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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 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.

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: 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.