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Industry: Email Alert RSS FeedInadequate caloric intake: a risk factor for mortality of geriatric patients in the acute-care hospital
Age and Ageing, May, 1998 by Raffaele Antonelli Incalzi, Oliviero Capparella, Antonella Gemma, Francesco Landi, Francesco PAgano, Luca Cipriani, Pierugo Carbonin
Introduction
Protein-calorie malnutrition is very common in geriatric and other adult patients in the acute-care hospital [1-10]. It predicts mortality, complications, a longer hospital stay and need of care independently of non-nutritional factors [3, 4, 7]. Nutritional interventions benefit some categories of malnourished patients [11-15]. Despite this, nutritional problems are frequently overlooked, probably because of the inadequate nutritional education of the average physician [2]. Providing adequate nutrition is not a routine medical activity: it is as if nutritional support were less important than pharmacological or surgical therapy [16, 17].
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Whether a relationship between clinical setting (medical, geriatric or surgical ward) and quality of nutritional support exists has not been studied. On theoretical grounds, surgeons may be more familiar with nutritional problems than physicians because of the advances in nutritional perioperative support in the last two decades [18]. We decided to test this hypothesis by comparing adequacy of caloric intake in surgical, medical and geriatric wards. The study aimed also to verify whether inadequate caloric intake was a determinant of the risk of hospital mortality.
Subjects and methods
Study population
Eighty-six patients aged 70 years or older consecutively admitted to the department of general surgery of the A. Gemelli University Hospital, Rome, for elective abdominal surgery between February and December 1994, were studied. Only candidates for operations causing a moderate surgical stress, e.g. hemicolectomy or subtotal gastrectomy, were selected. The patients' records were consulted on admission and on discharge or in the event of death, and clinical problems, type of surgical procedure and laboratory abnormalities were documented.
The following indicators of nutritional status were measured on admission and on discharge: body mass index, percent ideal weight, mid-arm circumference, serum albumin, serum haemoglobin. Mid-arm circumference was measured every 7 days if the stay exceeded 1 week.
The nutritional status was rated as fair, mildly impaired or severely impaired according to a previously reported method [7]. The assessor did not use a rigid scoring system but noted the following variables: anorexia, recent weight loss, wasting of muscle and fat, oedema, ascites and the effects of malnutrition on functional capabilities. Patients with life-threatening illnesses were considered to be malnourished only if clinical signs of malnutrition were present. The assessor ignored laboratory data. This method of rating the nutritional status has been shown to be highly reproducible and to predict both mortality and length of stay of geriatric patients in the acute-care hospital [7].
The pre-admission performance of activities of daily living (ADL) was rated on a previously validated score: 1, independent in all ADL items; 2, dependent in 1-5 ADL items; 3, dependent in all ADL items [7]. Cognitive and affective status on admission were explored by administering the Geriatric Depression Scale and the Mini Mental Status Examination (MMSE), respectively [19, 20].
The energy requirement was estimated to be 1.65 times the basal metabolic rate [21]. This estimate meets the energy requirements in a relatively sedentary adult. Indeed, decreased physical activity was considered to counterbalance the effects of progressive illness and surgery on energy requirement [22]. The optimal ratio of non-protein calories to nitrogen was assumed to be 150. This ratio prevents a negative nitrogen balance in patients experiencing moderate hypercatabolism [23]. Both the total caloric intake and the proportion of nutrients were corrected in patients having body mass index [is less than] 22 or [is greater than] 30 kg/[cm.sup.2] and/or diseases, such as renal failure and diabetes mellitus or requiring nutritional treatment [24]. In the event of septic complications, energy requirement was assumed to increase by 25%, and the optimal fraction of the caloric intake provided by lipids was estimated to be 30% [24].
Nutrient intake including enteral or intravenous supplementation was checked daily by a geriatrician and a nurse who estimated the consumed fraction of each portion. Snacks, extra servings and beverages were also recorded. Dietary information was converted in the daily caloric and protein energy intake according to the US Department of Agriculture Food Composition Tables and the Drug Product Information File [25, 26]. The average daily caloric intake was computed and expressed as a fraction of that required.
Control population
The controls were 284 patients over 70 years of age consecutively admitted for acute medical problems to the geriatric (135 patients) and internal medicine (149 patients) wards of the same university hospital in the same period.
Clinical and nutritional assessment was performed and the nutritional needs were calculated as for the study population. The catabolic effects of the acute medical illness and of the surgical stress experienced respectively by the control and study patients were considered to be comparable because the study population did not undergo emergency surgical procedures. Patients with oedema or dehydration on admission had their nutritional assessment performed after restoration of euvolemia.
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