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To purchase or authenticate to the full-text of this article, please visit this link: http://dx.doi.org/10.1111/j.1532-5415.2008.01789.x Byline: Richard A. Dennis (*[dagger]), Larry E. Johnson ([dagger][double dagger]), Paula K. Roberson (s.), Muhannad Heif ([dagger][double dagger]), Melinda M. Bopp ([dagger]), Judy Cook ([double dagger]), Dennis H. Sullivan (*[dagger]) Keywords: elderly; prealbumin; nutrition; calorie counts; C-reactive protein Abstract: 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. Author Affiliation: (*)Geriatric Research Education and Clinical Center, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas ([dagger])Donald W. Reynolds Department of Geriatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas ([double dagger])Geriatrics and Extended Care Service, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas (s.)Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, Arkansas. Article note: Address correspondence to Dennis H. Sullivan, MD, Geriatric Research Education and Clinical Center (Building 170, 3J/NLR), Central Arkansas Veterans Healthcare System, 4300 W 7th Street, Little Rock, AR 72205. E-mail: SullivanDennisH@uams.edu

A study of the changes in albumin over a period of three months in older veteran patients who are discharged from hospitals is presented. The purpose of the study is to determine the conditions preceding persistent hypoalbuminemia. The analysis is useful for determining long-term survival prospects of the veteran.

The prognostic significance of weight change in frail elderly patients is examined. The findings state that 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.

Objectives:Assess whether postoperative nightly enteral nutrition support improves outcomes of elderly patients with an acute hip fractureDesign:Randomized controlled trialSetting:A University and a Department of Veteran’s Affairs HospitalSubjects:Adults >64 years of age who underwent surgical repair of an acute hip fractureInterventions: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 survivalResults: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.

Objective:This non-blinded randomized controlled trial was the first phase of a planned series of investigations designed to test the efficacy of aggressive post-operative enteral nutrition support to decrease the rate of post-operative complications or improve long-term outcomes in specifically defined subgroups of elderly patients who have sustained a hip fracture requiring surgery.Methods:Eighteen patients (17 males) were randomized to the treatment (eight male subjects) or control groups. The control group (mean age 76.5±6.1 years) received standard post-operative care. Subjects in the treatment group (mean age 74.5±2.1 years) received 125 cc/hour of nasoenteral tube feedings over 11 hours each night in addition to standard post-operative nutritional care.Results:Both the treatment and control groups had reduced volitional nutrient intakes for the first 7 post-operative days (3,966±2,238 vs. 4,263±2,916 kJ/day [948±535 vs. 1019±697 kcal/day], p=0.815), but the treatment subjects had a greater total nutrient intake (7,719±2,109 vs. 4,301±2,858 kJ/day [1845±504 vs. 1028±683 kcal], p=0.012). On average, treatment subjects were tube fed for 15.8±16.4 days. There was no difference between the groups (treatment vs. controls) in the rate of post-operative life-threatening complications (25 vs. 30%, p=1.00) or in-hospital mortality (0 vs. 30%, p=0.216). Mortality within 6 months subsequent to surgery was lower in the treatment group compared to the controls (0 vs. 50%, p=0.036).Discussion:We conclude that nightly enteral feedings are a safe and effective means of supplementing nutrient intake. The greatest impact of nutrition support may be to reduce mortality.