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      Malnutrition is associated with increased mortality in older adults regardless of the cause of death

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          Abstract

          Malnutrition predicts preterm death, but whether this is valid irrespective of the cause of death is unknown. The aim of the present study was to determine whether malnutrition is associated with cause-specific mortality in older adults. This cohort study was conducted in Sweden and included 1767 individuals aged ≥65 years admitted to hospital in 2008–2009. On the basis of the Mini Nutritional Assessment instrument, nutritional risk was assessed as well nourished (score 24–30), at risk of malnutrition (score 17–23·5) or malnourished (score <17). Cause of death was classified according to the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, into twenty different causes of death. Data were analysed using Cox proportional hazards regression models. At baseline, 55·1 % were at risk of malnutrition, and 9·4 % of the participants were malnourished. During a median follow-up of 5·1 years, 839 participants (47·5 %) died. The multiple Cox regression model identified significant associations (hazard ratio (HR)) between malnutrition and risk of malnutrition, respectively, and death due to neoplasms (HR 2·43 and 1·32); mental or behavioural disorders (HR 5·73 and 5·44); diseases of the nervous (HR 4·39 and 2·08), circulatory (HR 1·95 and 1·57) or respiratory system (HR 2·19 and 1·49); and symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (HR 2·23 and 1·43). Malnutrition and risk of malnutrition are associated with increased mortality regardless of the cause of death, which emphasises the need for nutritional screening to identify older adults who may require nutritional support in order to avoid preterm death.

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          Most cited references17

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          Protein and energy supplementation in elderly people at risk from malnutrition.

          Evidence for the effectiveness of nutritional supplements containing protein and energy, often prescribed for older people, is limited. Malnutrition is more common in this age group and deterioration of nutritional status can occur during illness. It is important to establish whether supplementing the diet is an effective way of improving outcomes for older people at risk from malnutrition. This review examined trials for improvement in nutritional status and clinical outcomes when extra protein and energy were provided, usually as commercial 'sip-feeds'. We searched The Cochrane Library, MEDLINE, EMBASE, Healthstar, CINAHL, BIOSIS, CAB abstracts. We also hand searched nutrition journals and reference lists and contacted 'sip-feed' manufacturers. Randomised and quasi-randomised controlled trials of oral protein and energy supplementation in older people, with the exception of groups recovering from cancer treatment or in critical care. Two reviewers independently assessed trials prior to inclusion and independently extracted data and assessed trial quality. Authors of trials were contacted for further information as necessary. Sixty-two trials with 10,187 randomised participants have been included in the review. Maximum duration of intervention was 18 months. Most included trials had poor study quality. The pooled weighted mean difference (WMD) for percentage weight change showed a benefit of supplementation of 2.2% (95% confidence interval (CI) 1.8 to 2.5) from 42 trials. There was no significant reduction in mortality in the supplemented compared with control groups (relative risk (RR) 0.92, CI 0.81 to 1.04) from 42 trials. Mortality results were statistically significant when limited to trials in which participants (N = 2461) were defined as undernourished (RR 0.79, 95% CI 0.64 to 0.97).The risk of complications was reduced in 24 trials (RR 0.86, 95% CI 0.75 to 0.99). Few trials were able to suggest any functional benefit from supplementation. The WMD for length of stay from 12 trials also showed no statistically significant effect (-0.8 days, 95% CI -2.8 to 1.3). Adverse effects included nausea or diarrhoea. Supplementation produces a small but consistent weight gain in older people. Mortality may be reduced in older people who are undernourished. There may also be a beneficial effect on complications which needs to be confirmed. However, this updated review found no evidence of improvement in functional benefit or reduction in length of hospital stay with supplements. Additional data from large-scale multi-centre trials are still required.
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            Nutritional status using mini nutritional assessment and subjective global assessment predict mortality in geriatric patients.

            To evaluate the clinical assessment of nutritional status and mortality in geriatric patients. Prospective follow-up study. Acute geriatric inpatient ward. Eighty-three consecutive acute geriatric patients (mean age +/- standard deviation = 83 +/- 7; 68% women). Patients were classified as (1) having protein-energy malnutrition (PEM), (2) having moderate PEM or being at risk for PEM, or (3) being well nourished according to Subjective Global Assessment (SGA) and Mini Nutritional Assessment (MNA). Body mass index ((BMI) kg/m2), arm anthropometry, and handgrip strength were determined. In a subgroup of patients (n = 39), body composition was analyzed using dual energy x-ray absorption and bioelectrical impedance. Three-year mortality data were obtained from the Swedish population records. Twenty percent and 26% of the patients were classified as having PEM based on SGA and MNA, respectively, whereas 43% and 56%, respectively, were classified as having moderate PEM or being at risk for PEM. Objective measures, such as BMI, arm anthropometry, handgrip, and body fat were 20% to 50% lower in the malnourished group than in the well-nourished subjects (P <.05). Moreover, mortality was higher in those classified as being malnourished, ranging from 40% after 1 year to 80% after 3 years, compared with 20% after 1 year (P =.03-0.17) and 50% after 3 years (P <.01) in patients classified as being well nourished. Fewer than one-third of newly admitted geriatric patients had a normal nutritional status according to SGA and MNA. BMI, arm anthropometry, body fat mass, and handgrip strength were reduced, and 1-, 2-, and 3-year mortality was higher in patients classified as malnourished. The present data justify the use of SGA and MNA for the assessment of nutritional status in geriatric patients.
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              Body mass index and survival in men and women aged 70 to 75.

              To examine in an older population all-cause and cause-specific mortality associated with underweight (body mass index (BMI) or =30.0). Cohort study. The Health in Men Study and the Australian Longitudinal Study of Women's Health. Adults aged 70 to 75, 4,677 men and 4,563 women recruited in 1996 and followed for up to 10 years. Relative risk of all-cause mortality and cause-specific (cardiovascular disease, cancer, and chronic respiratory disease) mortality. Mortality risk was lowest for overweight participants. The risk of death for overweight participants was 13% less than for normal-weight participants (hazard ratio (HR)=0.87, 95% CI=0.78-0.94). The risk of death was similar for obese and normal-weight participants (HR=0.98, 95% CI=0.85-1.11). Being sedentary doubled the mortality risk for women across all levels of BMI (HR=2.08, 95% CI=1.79-2.41) but resulted in only a 28% greater risk for men (HR=1.28 (95% CI=1.14-1.44). These results lend further credence to claims that the BMI thresholds for overweight and obese are overly restrictive for older people. Overweight older people are not at greater mortality risk than those who are normal weight. Being sedentary was associated with a greater risk of mortality in women than in men.
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                Author and article information

                Journal
                British Journal of Nutrition
                Br J Nutr
                Cambridge University Press (CUP)
                0007-1145
                1475-2662
                February 28 2017
                March 14 2017
                February 28 2017
                : 117
                : 4
                : 532-540
                Article
                10.1017/S0007114517000435
                d3f46a88-999d-4bc3-a06b-d25e72ef9e5e
                © 2017

                https://www.cambridge.org/core/terms


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