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Purpose: The purpose of this quality improvement project was to examine the feasibility of rapidly converting a Tai Chi program for older Veterans from face-to-face to virtual classes., Methods: Eighteen Veterans attending our face-to-face Tai Chi course were invited to transition to virtual classes. Feasibility was defined as the ability of program staff and participants to successfully connect and complete the initial and subsequent classes by VA Video Connect (VVC) with little to no technical difficulties, participant ability to participate in the course without safety concerns, and favorable feedback from participants and program staff., Results: Nine of 18 Veterans agreed to transition to the virtual program and attended a median (interquartile range) of 11 (4-15) classes; they were younger (62.7 + 11.5 vs. 70.5 + 7.0 years, p < .05) and more likely to have the knowledge and equipment needed to participate (78% vs. 0%, p < .01) than nonparticipants. Tai Chi instructors and participating Veterans reported being able to connect to and complete the classes virtually with only minimal technical problems. No adverse events were reported. Feedback from the instructors and Veterans was positive and included comments on ease of use and enjoyability., Conclusion: Results suggest that virtual Tai Chi classes via VVC are feasible for some older Veterans., (Published 2022. This article is a U.S. Government work and is in the public domain in the USA.)

Purpose: To evaluate the effectiveness of an evidence-based 12-week Tai Chi course designed to improve balance and physical function in a population of older veterans., Methods: Community dwelling veterans of all ages with gait and balance problems were invited to participate in the Tai Chi program. Participants completed the Berg Balance Scale (BBS), the Timed Up and Go (TUG) test, and the Falls Efficacy Scale-International (FES-I) at baseline and again at the end of the program. Descriptive statistics were used to summarize study participants' characteristics. The change from baseline to the end of the 12-week program was calculated for each of the three primary outcome variables (BBS, TUG, FES-I)., Results: Twenty-two veterans, aged 58 years and above, with perceived gait and/or balance issues were enrolled in the program with completion by 11 veterans. Veterans who completed their final assessments showed the BBS, improved significantly (p = 0.004) from baseline to the 12-week assessment. The TUG scores improved by a median of 1.3 s (p = 0.022). There was not a significant change in the FES-I., Conclusions: Preliminary findings provide evidence of the effectiveness of a 12-week Tai Chi program to improve functional outcomes for older veterans with mild to moderate gait and balance problems., (Published 2020. This article is a U.S. Government work and is in the public domain in the USA.)

Our work identifies subjects based on their height and the distance between their joints. Using a depth sensing camera, we obtained the position of a person's joints in 3D space relative to each other. The distances between adjacent joints and height of a subject's head are used to create a vector of eight features for an individual to use for identification. Using modified KNN, full and partial feature sets were used to identify subjects. Additionally, our classifier can be utilized to assess ambulation (such as walking's velocity and distance) of subject, when identified.

Purpose: The purpose of this nurse-led project was to increase the number of interprofessional Tai Chi instructors for veterans through a 5-week (32 hours) training of trainers (ToT) course led by a Tai Chi master trainer., Methods: This project was designed to evaluate the effectiveness of using the ToT model to increase the availability of Tai Chi to veterans. To understand how well the ToT course met learners' needs, a two-phase course evaluation was conducted., Results: Fifteen interprofessional employees enrolled in and completed the course. Most learners were white (67%) females (67%) with a median age of 50 years. All agreed that the training provided the skills, materials, and confidence to lead Tai Chi classes. Most (93%) indicated experiencing positive health benefits from the training and none experienced any negative effects. The 3-month follow-up evaluation indicated that 10 (67%) were teaching veterans in individual or group classes with two others assisting. Twelve instructors taught more than 150 veterans., Conclusions: Overall, learners evaluated this ToT course positively and indicated their needs were met and felt prepared to teach Tai Chi despite being inexperienced. The course was a success with 80% of new instructors teaching or coteaching Tai Chi to veterans., (Published 2019. This article is a U.S. Government work and is in the public domain in the USA.)

Apathy is a common and disabling behavioral concomitant of many neurodegenerative conditions. The presence of apathy with Mild Cognitive Impairment (MCI) is linked with heightened rates of conversion to Alzheimer's disease. Improving apathy may slow the neurodegenerative process. The objective was to establish the efficacy of repetitive transcranial magnetic stimulation (rTMS) in improving apathy in older adults with MCI. An 8-week, double-blind, randomized, sham-controlled cross-over study was conducted in nine subjects (66 ± 9 years) with apathy and MCI. Subjects were randomized to rTMS or sham treatment (5 days/week) for 2 weeks following which they underwent a 4-week treatment-free period. Subjects then crossed-over to receive the other treatment for 2 weeks. The primary (apathy (AES-C)) and secondary (cognition (3MS & MMSE), executive function (TMT-A & TMT-B), and clinical global impression (CGI)) outcomes were assessed at baseline, 2, 6, and 8 weeks. After adjusting for baseline, there was a significantly greater improvement in the AES-C with rTMS compared to sham treatment at 2 weeks. There was significantly greater improvement in 3MS, MMSE, TMT-A, and CGI-I with rTMS compared to the sham treatment. This study establishes that rTMS is efficacious in improving apathy in subjects with MCI., (Published by Elsevier B.V.)

Objective: Apathy is a common behavioral problem in Alzheimer's disease. Apathy has profound consequences, such as functional impairment, higher service utilization, higher caregiver burden, and increased mortality. The authors' objective was to study the effects of methylphenidate on apathy in Alzheimer's disease., Method: A 12-week, prospective, double-blind, randomized, placebo-controlled trial (methylphenidate versus placebo) was conducted in community-dwelling veterans (N=60) with mild Alzheimer's disease. The primary outcome for apathy (Apathy Evaluation Scale-Clinician) and secondary outcomes for cognition (Mini-Mental State Examination, Modified Mini-Mental State Examination), functional status (activities of daily living, instrumental activities of daily living), improvement and severity (Clinical Global Impressions Scale [CGI]), caregiver burden (Zarit Burden Scale), and depression (Cornell Scale for Depression in Dementia) were measured at baseline and at 4, 8, and 12 weeks., Results: Participants were all men (77 years old, SD=8). After adjusting for baseline, the methylphenidate group had significantly greater improvement in apathy than the placebo group at 4 weeks, 8 weeks, and 12 weeks. At 12 weeks, there was also greater improvement in cognition, functional status, caregiver burden, CGI scores, and depression in the methylphenidate group compared with the placebo group., Conclusions: Methylphenidate improved apathy in a group of community-dwelling veterans with mild Alzheimer's disease. Methylphenidate also improved cognition, functional status, caregiver burden, CGI scores, and depression.

Background/Objectives . Balance problems are well-established modifiable risk factors for falls, which are common in older adults. The objective of this study was to establish the efficacy of a Wii-Fit interactive video-game-led physical exercise program to improve balance in older Veterans. Methods . A prospective randomized controlled parallel-group trial was conducted at Veterans Affairs Medical Center. Thirty community dwelling Veterans aged 68 (±6.7) years were randomized to either the exercise or control groups. The exercise group performed Wii-Fit program while the control group performed a computer-based cognitive program for 45 minutes, three days per week for 8-weeks. The primary (Berg Balance Scale (BBS)) and secondary outcomes (fear of falling, physical activity enjoyment, and quality of life) were measured at baseline, 4 weeks, and 8 weeks. Results . Of 30 randomized subjects, 27 completed all aspects of the study protocol. There were no study-related adverse events. Intent-to-treat analysis showed a significantly greater improvement in BBS in the exercise group (6.0; 95% CI, 5.1-6.9) compared to the control group (0.5; 95% CI, -0.3-1.3) at 8 weeks (average intergroup difference (95% CI), 5.5 (4.3-6.7), p < 0.001) after adjusting for baseline. Conclusion . This study establishes that the Wii-Fit exercise program is efficacious in improving balance in community dwelling older Veterans. This trial is registered with ClinicalTrials.gov Identifier NCT02190045., Competing Interests: There is no financial conflict of interests or personal conflict of interests relevant to the submitted manuscript for any authors.

Background/objective: Balance problems are common in older adults with Alzheimer's disease (AD). The objective was to study the effects of a Wii-Fit interactive video-game-led physical exercise program to a walking program on measures of balance in older adults with mild AD., Methods: A prospective randomized controlled parallel-group trial (Wii-Fit versus walking) was conducted in thirty community-dwelling older adults (73±6.2 years) with mild AD. Home-based exercises were performed under caregiver supervision for 8 weeks. Primary (Berg Balance Scale, BBS) and secondary outcomes (fear of falls and quality of life) were measured at baseline, 8 weeks (end of intervention), and 16 weeks (8-weeks post-intervention)., Results: At 8 weeks, there was a significantly greater improvement (average inter-group difference [95% CI]) in the Wii-Fit group compared to the walking group in BBS (4.8 [3.3-6.2], p < 0.001), after adjusting for baseline. This improvement was sustained at 16 weeks (3.5 [2.0-5.0], p < 0.001). Analyses of the secondary outcome measures indicated that there was a significantly greater improvement in the Wii-Fit group compared to walking group in Activity-specific Balance Confidence scale (6.5 [3.6-9.4], p < 0.001) and Falls Efficacy Scale (-4.8 [-7.6 to -2.0], p = 0.002) at 8 weeks. However, this effect was not sustained at 16 weeks. Quality of life improved in both groups at 8 weeks; however, there were no inter-group differences (p = 0.445)., Conclusion: Home-based, caregiver-supervised Wii-Fit exercises improve balance and may reduce fear of falling in community-dwelling older adults with mild AD.

The purpose of this study was to evaluate a multi-component method for capturing nutrient intake, which used observation, photography, and an innovative computer program. To assess reliability and accuracy, multiple responsible employees (REs) independently conducted nutrient intake assessments on simulated meals; each RE's results relating to energy intake were compared to those from the other REs and to those obtained by pre- and post-meal weighing of the food items. System efficiency was assessed by having REs perform independent assessments on the same set of simulated meals using either the new or traditional hospital method for which the REs had to document each food item served and then find the items in a computer database-steps that were automated in the new method. Interrater reliability for energy intake estimated on clinic wards was excellent (intraclass correlation coefficient = 0.975, 95% CI 0.958 to 0.992) and there was a high level of agreement between the REs' estimates and the true values determined by food weighing; per the method of Bland and Altman the mean difference between the two types of estimates was 0.3 kcal (95% CI, -8.1 to 8.7 kcal) with limits of agreement of -79.5 kcal to 80.1 kcal. Compared to the traditional method, energy intake assessments could be completed using the multi-component method in less than a third of the time. These results indicate the multi-component method is an accurate, reliable, and efficient method of obtaining energy intake assessments for hospitalized patients., Competing Interests: The funding sponsors had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, and in the decision to publish the results.

Obtaining a detailed assessment of a hospitalized patient's nutrient intake is often critically important to ensuring the patient's successful recovery. However, this process is often laborious and prone to error. Inaccurate nutrient intake assessments result in the inability of the healthcare team to recognize patients with developing nutritional deficits that contribute to delayed recovery and prolonged lengths of stay. This paper describes an innovative, easy to use system designed to increase the precision of calorie count reports by using a combination of photography, direct observation, and a specially developed computer program. Although the system was designed specifically for use in a Department of Veterans Affairs Hospital, it has the potential to be adapted for use in other hospital environments.

Background: Immune function may influence the ability of older adults to maintain or improve muscle mass, strength, and function during aging. Thus, nutritional supplementation that supports the immune system could complement resistance exercise as an intervention for age-associated muscle loss. The current study will determine the relationship between immune function and exercise training outcomes for older adults who consume a nutritional supplement or placebo during resistance training and post-training follow-up. The supplement was chosen due to evidence suggesting its ingredients [arginine (Arg), glutamine (Gln), and β-hydroxy β-methylbutyrate (HMB)] can improve immune function, promote muscle growth, and counteract muscle loss., Methods/design: Veterans (age 60 to 80 yrs, N = 50) of the United States military will participate in a randomized double-blind placebo-controlled trial of consumption of a nutritional supplement or placebo during completion of three study objectives: 1) determine if 2 weeks of supplementation improve immune function measured as the response to vaccination and systemic and cellular responses to acute resistance exercise; 2) determine if supplementation during 36 sessions of resistance training boosts gains in muscle size, strength, and function; and 3) determine if continued supplementation for 26 weeks post-training promotes retention of training-induced gains in muscle size, strength, and function. Analyses of the results for these objectives will determine the relationship between immune function and the training outcomes. Participants will undergo nine blood draws and five muscle (vastus lateralis) biopsies so that the effects of the supplement on immune function and the systemic and cellular responses to exercise can be measured., Discussion: Exercise has known effects on immune function. However, the study will attempt to modulate immune function using a nutritional supplement and determine the effects on training outcomes. The study will also examine post-training benefit retention, an important issue for older adults, usually omitted from exercise studies. The study will potentially advance our understanding of the mechanisms of muscle gain and loss in older adults, but more importantly, a nutritional intervention will be evaluated as a complement to exercise for supporting muscle health during aging., Trial Registration: Clinicaltrials.gov identifier: NCT02261961, registration date 10 June 2014, recruitment active.

Background: It is unclear whether serial measures of body weight are valid indicators of nutritional status in older patients recovering from illness. Objectives. Investigate the relative influence of nutrient intake and changes in peripheral edema on weight change., Methods: A prospective cohort study of 404 older men (mean age = 78.7±7.5 years) admitted to a transitional care unit of a Department of Veterans Affairs nursing home. Body weight and several indicators of lower extremity edema were measured at both unit admission and discharge. Complete nutrient intake assessments were performed daily., Results: Over a median length of stay of 23 days (interquartile range: 15-41 days), 216 (53%) participants gained or lost more than or equal to 2.5% of their body weight. Two hundred eighty-two (70%) participants had recognizable lower extremity pitting edema at admission and/or discharge. The amount of weight change was strongly and positively correlated with multiple indicators of both nutrient intake and the change in the amount of peripheral edema. By multivariable analysis, the strongest predictor of weight change was maximal calf circumference change (partial R (2) = .35, p < .0001), followed by average daily energy intake (partial R (2) = .14, p < .0001), and the interaction of energy intake by time (partial R (2) = .02, p < .0001)., Conclusions: Many older patients either gain or lose a significant amount of weight after admission to a transitional care unit. Because of the apparent high prevalence of co-occurring changes in total body water, the weight changes do not necessarily represent changes in nutritional status. Although repeat calf circumference measurements may provide some indication as to how much of the weight change is due to changes in body water, there is currently no viable alternative to monitoring the nutrient intake of older recuperative care patients in order to ensure that their nutrient needs are being met.

Objectives: To determine the relationships between physical function, systemic inflammation, and nutrient intake in elderly adults who are deconditioned or recovering from medical illness., Design: Prospective observational study., Setting: Recuperative care and rehabilitation setting of a Veterans Affairs hospital., Participants: Older adults assessed to be in need of and likely to benefit from specialized inpatient care (N = 336, aged 78.9 ± 7.5, median length of stay 24 days)., Measurements: Functional assessments and plasma analyses for albumins and inflammatory markers were performed at admission and discharge. Complete nutrient intake assessments were performed daily. Katz (independence in activities of daily living) and walking endurance (distance capability and summation of need for assistive device and human help) scores were based on direct observation and provider query. Data were analyzed using least-squares and logistic regression analyses., Results: Changes in physical function between admission and discharge were positively correlated with change in nutrient intake and inversely correlated with inflammation at admission and its change. Participants in the upper quartile of change for nutrient intake (particularly improved protein intake) were two to three times as likely to experience a clinically significant change in functional status during the hospitalization. Similarly, the odds of experiencing an improvement in physical function were two to four times as great for participants whose C-reactive protein levels declined as for those whose levels increased. These relationships remained significant after controlling for age, length of stay, and other baseline indicators of health status., Conclusion: Protein intake and inflammation are significantly correlated with functional recovery for aging individuals undergoing recuperative care and rehabilitation. Future studies should investigate whether combined interventions that target these factors improve recovery during hospitalization for this population., (© 2012, Copyright the Authors Journal compilation © 2012, The American Geriatrics Society.)

Objectives. To determine the effects on balance and gait of a Wii-Fit program compared to a walking program in subjects with mild Alzheimer's dementia (AD). Methods. A prospective randomized (1 : 1) pilot study with two intervention arms was conducted in an assisted living facility with twenty-two mild AD subjects. In both groups the intervention occurred under supervision for 30 minutes daily, five times a week for eight weeks. Repeated measures ANOVA and paired t-tests were used to analyze changes. Results. Both groups showed improvement in Berg Balance Scale (BBS), Tinetti Test (TT) and Timed Up and Go (TUG) over 8 weeks. However, there was no statistically significant difference between the groups over time. Intragroup analysis in the Wii-Fit group showed significant improvement on BBS (P = 0.003), and TT (P = 0.013). The walking group showed a trend towards improvement on BBS (P = 0.06) and TUG (P = 0.07) and significant improvement in TT (P = 0.06). Conclusion. This pilot study demonstrates the safety and efficacy of Wii-Fit in an assisted living facility in subjects with mild AD. Use of Wii-Fit resulted in significant improvements in balance and gait comparable to those in the robust monitored walking program. These results need to be confirmed in a larger, methodologically sound study.

Objectives: To determine the relationship between prealbumin, nutrient intake, and indicators of inflammation for recuperative and rehabilitative care patients., Design: Prospective cohort., Setting: Recuperative Care Unit within a Veterans Administration Nursing Home Care Unit., Participants: One hundred eleven men (100 white; mean age 80, range 64-93)., Measurements: Prealbumin and seven markers of inflammation (C-reactive protein (CRP), tumor necrosis factor, and interleukin-6 (IL-6) and their soluble receptors) were measured at admission and discharge (median length of stay 23 days, interquartile range 15-40 days). Detailed calorie counts were performed daily, and intake was expressed as a percentage of estimated requirements for protein (1.5 g/kg body weight per day) and energy (Harris-Benedict equation). The study objective was examined using least-squares regression analysis., Results: Discharge prealbumin and the change in prealbumin were positively correlated with protein and energy intake and inversely correlated with markers of inflammation, particularly CRP and IL-6. When all covariates were included in a multivariable regression analysis, the markers of inflammation predominantly accounted for the variance in prealbumin change (56%), whereas discharge protein intake accounted for 6%., Conclusion: For older recuperative care patients, prealbumin and its change during hospitalization are positively associated with protein intake, but inflammation or changes in inflammation appear to exert a much more-powerful influence on prealbumin concentration. Given the potential confounding effects of inflammation, monitoring the change in prealbumin is not an adequate substitute for a more-detailed nutritional assessment in this population.

Objective: To determine the functional outcomes and discharge setting of older patients receiving inpatient rehabilitation for debility (ICD-9-CM, 799.3)., Design: Retrospective cohort study of 63,171 individuals >or= 65 yrs old with a primary (23%) or comorbid (77%) debility diagnosis from the Uniform Data System for Medical Rehabilitation (UDSMR) database for 2002-2003., Results: Patients with a primary diagnosis of debility (PDD) had a lower mean rehabilitation efficiency score (functional change per day) as compared with the rest of the subjects (1.7 vs. 1.9, P<0.001), including those with a Centers for Medicare & Medicaid Services (CMS) 75% rule primary diagnosis (1.8, P<0.001). The PDD group was less likely to be discharged home (68% vs. 73%, P<0.001) and more likely to be discharged to a hospital (13% vs. 11%, P<0.001)., Conclusions: From a clinical perspective, the functional recovery of older patients with debility is essentially the same, regardless of whether this is a primary or comorbid diagnosis. Their functional improvement is also comparable with that reported for other CMS 75% rule diagnoses, although the debility patients are less likely to be discharged home. More than 10% of these patients were discharged to acute hospital settings. Further research is warranted to identify the most appropriate rehabilitation setting for patients with debility.

Objective: To investigate the association between serum albumin, prealbumin, various serum inflammation associated-cytokines, and mortality in older geriatric recuperative care patients., Design: A prospective cohort study., Setting: A geriatric rehabilitation unit of a university-affiliated Department of Veterans Affairs hospital., Participants: Participants were 53 geriatric patients (mean age 78 +/- 7.3, 96% male) admitted to a Geriatric Evaluation and Management (GEM) unit. Patients with documented near-terminal medical disorder, overt infections, and any systemic or localized inflammatory disorders were excluded., Measurements: Inflammation-associated cytokines (IL-8, IL-1beta, IL-6, IL-10, TNF-alpha), albumin, prealbumin, and C-reactive protein were measured at hospital discharge and each subject was then tracked for 1 year., Main Results: By Cox Proportional-Hazards Regression analysis, the strongest predictor of mortality within 6 months of study entry was the serum IL-6. For each log increase in IL-6, there was nearly a 9-fold greater 6-month mortality risk (RR 8.99, 95% CI 1.65 to 49.03). The association between albumin and mortality was no longer significant after controlling for IL-6. There was a strong inverse correlation between IL-6 and both albumin (R2 0.39, P < .001) and prealbumin (R2 0.41, P < .001)., Conclusion: Subclinical inflammation appears to be an important factor contributing to low serum albumins in older recuperative care patients and may confound the association between albumin and mortality in this population. More in-depth studies of these associations are warranted.

Objectives: To determine the independent and combined effects of progressive resistance muscle strength training (PRMST) and megestrol acetate (MA) on strength, muscle mass, and function in older recuperative care patients., Design: Double-blind, randomized, controlled intervention using a two-by-two factorial design and conducted between 1999 and 2001., Setting: University-affiliated Department of Veterans Affairs hospital., Participants: Twenty-nine patients (mean age 79.4 +/- 7.4, 90% white) aged 65 and older and had recent functional decline., Interventions: After randomization to one of four treatment groups (low-resistance exercises plus 800 mg per day of MA or a placebo or high-intensity PRMST plus 800 mg/d of MA or placebo), subjects received training and the drug or placebo for 12 weeks., Measurements: Change in muscle strength, mid-thigh muscle area, and aggregate functional performance score as assessed using analysis of covariance., Results: Five subjects withdrew from the study before its completion. Based on intent-to-treat analyses, subjects who received high-intensity PRMST and placebo experienced the greatest strength gains. The addition of MA was associated with worse outcomes than with high-intensity exercise training alone, especially with regard to the leg exercises. Post hoc analysis demonstrated that subjects who received high-intensity PRMST and placebo experienced significantly greater percentage increases in leg strength than subjects in either of the MA treatment groups (P<.05 for each comparison). There was also a significant negative effect of MA on physical function. In general, subjects who received MA experienced a deterioration in aggregate physical function scores, whereas the remaining subjects improved (-0.80+/-0.40 vs 0.48+/-0.41, P=.04). There was not a significant interaction between exercise and MA for any outcome., Conclusion: High-intensity PRMST is a safe and well-tolerated exercise regimen for frail elderly patients. The addition of MA appears to blunt the beneficial effects of PRMST, resulting in less muscle strength and functional performance gains.

Objectives: To determine change in albumin from hospital discharge to 3-month follow-up and the prognostic significance of persistent hypoalbuminemia in older veteran patients., Design: A prospective cohort study., Setting: A geriatric rehabilitation unit of a university-affiliated Department of Veterans Affairs hospital., Participants: The study population consisted of 282 subjects (of 322 randomly selected discharges who were free of cancer and terminal conditions) that completed the 90-day postdischarge assessment; most were older (75.4+/-8.6), white (76%), and male (99%)., Measurements: Each subject completed a comprehensive discharge assessment, had a repeat albumin an average of 94 days later, and was then tracked for 5 years. The strongest predictors of survival were identified using Cox proportional hazards regression analysis., Results: Between hospital discharge and the 3-month reassessment, albumins improved by more than 2 g/L in 122 subjects (43%), stayed the same in 112 subjects (40%), and deteriorated by more than 2 g/L in the rest. During follow-up, 190 subjects (67%) died. Of the 38 nutritional, functional, demographic, and illness severity variables evaluated, the 3-month postdischarge albumin was the strongest predictor of long-term mortality. Those with albumins less than 35 g/L had a 2.6 times greater mortality than those with albumins of 40 g/L or greater (relative risk=2.6, 95% confidence interval=1.8-3.8). After controlling for 3-month albumin, hospital-discharge albumin was not significantly associated with long-term mortality., Conclusion: In older people, a low serum albumin 3 months after hospital discharge is associated with a poor long-term prognosis. It is not known whether this represents ongoing inflammation or inadequate nutrition.

Objectives: Assess whether postoperative nightly enteral nutrition support improves outcomes of elderly patients with an acute hip fracture, Design: Randomized controlled trial., Setting: A University and a Department of Veteran's Affairs Hospital, Subjects: Adults >64 years of age who underwent surgical repair of an acute hip fracture., Interventions: Subjects randomized to the control (Ctrl) group received standard care while the treatment (Tx) group received standard care plus up to 1,375 Kcal [5,755 kJ/d] of nasoenteral tube feedings each night. When tube feedings had to be discontinued, Tx subjects were asked to drink an equivalent amount of the nutritional supplement each night., Measures of Outcome: Rate of postoperative complications and 6-month postoperative survival., Results: Fifty-seven patients were randomized to the Tx (n = 27, mean age 75.9 +/- 7.4 yrs) or Ctrl groups (age 81.7 +/- 7.7 yrs). All subjects had reduced volitional nutrient intakes after surgery. During the first week subsequent to surgery, there was no difference between the treatment and control groups in the amount of nutrients that they volitionally consumed during the day. However, the treatment subjects had a greater total daily nutrient intake (Median 5,866 (IQR 5,024 to 7,335) kJ/d vs. 3,965 (IQR 2,968 to 4,664) kJ/d, p < 0.001). However, by the second postoperative week this difference was no longer statistically significant. Intolerance to the tube feedings developed commonly. There was no difference between the groups in the rate of postoperative life-threatening complications or mortality within six months subsequent to surgery., Conclusions: This study failed to confirm findings from a prior study of improved postoperative survival with nutrition support. However, it was conducted on multiple hospital wards which may have contributed to the higher rate of tube-related problems and less nutrient delivery signifying the need for further study.

Objectives: To evaluate the prognostic significance of weight change in frail elderly patients., Design: Prospective study., Setting: The general medical or surgical wards of a university-affiliated Department of Veterans Affairs hospital., Participants: Six hundred sixty randomly selected subjects aged 65 or older., Measurements: At admission and discharge, each subject completed a standardized diagnostic evaluation, including demographic variables, and basic medical, functional, and nutritional assessments. Weights were recorded from hospital or clinic visits in the year before admission, during the current hospitalization, and after discharge for a median of 5.6 years. Average yearly intraindividual weight change was calculated using least-squares regression. Associations between intraindividual weight change and mortality were identified using Cox proportional hazards regression., Results: During the study, 314 subjects (48%) died. A U-shaped association between weight change and mortality was observed. Those who were relatively weight stable (+/-1 kg/y) had the lowest mortality (28%). Compared with this group, the adjusted relative risks (ARR) of death for those who lost 1 or more to less than 3 kg/y and 3 or more kg/y were 2.14 (95% confidence interval (CI)=1.52-3.00) and 3.59 (95% CI=2.58-4.99), respectively. The ARR associated with a weight gain of 1 or more to less than 3 kg/y and 3 or more kg/y was 1.38 (95% CI=0.91-2.10) and 3.73 (95% CI=2.34-5.94), respectively. The amount of bidirectional weight fluctuation (estimated using coefficient of variance) was not significantly associated with mortality., Conclusion: For reasons that are not clear, elderly patients who gain 3 or more kg/y after hospital discharge are at nearly the same risk of mortality as those who lose this amount of weight.

Background: Although weight change in older persons has proven prognostic significance, it is not known whether monthly weights obtained by the clinical staff in long-term care institutions are reliable enough to be useful in identifying at-risk residents. The objective of this study was to determine whether an association exists between mortality risk and the intraresident variation in weight in long-term care institutions., Methods: For this study, 900 nursing home residents with a recently identified nutritional problem from 96 long-term care facilities in 8 states were randomly selected. At study entry, nutritional, health status, and demographic data were extracted from the nursing home chart or the Minimum Data Set. Weights obtained by the nursing home staff were recorded at baseline and during each of the subsequent 6 months. Cox proportional hazards regression analysis was used to assess relationships between weight parameters and mortality risk during the 7 months of observation., Results: During the study, 435 (48%) participants had at least 1 monthly weight that differed from the previous month's weight by > or =5%; 163 (18%) participants had this magnitude of a 1-month weight change more than once. By controlling for the linear trend (i.e., slope) of each residents' weight change between the first to the last weight, the average month-to-month residual variability in the resident's weights was calculated. This residual variability or "average random fluctuation" in weight from 1 month to the next was > or =2% in 229 (25%) participants and > or =3% in 82 (9%) participants. Despite the large random fluctuation in the residents' weights, weight loss was an important prognostic indicator. Those who lost > or =5% in any month had a 10-fold increased risk for death compared with those who gained weight (adjusted relative risk, 10.6; 95% confidence interval, 3.2 to 35.5). The average random fluctuation in weight was associated with an increased risk for death only at the upper 10th percentile for the population., Conclusions: Many nutritionally compromised elderly nursing home residents experience significant bidirectional fluctuations in their weight from month to month. How much of this variability is due to measurement error is not known. However, a weight loss of > or =5% in any month has important prognostic implications.

Objective: To determine whether elderly patients with protein-energy undernutrition at admission are at increased risk for subsequent life-threatening events after controlling for illness severity., Design: Prospective cohort study., Setting: University-affiliated Department of Veterans Affairs hospital., Patients: Five hundred eighty-six nonterminal patients (mean age 74 +/- 6 [SD] years, 98% male, 86% white) with a length of stay of 3 days or more., Main Outcome Measures: Life-threatening complications., Results: Subsequent to admission, 37 subjects (6.3%) experienced at least 1 life-threatening complication. All of the putative nutrition variables examined and many non-nutrition, illness severity measures were strongly correlated with the risk of a life-threatening complication by univariate analyses (P <.05 for all analyses). After controlling for illness severity, admission serum albumin, prealbumin, and cholesterol were no longer significantly correlated with the outcome. In contrast, weight loss (>5% within 6 months), body mass index, mid-arm circumference, and suprailiac skinfold thickness remained strong independent predictors. The adjusted relative risk of a life-threatening complication ranged from 2.9 (95% confidence interval [CI], 1.3 to 6.4) for a body mass index <22 kg/m2 to 7.1(95% CI, 2.0 to 25.7) for a suprailiac skinfold thickness in the lower tertile for the study population. The putative nutrition and illness severity variables were highly intercorrelated., Conclusions: There is a complex interrelationship between nutritional status, illness severity, and clinical outcomes among the hospitalized elderly. The serum secretory proteins and cholesterol are correlated with other indicators of illness severity and adverse outcomes, but may not be good markers of nutritional risk. In contrast, weight loss, a low body mass index, and other indicators of lean and fat mass depletion appear to place the patient at increased risk for adverse outcomes independent of illness severity. Whether it is possible to reverse such established nutritional deficits and reduce complication risk in the acute care setting remains to be determined.

Background: The importance of undernutrition as a determinant of postdischarge mortality among hospitalized elderly people remains controversial. The purpose of this study was to investigate this issue., Methods: The study included 660 elderly patients (85% white, 98% men, average age 73 +/- 6 years) discharged from a university-affiliated Department of Veterans Affairs Hospital, who were followed for 1 year. Associations between patient characteristics at hospital discharge and mortality were identified utilizing Cox Proportional Hazards Regression analysis., Results: In the year following hospital discharge, 85 subjects (13%) died. After adjusting for illness severity (Acute Physiology and Chronic Health Evaluation II score) and functional status (Katz Index of Activities of Daily Living score), a body mass index (BMI)