Unintended Weight Loss in Older Adults

UWL: Screening and Assessment Methods (2009)

Citation:

Magri F, Borza A, del Vecchio S, Chytiris S, Cuzzoni G, Busconi L, Rebesco A, Ferrari E. Nutritional assessment of demented patients: a descriptive study. Aging Clin Exp. 2003; 15(2): 148-153.   

PubMed ID: 12889847
 
Study Design:
Before-After Study
Class:
D - Click here for explanation of classification scheme.
Quality Rating:
Neutral NEUTRAL: See Quality Criteria Checklist below.
Research Purpose:

To evaluate nutritional status in demented patients, as a whole and according to type of dementia, at the moment of hospital discharge and before discharge, to verify the effects of nutritional supplements during hospitalization on cognitive and functional performance.

Inclusion Criteria:
  • Old, demented patients
  • Diagnosis of possible or probable senile dementia according to criteria of DSM-IV for dementia, NINCDS-ADRA for dementia of Alzheimer's type and NINDS-AIREN for vascular dementia.
Exclusion Criteria:

None specifically mentioned.

Description of Study Protocol:

Recruitment

Patients were admitted to the Alzheimer section from January 1999 to October 2000.

Design

Before-after, descriptive study.

Intervention

Some demented patients underwent nutritional support, mainly by vitamin and folate supplements, and received high-protein meals and care during meals by nurses and caregivers.

Statistical Analysis

  • Data analyzed by Friedman analysis of variance (ANOVA) and Kendal coefficient of concordance test and Kruskal-Wallis ANOVA, and were compared using the Mann-Whitney U test
  • Correlations between nutritional data and cognitive and functional parameters were calculated by Spearman's rank order correlation coefficient.
Data Collection Summary:

Timing of Measurements

Measurements made before discharge and at the end of the hospitalization period. Mean hospitalization period was 45 days.

Dependent Variables

  • Anthropometric measures: height, weight, waist and hip girth, skinfold thickness, BMI and mid-arm muscle circumference
  • Body composition measured through bioelectric impedance
  • Biochemical measurements:  hemoglobin, total serum protein, albumin, transferrin, total lymphocyte count, total cholesterol, triglycerides, serum folate and vitamin B12
  • Mini Nutritional Assessment (MNA)
  • Daily dietary intake for at least seven days
  • Severity of dementia and cognitive impairment assessed by Clinical Dementia rating (CDR), Mini Mental State Examination (MMSE) score and Test for Severe Impairment (TSI)
  • Behavioral and functional status was evaluated by the Geriatric Depression Scale (GDS), Neuropsychiatric Inventory (UCLA-NPI), Barthel Index and Tinetti Scale
  • Comorbidity assessed by Cumulative Illness Rating Scale
  • Caregivers' stress assessed by the Green Scale.

Independent Variables

Some demented patients underwent nutritional support, mainly by vitamins and folate supplements, and received high-protein meals and care during meals by nurses and caregivers.

Description of Actual Data Sample:

Initial N: 174 old demented patients

Attrition (final N): 174 patients (150 women, 24 men)

Age: Mean age, 80.2±8 years; range, 60 years to 95 years

Ethnicity: Not mentioned

Location: Italy.

 

Summary of Results:

 

Variables

Malnourished (MNA<17, n=62) At Risk for Malnutrition (MNA 17 to 23.5, n=83) Well-Nourished (MNA>24, n=29) P value

Age (years)

80.0±9.02 80.48±8.10 79.15±7.73 NS
Onset of Dementia 47.07±40.98 48.10±55.82 50.60±66.77 NS
MMSE 16.04±6.443 15.78±7.53 16.00±5.93 NS
CDR 2.34±1.21 2.19±1.13 1.71±0.77 <0.05
TSI 12.70±6.81 11.50±6.39 18.67±3.8 <0.05
NPI-UCLA 25.74±18.37 16.43±15.43 20.10±13.73 NS
GDS 14.10±7.2 12.30±6.42 9.06±5.44 <0.05
Barthel 37.04±31.06 64.59±7.52 76.35±25.80 <0.001
Tinetti 8.42±7.59 15.7±13.15 19.50±4.62 <0.01
Total protein (g/dL) 6.61±0.74 6.99±0.54 7.00±0.59 <0.01
Serum albumin (g/dL) 3.52±0.56 3.87±0.44 3.94±0.61 <0.001
Transferrin (mg/dL) 146.9±50.1 169.8±55.8 168.0±52.8 <0.05

Total cholesterol (mg/dL)

193.0±53.2

215.1±45.8

199.4±46.5

<0.05

Other Findings

In all subgroups of demented patients, obtained according to type of dementia, the mean MNA score was indicative of risk for malnutrition.

Furthermore, the MNA score was significantly related to severe cognitive impairment, functional status, comorbidity, BMI values and transferrin and total protein serum levels.

Malnourished patients and demented elderly at risk for malnutrition (according to the MNA score) were given oral nutritional supplements during hospitalization, lasting a mean of 45 days.

Before discharge, these two subtypes of demented patients showed substantial maintenance of their cognitive, functional and nutritional status, whereas the subgroup of well-nourished demented patients exhibited significant worsening of the nutritional pattern.

Author Conclusion:

In conclusion, the multi-dimensional approach to demented patients must include nutritional assessment because, within the context of neurogenerative dementia, diet and to a lesser extent eating behavior are the only modifiable factors that can improve the quality of life of patients and caregivers. The MNA seems to be a good tool for early detection of malnutrition and for follow-up with nutritional intervention or educational programs. Lastly, prevention strategies and special attention on the part of physicians and caregivers to the nutritional markers of demented patients may act in synergy with specific pharmacologic treatment for cognitive deficits.

Funding Source:
Other: Not described
Reviewer Comments:

Large sample of demented patients. Unclear whether all admitted patients during that time were part of the study. More detail could have been provided about which subjects received the vitamin and protein supplements.

Quality Criteria Checklist: Primary Research
Relevance Questions
  1. Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) Yes
  2. Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? Yes
  3. Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? Yes
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies) Yes
 
Validity Questions
1. Was the research question clearly stated? Yes
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? Yes
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated? Yes
  1.3. Were the target population and setting specified? Yes
2. Was the selection of study subjects/patients free from bias? ???
  2.1. Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? No
  2.2. Were criteria applied equally to all study groups? N/A
  2.3. Were health, demographics, and other characteristics of subjects described? Yes
  2.4. Were the subjects/patients a representative sample of the relevant population? ???
3. Were study groups comparable? Yes
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) Yes
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? Yes
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) Yes
  3.4. If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? N/A
  3.5. If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) N/A
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? N/A
4. Was method of handling withdrawals described? ???
  4.1. Were follow-up methods described and the same for all groups? ???
  4.2. Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) ???
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? ???
  4.4. Were reasons for withdrawals similar across groups? ???
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study? N/A
5. Was blinding used to prevent introduction of bias? Yes
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? N/A
  5.2. Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) Yes
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? N/A
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status? N/A
  5.5. In diagnostic study, were test results blinded to patient history and other test results? N/A
6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? ???
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied? No
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? N/A
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? Yes
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? ???
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? No
  6.6. Were extra or unplanned treatments described? N/A
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? ???
  6.8. In diagnostic study, were details of test administration and replication sufficient? N/A
7. Were outcomes clearly defined and the measurements valid and reliable? Yes
  7.1. Were primary and secondary endpoints described and relevant to the question? Yes
  7.2. Were nutrition measures appropriate to question and outcomes of concern? Yes
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? Yes
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? Yes
  7.5. Was the measurement of effect at an appropriate level of precision? Yes
  7.6. Were other factors accounted for (measured) that could affect outcomes? Yes
  7.7. Were the measurements conducted consistently across groups? Yes
8. Was the statistical analysis appropriate for the study design and type of outcome indicators? Yes
  8.1. Were statistical analyses adequately described and the results reported appropriately? Yes
  8.2. Were correct statistical tests used and assumptions of test not violated? Yes
  8.3. Were statistics reported with levels of significance and/or confidence intervals? Yes
  8.4. Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? N/A
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? ???
  8.6. Was clinical significance as well as statistical significance reported? Yes
  8.7. If negative findings, was a power calculation reported to address type 2 error? N/A
9. Are conclusions supported by results with biases and limitations taken into consideration? Yes
  9.1. Is there a discussion of findings? Yes
  9.2. Are biases and study limitations identified and discussed? No
10. Is bias due to study's funding or sponsorship unlikely? Yes
  10.1. Were sources of funding and investigators' affiliations described? Yes
  10.2. Was the study free from apparent conflict of interest? Yes