to 1,800 mL/day . The variance in total water intake was significantly accounted for by type of liquid beverages ( thin vs thick ) , type of ONS , total energy intake , total activities of daily living dependence , sex , and BMI ( R(2)=0.56 ; P<0.001 ) . CONCLUSIONS Dehydration and inadequate total water intake is prevalent in LTC residents across all BMI categories . Type of liquid beverages , type of ONS , and type of between-meal snacks are factors that could be targeted for nutrition interventions design ed to prevent or reverse dehydration BACKGROUND & AIMS Elderly subjects are at risk for undernutrition . Restrictive diets may increase this risk . The aim was to evaluate the impact of restrictive diets on undernutrition and its risk in free-living elderly . METHODS Ambulatory patients over age 75 and under a restrictive diet ( low salt , low cholesterol , diabetic ) were included prospect ively , along with age- and gender-matched controls . Weight and height were measured , and the short-form of the Mini Nutritional Assessment was scored . Groups were compared to determine variables associated with a low MNA-SF ( ® ) . RESULTS 95 patients in the diet group ( 62 F , 33 M , 80 ± 4 y ) and 95 controls ( 57 F , 38 M , 82 ± 5 y ) were included .  Restrictive diets ( low salt n = 33 , diabetic n = 19 , low cholesterol n = 15 , combination n = 27 ) had been followed since 11.0 ± 5.9 years . Using the cut-off of 12 for MNA-SF ( ® ) , 44 patients in the diet group were at risk vs. 22 among controls ( P < 0.001 ) . In multivariate analysis , a restrictive diet increased the probability of having an MNA-SF ( ® ) < 12 ( OR = 3.6 , (95%)CI = 1.8 - 7.2 , P < .001 ) . CONCLUSIONS Restrictive diets in patients over 75 increase the risk of undernutrition . On an individual level , these diets may need re assessment . Society guidelines should promote specific recommendations for the elderly PURPOSE To evaluate the effect of adding exercise to a hypocaloric diet on changes in appendicular lean mass and strength in frail obese older adults undergoing voluntary weight loss . METHODS Thirty frail older ( age , 70 + /- 5 yr ) obese ( body mass index , 37 + /- 5 kg.m ) adults were r and omly assigned to 6 months of diet/behavioral therapy ( diet group , n = 15 ) or diet or behavioral therapy plus exercise that incorporated progressive resistance training ( PRT ; diet + exercise group ; n = 15 ) . Body composition was assessed using dual-energy x-ray absorptiometry , and muscle strength was assessed using one-repetition maximum . The volume of upper extremity ( UE ) and lower extremity ( LE ) exercise training was determined by multiplying the average number of repetitions performed by the average weight lifted during the first three exercise sessions and during the last three exercise sessions of the study . RESULTS The diet and the diet + exercise groups had similar ( P > 0.05 ) decreases in weight ( 10.7 + /- 4.5 vs 9.7 + /- 4.0 kg ) and fat mass ( 6.8 + /- 3.7 vs 7.7 + /- 2.9 kg ) . However , the diet + exercise group lost less fat-free mass ( FFM ; 1.8 + /- 1.5 vs 3.5 + /- 2.1 kg ) , LE lean mass ( 0.9 + /- 0.8 vs 2.0 + /- 0.9 kg ) , and UE lean mass ( 0.1 + /- 0.2 vs 0.2 + /- 0.2 kg ) than the diet group ( P < 0.05 ) . The diet + exercise group had greater increases in percent of weight as FFM ( FFM / weight x 100 ) than the diet group ( 7.9 + /- 3.3 vs 5.4 + /- 3.7 % ; P < 0.05 ) . Despite lean mass losses , the diet + exercise group increased UE and LE strength in response to exercise ( 17 - 43 % ) , whereas the diet group maintained strength . The volume of UE and LE exercises correlated with the amount of UE and LE lean mass ( r = 0.64 - 0.84 ; P < 0.05 ) . CONCLUSION Exercise added to diet reduces muscle mass loss during voluntary weight loss and increases muscle strength in frail obese older adults . Regular exercise that incorporates PRT should be used to attenuate muscle mass loss in frail obese older adults on weight-loss therapy OBJECTIVE We tested the hypothesis that a multifaceted 11-wk intervention comprising nutrition , group exercise , and oral care would have a significant influence on nutrition and function in elderly ( > or=65 y ) nursing-home residents . METHODS The study was an 11-wk r and omized controlled intervention study with nutrition ( chocolate and homemade oral supplements ) , group exercise twice a week ( 45 - 60 min , moderate intensity ) , and oral care intervention one to two times a week , with the aim of improving nutritional status and function in elderly nursing-home residents . A follow-up visit was made 4 mo after the end of the intervention . Assessment s were weight , body mass index , dietary intake , h and grip strength , Senior Fitness Test , Berg 's Balance Scale , and the prevalence of plaque . RESULTS A total of 121 subjects ( 61 % ) accepted the invitation and 62 were r and omized to the intervention group . Six of these dropped out during the 11 wk . At the 4-mo follow-up there were 15 deaths in the intervention group and 8 in the control group . The nutrition and exercise were well tolerated . After 11 wk the change in percentage of weight ( P = 0.005 ) , percentage of body mass index ( P = 0.003 ) , energy intake ( P = 0.084 ) , protein intake ( P = 0.012 ) , and Berg 's Balance Scale ( P = 0.004 ) was higher in the intervention group than in the control group . In addition , the percentage of subjects whose functional tests improved was higher in the intervention group . Both groups lost the same percentage of weight after the intervention ( P = 0.908 ) . The total percentage of weight loss from baseline to follow-up was higher in the control group ( P = 0.019 ) . Oral care was not well accepted and the prevalence of plaque did not change . CONCLUSION It is possible to improve nutrition and function in elderly nursing-home residents by means of a multifaceted intervention consisting of chocolate , homemade supplements , group exercise , and oral care
BACKGROUND Malnutrition and dehydration are widespread in older people , and obesity is an increasing problem .
In clinical practice , it is often unclear which strategies are suitable and effective in counteracting these key health threats .
AIM To provide evidence -based recommendations for clinical nutrition and hydration in older persons in order to prevent and /or treat malnutrition and dehydration .
Further , to address whether weight-reducing interventions are appropriate for overweight or obese older persons .