DEVELOPMENT OF AN INTEGRATED SCREENER FOR UNDERNUTRITION WITHIN A COMPREHENSIVE GERIATRIC ASSESSMENT SYSTEM

O.R.L. Wright¹, K. Klein², P. Lakhan³, A.P. Vivanti⁴, L.C. Gray⁵

1. PhD, Centre for Dietetics Research (C-DIET-R), School of Human Movement and Nutrition Sciences, The University of Queensland; Brisbane, Australia; 2. PhD, Statistics Unit, QIMR Berghofer Medical Research Institute, Brisbane, Australia; Clinical Trials and Biostatistics Unit, QIMR Berghofer Medical Research Institute, Brisbane, Australia; 3. PhD, Research Fellow, Centre for Research in Geriatric Medicine, The University of Queensland, Brisbane, Australia; 4. Professional Doctorate, Research Dietitian, Department of Nutrition and Dietetics, The Princess Alexandra Hospital, Brisbane, Australia; 5. MD, PhD , Professor, Centre for Research in Geriatric Medicine, The University of Queensland, Brisbane, Australia

Corresponding Author: Dr Olivia Wright, Centre for Dietetics Research, School of Human Movement and Nutrition Sciences, The University of Queensland, Brisbane QLD Australia, Ph: +61 7 3365 6669; Fax: +61 7 3365 6877; Email: o.wright@uq.edu.au

Abstract

Objective: To develop a screener for the presence of undernutrition in older adults in acute care utilizing items within a comprehensive geriatric assessment (CGA) instrument (the interRAI Acute Care). Design: Prospective cohort study and retrospective medical record review of nutritional assessment data. Setting: Acute care tertiary teaching hospital in Brisbane, Australia. Participants: Five hundred fifty-seven general medical patients aged 70 and older admitted to the hospital. Measurements: Prevalence of geriatric syndromes at admission; measures of functional status (activities of daily living), cognition, behavioural symptoms, social support, community assistance services, health conditions, medications and other medical treatments, weight, body mass index (BMI), mode of nutritional intake; demographic variables and Subjective Global Assessment (SGA) of nutritional status. These measures were tested for their prediction of undernutrition using a logistic regression model and decision tree analysis. Results: The following variables were significant independent predictors of undernutrition on admission, after adjustment for age and gender: (i) feeling sad/depressed (OR: 3.494 [1.124-10.864]; p<0.05); (ii) short term memory recalling ability (OR: 3.325 [1.152-9.594]; p<0.05); (iii) weight loss of 5% or more in the last 30 days or 10% or more in the last 180 days (OR: 2.877 [0.983-8.416]; p=0.05); (iv) fatigue (OR: 3.494 [1.414-43.205]; p<0.05). Decision tree analysis revealed two models most predictive of undernutrition: (i) short term memory recalling ability and depression (AUC 72.8% [95% CI: 65%-80.6%]); (ii) short term memory recalling ability and recent weight loss (5% or more in the last 30 days or 10% or more in the last 180 days) (AUC: 74.8% [95% CI: 65.9% – 83.6%]). Conclusion: Several measures within the interRAI-AC may be used as part of a screener for undernutrition in acute hospital patients aged 70 years or older. The combination of short term memory recalling ability and percentage weight loss provides the most statistically robust screener for undernutrition within the interRAI-AC.

Key words: Undernutrition, comprehensive geriatric assessment.

Background

Population aging together with increased life expectancy is resulting in inexorable growth in demand for hospital services by frail older people. In the face of finite hospital resources, there is a need to provide care efficiently, while at the same time meeting the increasing (and appropriate) expectation that care will be of the highest standard. Comprehensive geriatric assessment (CGA), and the processes embodied within it are associated with more accurate diagnosis, better targeted and appropriate medical treatment, improvements in patient functional status, quality of life, disease prognosis and clinical outcomes (1). The coordinated multidisciplinary assessment process underpinning CGA facilitates rapid investigation of a range of complex, interactive co-morbidities, which can then be treated in the context of the “whole person”. Efficacy of the multidisciplinary elements of CGA has been examined briefly (2); however, the validity of the measures used within CGA to assess disciplinary components needs further investigation.

The screening of nutritional status in order to identify patients who are under nourished is an important aspect of CGA, as treatment has significant potential to improve patient quality of life, clinical outcomes and reduce hospital costs (3). Undernutrition is documented in around 50-60% of acute geriatric inpatients aged 65 years or older and is recognized as a marker of frailty and prognosis (4). There are numerous tools for screening and assessing undernutrition which incorporate various subjective, anthropometric, clinical or biochemical components. Implementation and validation of these tools, internationally, is challenged by the absence of an absolute gold standard for nutrition assessment, time constraints, or lack of awareness of the most appropriate tools to use. Biochemical assessment methods (for example, the commonly used serum albumin) may be affected by hydration and disease processes (particularly renal and liver conditions), and thus represent client illness rather than nutrient intake (5). Therefore, studies utilizing these assessment techniques, on the whole, are more likely to obtain higher prevalence rates of undernutrition than other methods. A range of biochemical and anthropometric parameters (weight, height, body mass index [BMI], percentage weight loss, albumin) have been used as part of CGA to assess nutritional status; however, structured nutritional assessment using validated tools is not usually performed. Although numerous studies of nutrition screening and assessment tools exist, no studies assessing the agreement between nutritional measures within CGA and validated nutrition assessment tools have been completed.

Valid and reliable tools to assess nutritional status are the Subjective Global Assessment (SGA)(6) and its derivative, the Patient Generated Subjective Global Assessment (PG-SGA)(7). The SGA and PG-SGA involve assessments of medical history, a physical examination and evaluation of biochemical laboratory results (8). A combination of these items determines whether patients are classified as well nourished (Score A), mild to moderately malnourished (Score B) or severely malnourished (Score C) (6). Nutritional status (A, B or C) is documented in the patient’s hospital medical chart. The SGA is particularly valuable for identifying those with established undernutrition in this setting (9). It demonstrates acceptable predictive ability with sensitivity and specificity of 82% and 72% respectively (6).

This paper presents a sub-analysis of data from a larger cohort study examining the prevalence of geriatric syndromes and outcomes in an acute hospital setting (10). The purpose of this sub-analysis was to determine which geriatric syndromes or related variables within a CGA instrument used internationally were significantly associated with the presence of undernutrition on admission to acute care and could therefore be used to derive a new screener for undernutrition within CGA.

Methods

Study sample

Patients admitted to the General Medical Unit (GMU) of a large tertiary teaching hospital in Brisbane, Australia (2005-2008), aged ≥ 70 years, who were expected to remain in hospital for more than 48 hours were eligible for inclusion in this study. Consent was obtained from patients on admission to the GMU. Exclusion criteria included: (i) patients admitted to intensive or coronary care units; (ii) patients admitted to the general medical unit for terminal care only, and (iii) patients transferred from a general medical to another unit within 24 hours of admission. When cognitive impairment was documented in the medical notes or suspected by a study assessor (in the absence of any medical documentation), consent from the relevant proxy

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was obtained. Demographic data were obtained from the medical record system in relation to non-consenting patients to establish comparability to consenting patients.

Data collection instruments and methods

The interRAI-Acute Care (interRAI-AC) was used for comprehensive geriatric assessment in this study (11) and includes data pertaining to geriatric syndromes (and risks of acquiring them) collected in the pre-morbid, admission and discharge periods. The interRAI-AC provides a comprehensive evaluation of older patients’ functional status, geriatric syndromes, cognition, behavioural symptoms, social supports, community assistance services, health conditions, medications and other medical treatments, weight, height, percentage weight loss over time and mode of nutritional intake, and all of these domains were examined in this study. The methods and zoloftonline-generic.com reliability of data collection for all of these domains is detailed elsewhere (12, 13). Admission data was used for the purposes of this study and trained nurses conducted all assessments. Application of the interRAI-AC results in the identification and documentation of a comprehensive range of geriatric syndromes and risks, in contrast to the current paucity of documentation of these parameters in patient medical files noted in the literature (14).

A retrospective medical record review was completed for this study to obtain SGA data that matched the patients included from 2005-2008, identified by hospital record number and date of birth. Exclusion criteria for this routine data collection included patients with acute psychiatric conditions. The SGAs had been completed by hospital dietitians fully trained in its administration, as part of standard clinical practice. Standard practice at the hospital involved using the Malnutrition Screening Tool (MST) to identify patients at risk of malnutrition who required nutritional assessment using the SGA (13). A number of studies have used the SGA in older adults to assess undernutrition and have shown it is a valid, reproducible indicator of nutritional status in this group (6). Data for patients transferred from coronary or intensive care units were not available as these patients were excluded from the original cohort study where data for this study was sourced. If multiple SGAs were located throughout the hospital admission, the assessment completed on admission was used.

Statistical analysis

A combined version of SGA B + SGA C was used as the “undernourished” category. Continuous and normally distributed variables (age) were summarized as means with standard deviations (SD). Differences in results for all interRAI-AC measures were compared between males and females using independent t-tests for means, Chi square tests for variables with two categories and Kruskal-Wallis tests for variables with more than two categories. Statistically significant results are presented. Chi square tests were completed to test associations between clinical (geriatric) characteristics and demographic/service provision variables measured by the interRAI-AC and nutritional status defined by SGA. Items with statistically significant associations were included in backward, stepwise logistic regression models to determine independent effects. Standard regression diagnostics were performed. All models were adjusted for potential confounders (age and gender). Significant independent variables from the regression analysis were passed onto the decision tree analyses. Receiver operating characteristic (ROC) curve analyses using the results from the decision tree analyses were then performed to determine the most reliable predictors from the parsimonious model. Statistical significance was assessed at the 5% level for all analyses. The analyses were completed using SPSS version 16.0 (SPSS Inc. Chicago, IL, USA) and R version 2.15.3. The Human Research Ethics Committee at the Princess Alexandra Hospital (2004/079; 2008/130) and the Medical Research Ethics Committee at the University of Queensland (2008001564) approved all study procedures.

Results

Sample characteristics

This study included 557 patients aged 70 to 102 years (mean 82 ± 7.1); 43.7% were male (n=244/557), and 212 (38.0%) were married. Characteristics of the sample are presented in Table 1. The median length of stay was 7 days (2 – 99 days). Two hundred and one patients (36.0%) lived alone, 204 (36.6%) had been admitted to hospital in the previous 90 days and 63 (11.3%) were admitted from a low- or high-level long-term care facility. Forty-three per cent used formal community services before hospital admission. The most frequent admission diagnoses were falls (9%), chest pain (5%), urosepsis or urinary tract infection (4%), fractured neck of femur (3%), congestive cardiac failure (2%) and abdominal pain (0.9%). An additional 249 eligible patients (or their next of kin) refused consent, mainly due to ill health or not wishing to participate in research. The median age and gender distribution of excluded patients was similar to those participants in the study.

Table 1 Characteristics of the sample

*Mean (SD) or median (range); †ANOVA, Kruskal Wallace or Chi-square test

Of the 557 patients for whom interRAI-AC data was available, 111 nutritional assessments using the SGA had been completed (20%) as part of standard dietetics practice at the hospital, and this determined the sample size available for reliability, regression and decision tree analyses. There were no statistically significant differences in characteristics including age, gender, marital status, country of birth, living arrangement, residence/transition status, time since last hospital stay, BMI or length of stay, between patients who had SGA’s completed and those who did not. Females were statistically significantly older than males in the sample by around three years (p<0.001). Undernutrition according to the SGA was more prevalent in males than females (p=0.041). Males were more likely to have had recent weight loss than females (p=0.002), which coincides with their higher rates of undernutrition. Females were less likely to be walking independently on admission (p=0.018) and had higher rates of pain frequency compared to males (p=0.002). Males were more independent with eating on admission than females (p=0.034); however, their rates of undernutrition were higher than females (p=0.041). Females were less independent than males with personal hygiene (p=0.009) and bathing (p=0.004) on admission. A significant proportion of females were widowed compared to males (p=0.001) and lived alone (p=0.001). Females appeared to utilise fewer community services prior to admission due to a higher proportion living in the institutional setting; however, further analysis indicated females were more likely to have housekeeping services (p=0.012), medication aid services (p=0.019) and personal care assistance (p=0.022). Interestingly, there was no significant difference in length of stay between those who were classified as well nourished or malnourished according to the SGA in this study (p=0.99).

Associations between other CGA measures and undernutrition as defined by SGA

The association between CGA measures collected on the interRAI-AC and undernutrition (SGA) were investigated. All variables relating to physical function and Activities of Daily Living (ADL) on the interRAI-AC are categorical and rated on a scale of 0 to 6, with 0 meaning “independent”, 1 independent with set up help and 2-6 being grades of modified independence or impairment. For the purposes of this analysis, these interRAI-AC variables were categorised into either “independent” or “not independent”. Variables relating to fatigue, pain and sadness/depression are rated as zero (none) with categories above one representing various levels of severity or timing (for example, presence in the past 3 days to 24 hours). The variable for pressure ulcer severity is rated as zero (no pressure ulcer) with 1-4 being increasing levels of severity. Frequency analyses for these variables organised by SGA groupings (A, B or C) were examined to inform variable organisation for the analysis. Based on the small sample sizes (i.e. less than 10 cases) for each severity grading for fatigue, pain, sadness/depression and pressure ulcer, it was decided to dichotomise each of these variables to either “absent” or “present”. Percentage weight loss of 5% in last 30 days or 10% in last 180 days is categorised as either “yes” or “no”. Chi-square tests presented in Table 2 show which items on the interRAI-AC were significantly associated with the presence of undernutrition according to SGA.

Table 2 CGA measures associated with undernutrition measured by SGA

Regression analyses

Binary logistic regression with backward wald covariate search models were used to establish which variables collected by the interRAI-AC were having significant independent associations with undernutrition. Analyses for variables collected at admission are presented in Table 3. The final, most parsimonious model is presented.

All of the variables included in Table 3 had statistically significant crude odds ratios. Impairment in short term memory was associated with the largest magnitude increase in crude odds for undernutrition on admission (almost six-fold). When all variables were included in the multivariable logistic regression model, feeling sad or depressed, impairment in short term memory and the presence of fatigue were the most significant interRAI-AC items associated with undernutrition on admission. Items relating to eating as an ADL, cognitive skills for daily decision making, personal hygiene as an ADL, walking as an ADL, ability to understand others, interest and pleasure in things enjoyed normally and BMI were not statistically significant in the parsimonious regression model.

Table 3 Stepwise, backward logistic regression of the association between geriatric syndromes collected by the interRAI-AC at admission with undernutrition as measured by SGA

*OR, odds ratio of undernutrition; †Odds ratios mutually adjusted for all other variables in the table; ‡CI, confidence interval for true estimate of adjusted odds ratio

Predictors of undernutrition at admission

Compared to people with no reported fatigue on admission, those with fatigue had roughly three and a half times higher odds of being undernourished. Compared to those who were eating standard texture diets at admission, the odds of undernutrition in people who were not eating standard texture diets was roughly four and a half times higher. Compared to patients who had no short term memory problems on admission, those with short term memory impairment were roughly three times more likely to be undernourished. Patients who had experienced recent weight loss (5% in 30 days; 10% in 180 days) were around four and a half times more likely to be undernourished, compared to those who did not have recent weight loss.

Decision tree analysis

Decision tree analyses were performed using significant independent variables from the logistic regression analysis. In model one, short term memory recalling ability and depression were able to separate the whole patient population into three groups in relation to undernutrition. In model two, short term memory recalling ability and recent weight loss (5% or more in the last 30 days or 10% or more in the last 180 days) separated the population into three subgroups in relation to nutritional status (See figure 1).

Figure 1 Decision tree analysis showing percentage weight loss and short-term memory recall items present in the interRAI-AC grouping patients into three groups

Receiver Operating Characteristic (ROC) Curve analysis

The results from the decision tree analysis were assessed via ROC curve analysis to evaluate their sensitivity and specificity for predicting the presence (or absence) of undernutrition on admission. Decision tree analysis one, including the variables short term memory recall and sad/depressed and hopeless, produced an area under the curve (AUC) of 72.8% (95% CI: 65%-80.6%), while decision tree analysis two, including the variables short term memory recall and percentage weight loss, was http://clomidgeneric-online24.com/proscar-pills-generic.php marginally better, returning an AUC of 74.8% (95% CI: 65.9% – 83.6%).

Development of the undernutrition screener algorithm

The aim of the development of the interRAI-AC undernutrition algorithm was to maximise sensitivity to facilitate thorough identification of patients who were undernourished. We utilised the combination of items with the highest AUC estimate. The algorithm developed included a combination of recent weight loss (5% or more in the last 30 days or 10% or more in the last 180 days) and short term memory recalling ability. Of the 49 patients diagnosed by dietitians as being undernourished, 2 had missing values on the interRAI-AC undernutrition screener due to 2 missing values for the recent weight loss component. Similarly, 2 of the 62 patients diagnosed by dietitians as not being undernourished had missing values on the interRAI-AC undernutrition screener for this variable. Therefore, of the 47 patients diagnosed by dietitians as undernourished, 41 were correctly rated as undernourished by the interRAI-AC undernutrition screener algorithm, yielding 87% sensitivity, 53% specificity, positive and negative predictive values of 59% and 84%.

Table 4 The performance of interRAI-AC undernutrition screener algorithm in patients with undernutrition

*Sensitivity = 0.87 (0.74-0.95); †Specificity = 0.53 (0.40-0.66); ‡PPV = 0.59 (0.47-0.71); §NPV = 0.84 (0.68-0.93); ||LHRT positive = 1.87 (1.40-2.50); {LHRT negative = 0.24 (0.11-0.52); #AUC = 0.748

Discussion

This study revealed three significant findings: (i) the interRAI-AC incorporates measures that coincide with internationally-recognised clinical definitions of undernutrition, i.e. the International Statistical Classification of Diseases and Related Health Problems Australian Modification, including: BMI, percentage weight loss and evidence of suboptimal intake; however, not all of these items were statistically associated with the presence of undernutrition as measured by the SGA in this study; (ii) items examining percentage weight loss over time, self-reported fatigue, depression and short term memory on admission contribute significantly to the prediction of undernutrition in older adults in acute care; (iii) the combination of self-reported short term memory recall and percentage weight loss provides the most statistically robust screener for undernutrition within the interRAI-AC at present.

A large proportion of nutrition screening practices used in geriatric settings rely on monitoring weight loss or BMI, or combinations of both (15). BMI < 18.5 kg/m² or unintentional weight loss (5-9% or ≥10%) with “evidence of suboptimal intake resulting in mild loss of subcutaneous fat and/or mild muscle wasting” are used to define undernutrition codes in the International Statistical Classification of Diseases and Related Health Problems Australian Modification (ICD-10-AM). Undernutrition is coded in the hospital medical record based on these criteria and is linked to increased health care reimbursements. Our study revealed unintentional weight loss (5% or more in the last 30 days or 10% or more in the last 180 days) as a significant predictor of undernutrition at admission in older adults; however BMI was not statistically significant, despite the testing of several different cut-offs, including BMI <18.5 kg/m², generic abilify <23 kg/m² and <25 kg/m². Percentage weight loss over time is a component of several nutritional screening and assessment tools (15). It is more sensitive as an indicator of subcutaneous fat loss and muscle wasting than weight alone, as spontaneous fluid shifts in hospital may cause inaccurate results. BMI does not adjust for the proportion of lean and fat tissue, and has been shown to underestimate undernutrition (16). There is also significant potential for error in the measurement (or reporting of) height and weight in hospital, reducing confidence in estimates relying on this information. It is therefore advantageous that one of the potential nutrition screeners we have derived from the interRAI-AC utilises percentage weight loss rather than BMI.

Poor short term recalling ability was a component of the interRAI-AC screener for undernutrition developed in this study. Cognitive impairment has clomid side effects been shown to increase the risk of undernutrition in older adults living in their own homes, and in nursing homes (17), and is associated with higher all-cause mortality in hospital (18); however, no previous nutrition screeners have incorporated such an item. In the MNA-SF, cognitive status is briefly mentioned within “neuropsychological problems”, but focuses on the presence of “dementia or depression” rather than short term memory issues. Self-reported sadness, depression or feelings of hopelessness contributed to the prediction of undernutrition on admission in this study, yet this type of item (depression/hopelessness only) is also absent from current nutrition screening tools. Recent studies have confirmed the importance of considering the presence of cognitive impairment and depression in the identification of undernutrition in older patients (19), therefore we consider our screener adds significant novelty to the field.

Fatigue on admission was significantly associated with admission undernutrition in our study. Undernutrition is recognised as a consequence of fatigue (20). Fatigue is also associated with acute undernutrition and poor food intake in hospital, as exhaustion prevents the ability to eat independently and to chew and swallow for the time it takes to finish a meal (21). Although it was not determined to be the most statistically robust item in our decision tree analysis, inclusion of the interRAI-AC item about fatigue in further validation studies with larger sample sizes is important, as this variable may assist in distinguishing between acute and chronic undernutrition on admission and this is of high clinical significance. No nutritional screening tools currently measure fatigue on admission therefore our work contributes novelty to the field.

Analysis of AUC indicated the screeners developed here would accurately predict the presence of undernutrition around 75% of the time. This is comparable to the predictive ability of other nutrition screening tools validated against the SGA (22-25). The Malnutrition Screening Tool (MST) is the most common nutrition screener used in Australian hospitals and has demonstrated a higher sensitivity (90-94%) and specificity (85-89%) against the SGA in hospital patients aged over 65 years (26, 27), with lower sensitivity and specificity in a larger sample of older adults in residential aged care (n=258) (83% sensitivity; 64% specificity) (28). The MNA-SF has very high demonstrated sensitivity (100%) against the SGA in elderly hospital patients aged 65 years and older; however, the specificity is lower (52.8%) (27). This is attributed to its more global assessment approach, as it includes a section for cognitive assessment and patients receive higher scores if they are in hospital. These statistical parameters and the cognitive component are similar to our new interRAI-AC nutrition screener, although our screener contains only two items compared to the MNA-SF’s 7 items. Despite these instruments being over-inclusive, they increase the likelihood of treatment of patients who are undernourished and the potential for prevention of malnutrition in the false positives, which increases in relevance as length of stay increases.

The interRAI-AC items for short term memory recall ability, percentage weight loss and feelings of sadness, depression or hopelessness have demonstrated good to excellent inter-rater reliability with kappas of 0.6 (95% CI: 0.44-0.75), 0.74 (95% CI: 0.88 – 0.91) and 0.92 (95% CI: 0.85 – 1.00) respectively (29). Inter-rater reliability for other nutrition screening tools has not been widely studied; however our screener is comparable to the MST, which has excellent demonstrated inter-rater reliability of kappa 0.88 (22).

Our study showed that 111/557 patients had received a nutritional assessment (20 per cent) as a result of standard practice at the hospital. Of that 20 per cent, around 44 per cent were undernourished. It is possible that at least 44 per cent of the remaining patients who had not received a nutritional assessment were also malnourished; however, they would not have received any targeted interventions, increasing their risk of nutritional decline in hospital and potentially, post-discharge. The incorporation of a malnutrition screener into CGA which is standard practice, has the potential to improve the identification of risk of malnutrition on admission in older adults, thereby improving referral rates to dietitians and other practitioners for well-targeted interventions.

Limitations

A limitation is that the data examined in this study was analysed retrospectively. The reliance on already completed SGA data meant that the study included patients already identified as “at risk” of undernutrition by standard screening practices at the hospital; however, this screening data was unavailable. The study was also limited by the relatively small proportion of nutritional assessments conducted as standard practice in this group of patients (n=111/557). Despite this, the similar trends identified using the larger dataset (n=557) in relation to the demographic and community service utilisation of patients, and the gender differences identified using the larger dataset (n=557), was a major strength of the study. The SGAs were completed by a range of dietitians and there is no inter-rater reliability data available; however, this tool has demonstrated good inter-rater reliability in previous work (6).

Conclusions

This study has identified several measures within the interRAI-AC that can be used as part of a screener for undernutrition in acute hospital patients aged 70 years or older. The combination of short term memory recall and percentage weight loss provides the most statistically robust screener for undernutrition within the interRAI-AC at present. This is the first study to quantify the potential for CGA to contribute to screening for undernutrition in acute care and demonstrates the significant potential for, and advantages of, multidisciplinary collaboration in the development and refinement of assessment tools in geriatric medicine.

The inclusion of measures encompassing cognition and/or depression alongside percentage weight loss in a screener for undernutrition is valuable, as it provides context around the diagnosis of undernutrition. The majority of nutrition screening and assessment tools focus on measures of weight and suboptimal food intake, but do not provide measures of potential explanations for these results, apart from poor appetite (8). The advantage of a nutrition screener with internationally-recognised clinical indicators (ICD-10-AM) in addition to contextual items incorporated within CGA, is that results can be interpreted alongside substantial clinical information about geriatric syndromes, demographic details, living arrangements and prior community services. This assists in determining the most effective and targeted intervention to either prevent nutritional decline or reduce the extent of undernutrition present while in hospital, in addition to planning appropriate care and services upon discharge.

Ethical Standards: Princess Alexandra Hospital HREC (2004/079; 2008/130) UQ MREC (2008001564)

Conflicts of Interest: NIL – The authors have no conflict of interest.

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25. Rubenstein LZ, Harker JO, Salvà A, Guigoz Y, Vellas B. Screening for Undernutrition in Geriatric Practice: Developing the Short-Form Mini-Nutritional Assessment (MNA-SF). The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 2001;56(6):M366-M72.

26. Wu M-L, Courtney MD, Shortridge-Baggett LM, Finlayson K, Isenring EA. Validity of the Malnutrition Screening Tool for Older Adults at High Risk of Hospital Readmission. J Gerontol Nurs. 2012;38(6):38-45.

27. Young AM, Kidston S, Banks MD, Mudge AM, Isenring EA. Malnutrition screening tools: Comparison against two validated nutrition assessment methods in older medical inpatients. Nutrition. 2013;29(1):101-6.

28. Isenring EA, Bauer JD, Banks M, Gaskill D. The Malnutrition Screening Tool is a useful tool for identifying malnutrition risk in residential aged care. Journal of Human Nutrition and Dietetics. 2009;22(6):545-50.

29. Wellens NIH, Van Lancker A, Flamaing J, Gray L, Moons P, Verbeke G, et al. Interrater reliability of the interRAI Acute Care (interRAI AC). Archives of gerontology and geriatrics. 2012;55(1):165-72.

INFLUENCE OF CHEMOSENSORY IMPAIRMENT ON INTAKE AND LIKING OF A FUNCTIONAL DRINK IN UNDERNOURISHED INSTITUTIONALIZED ELDERLY PEOPLE

C. Arganini¹, L.M. Donini², M. Peparaio¹, F. Sinesio¹

1. CRA-NUT Research Centre on Food and Nutrition, Roma, Italy; 2. Sapienza University of Rome, Experimental Medicine Department, Roma, Italy

Corresponding Author: C. Arganini, CRA-NUT Research Centre on Food and Nutrition, Via Ardeatina, 546, 00178 Roma, Italy, E-mail: arganini@inran.it

Abstract

Background: Age-related chemosensory impairments (i.e., reduction of taste and smell acuity) affect a large proportion of the population older than 65 years. These conditions can affect overall health, quality of life and influence food appreciation and intake. The knowledge about the relation between chemosensory perception and hedonic food liking in older people might facilitate the development of effective strategies aiming to improve their nutritional wellbeing. Objectives: The key objective of this study is to test the influence of a sensory compensatory strategy on liking and intake of a functional red fruit drink in undernourished nursing home elderly people. Design: The research consisted of three main phases. In the first step the enrolled subjects were classified on the basis of their taste and olfaction sensitivity; in the second step the sensory compensatory strategy, aiming to counteract age-associated sensory losses and increase product pleasantness, was identified; the last step consisted of 14 days of exposure to each drink variant (standard and enhanced) to observe the effects of sensory modifications on liking and intake. Setting: “Villa delle Querce” Clinical Rehabilitation Institute of Nemi (Rome- Italy). Participants: 76 elderly people (64-97 years). Results: Overall the prevalence of measured chemosensory impairments in this sample of institutionalized older adults was very high (81%). The sensory modification strategy did influence significantly neither the intake nor liking in the elderly people. Consistent with the findings of previous studies (3, 6, 24, 25) no significant correlation was found between sensory capabilities and hedonic responses. Conclusion: These findings highlight that, in accordance to other studies (2, 3, 6-8), the role of sensory compensatory strategies in increasing products appreciation and intake of institutionalized elderly people have been overestimated.

Key words: Chemosensory impairment, sensory compensatory strategy, undernutrition, institutionalized elderly people.

Introduction

In institutionalized elderly people poor energy intake is an important factor related to malnutrition which is often associated with frailty and increased morbidity and mortality (1). One of the potential causes of inadequate food intake is considered the age related reduction of taste and smell acuity (2). Several studies have found a progressive decline in taste and smell functioning, which tends to begin around 65 years of age (3, 4). The prevalence of sensory impairment is reported to be high and to increase with age (5-8).The causes can be physiological aging as well as certain disease states, pharmacologic and surgical interventions, radiation and environmental exposure (4). Chemosensory impairments are supposed to affect food perception and liking and consequently to modify food choice, although data in support of this “sequence of assumptions” are currently lacking (9, 10).

Chemosensory deficit experienced by elderly people generally cannot be reversed. However, sensory interventions including intensification of food taste and odor might compensate for reduced acuity. Food flavor enhancement strategies for undernourished patients have been used over the last 25 years to increase intake of nutrient dense food (11) with contradictory results (3, 6- 8). According to some studies (11-13) addition of flavor could be an efficient strategy to cope with nutritional problems such as “anorexia of aging”. However, as pointed out by Kremer et al (8) in these earlier studies poor sensory acuity of elderly people has been assumed but not measured. Previous studies (12, 14) suggested that higher liking for stronger flavor and taste is an age- related feature, which might be attributed to a compensation effect. Some authors suggested that elderly people may prefer a higher sweetness intensity (14). There are, however, other researches (3, 15) that are in contradiction with these findings. Also, in most hedonic studies, liking is based on first impressions of an evaluated product, and does not reflect preferences that result after a longer exposure to the product.

In the light of the above considerations, the aim of the present study is to observe the effect of a sensory compensatory strategy on the intake and hedonic response to a functional drink in undernourished elderly patients living in nursing home, classified on the basis of their taste and smell sensitivity compared to a group of healthy free living adults with normal chemosensory acuity.

The research consisted of three main phases. In the first step the enrolled subjects were classified on the basis of their taste and olfaction sensitivity; in the second step the sensory compensatory strategy, aiming to counteract age- associated sensory losses and increase product pleasantness, was developed; while, the last step consisted of 14 days of exposure to each drink variant (standard and enhanced) to observe the effects of sensory modifications on liking and intake.

Materials and Methods

Subjects

Residents from “Villa delle Querce” Clinical Rehabilitation Institute of Nemi (Rome, Italy) participated in this study. The local ethics committee approved the study.

A clinical screening was performed and the followings were evaluated for each individual: clinical status, number of pathologies, number of medications taken, cognitive functions (by Short Portable Mental Status Questionnaire, SPMSQ), nutritional status (with Mini Nutritional Assessment, MNA).

Inclusion criteria were: age >65 years; being at risk of malnutrition (MNA ≤23. 5); energy deficiency (intake of 20 kcal/kg/day or lower); no severe cognitive impairment (SPMSQ

Participants were selected for their physiological and cognitive ability to carry out the evaluation. After the screening 76 subjects were included in the study and provided

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their written informed consent. The mean age of the sample was 81.4 ±8.3 years (age range 64-97 years). Seventy percent participants were women. Prevalence of chemosensory impairments was measured on 76 individuals. Eleven participants dropped out because of taste dislike to the drink, health and personal reasons.

A group of adult (n=38; 30-50 years) with normal sensory acuity, recruited from the staff of CRA-NUT served as control.

Sensory classification

Chemosensory acuity was assessed by means of three validated sensitivity tests produced by Burghart (GmbH Wedel Germany). The original methodology of test administration (16, 17) was simplified in order to make it more suitable for elderly people (18, 19).

Testing for odor identification. This method is based on pen-like odor dispensing devices. Individuals were presented with 9 pens containing common odorants at an interval of 30 seconds. They were asked to smell each pen and to choose the odor name from four alternatives. For instance, whether it was presented orange odor, subjects had to choose between orange, strawberry, blackberry, pineapple.

Threshold odor test. Odor thresholds for phenylethanol were assessed using a single-staircase, three alternative forced choice (3- AFC) procedure. Three pens were presented in a randomized order, with two containing the solvent and the third the odorant. Subjects had to identify the odor-containing pen. Twelve triplets were presented at intervals of approximately 20 s.

Gustatory test . The used technique is based on strips made from filter paper which were impregnated with different taste solutions (sweet, sour, salty and bitter). Three concentrations were used for each taste quality resulting in a maximum total score of 12. The taste strips were presented in increasing concentrations in a randomized order and placed on the tongue. Then subjects were asked to close the mouth and choose one of five possible answers on a form (sweet, sour, salty, bitter, no taste).

Subjects were then classified in four groups on the basis of the performance in the screening test: 1) Normal chemosensory acuity/function; 2) Taste impaired (gustatory test

Subjects affected by anosmia and ageusia were excluded from successive evaluations.

Sensory compensatory strategy

The product employed is a functional red fruit (grapes, raspberries and red berry) drink containing antioxidant ingredients (Vitamin C, vitamin E and green tea extract), supplied by Barilla Food Company. The sensory compensatory strategy aiming to make the drink more palatable for elderly people, was developed with the aid of our expert sensory panel (n=8). Following the results of the sensory analysis, the manufacturer provided two versions of the functional drink: the standard version (red fruit drink commercially available) and the enhanced version with a significantly (p

Intervention study

Each subject was randomly assigned to consume 1 glass (125 ml) of one drink variant (enhanced or standard) along with breakfast for 14 consecutive days and, after 1 day washout period, switched to the other variant for 14 days. The subjects of the control group were asked to consume the functional drinks along with breakfast at their own home. The effects of exposure to the two variants of the drink on intake and hedonic response were assessed during the experimental period. Participants were asked to rate the “Liking “of the drink on the 1st , 6h and 14th day of each treatment with a 7 point Likert Scale. The left anchor of the scale was explained as “I don’t like it at all” and the right anchor corresponded with “I like it very much”. The intake was measured daily, only on the elderly subjects, on the basis of leftover.

Data Analysis

All statistical analyses were performed using XLSTAT v. 2012.1.01 (Addinsoft).

The distribution of the prevalence of chemosensory impairment by gender was tested using Chi-square analysis and Fisher’s exact test.

Data on hedonic ratings were submitted to the analysis of variance (ANOVA) to test the effect of drink samples (standard, sensory enhanced), subject clusters (C= control group; N= elderly with no sensory deficit; S= elderly with smell impairment; T= elderly with taste impairment; TS= elderly with taste and smell impairment), sequence of drink sample administration and time (1, 6, 14 days of treatment). The two-way interactions were also analyzed.

One-way ANOVA and Fisher’s least significant difference were performed for mean separation.

Results

Prevalence of chemosensory impairment

Overall the prevalence of measured chemosensory impairment in this sample of institutionalized elderly people was very high (81%).

Table 1 shows in details the prevalence of taste and smell impairment for the whole sample and by gender. The distribution of chemosensory impairment did not significantly differ for gender (P=0.656). Measured taste impairment is the same among men and women, while smell impairment tended to be higher in men. The observed very high prevalence of taste impairment is probably related to the intake of large number of medications, as polypharmacy is considered a common cause of impaired chemosensory perception (20).

Table 1: Prevalence of chemosensory impairment and gender distribution

Intake

The daily intake was measured registering the amount of leftover in the glass. The scale was from 0 to 4, where 0 means no leftover; 1= 1 /4 of the glass; 2= half glass; 3= ¾ glass, and 4= full glass. A high variability of leftover was observed. No effect of sample (standard or sensory enhanced) on intake (P=0.980) was observed. No significant difference among the groups of subjects (P= 0.974) was detected. Average intake was 70% of sample both for standard and enhanced variant. Intake was stable over time.

Hedonic ratings

Liking was measured on 67 elderly (11 drop-out) grouped by their taste and olfactory sensitivity and on 38 adults with normal sensory acuity (control group).

According to the ANOVA results, the compensatory strategy did not lead to an increase of the product liking among the elderly. From the analysis of variance it emerged that overall the elderly people rated both drink variants more positively then the control group (Patarax without prescription(P=0.447). No significant interactions were found.

In table 2 the hedonic ratings of the different groups of subjects for the standard sample at day 1, 6 and 14 of treatment are reported. Liking is significantly lower in the control group and in elderly people with normal sensory acuity at the beginning (day 1) of the treatment (P= 0.052).

A lightly downward trend in liking over time was observed for the standard sample in the control group (P = 0.073) while a significant increase among the group of elderly with normal sensory acuity (P =0.042). In the groups of elderly with sensory deficit the liking doesn’t change over time.

In table 3 the hedonic ratings for the enhanced sample of the different groups of subjects are reported. Overall the hedonic response to the enhanced variant does not significantly change in any group after 14 days repeated exposure. The four subgroups of elderly rated the enhanced drink more positively then the control group (P

Table 2: Hedonic ratings with standard deviations for the standard sample of the different groups of subjects. C=control group; N= elderly with no sensory deficit; S= elderly with smell impairment; T= elderly with taste impairment; TS= elderly with taste and smell impairment

In the rows means with different letter are statistically different; 1. Lower than S, T, TS at p
% (95%CI)**

Table 3: Hedonic ratings for the enhanced sample of the different groups of subjects. C=control group; N=elderly with no sensory deficit; S= elderly with smell impairment; T=elderly with taste impairment; TS=elderly with taste and smell impairment

1. Lower than N, S, T, TS at p

Discussion

Prevalence of chemosensory impairment

The prevalence of measured chemosensory impairments in this study was quite high. Specifically, the frequency of smell impairment in this population of frail elderly people was comparable to data obtained in previous studies (2, 5), while the frequency of taste impairment was higher than expected on the basis of previous investigations, pointing out that aging seems to affect smell stronger then taste (6-8). This could be related to the health condition and large use of medications (20) in the sample considered in the present study. Moreover, overall men seem to have higher prevalence of chemosensory impairment as reported in other studies (5, 21).

Intake and hedonic responses

The intake of both drinks was consistent over time in all groups of subjects and was not influenced by the sensory modification. So the compensatory strategy was not proven to be effective in increasing the intake of the drink. The general consistency of hedonic ratings over time indicates that both drink variants were equally accepted among the elderly subjects.

Overall, as shown in other researches (3, 22) the elderly subjects rated the samples more positively than the adult group. This result can be due to the perceived health benefits of the drink or to the novelty respect to a monotonous diet at the nursing home, although should also be considered as a relevant factor the willingness of the elderly people to please the interviewer.

Consistently with the findings of previous studies (3, 6, 23, 24) no significant correlation was found between sensory capabilities and hedonic responses in elderly people. Here subjects with taste impairments rated more positively the enhanced sample, but as the relation is not significant and the size of the subgroups in this study is small, and further investigation is needed to explore the association.

Conclusion

This research does not support the assumption that age associated decline in chemosensory acuity inevitably reduces food liking and intake. In accordance with other studies (2, 3, 6-8) it can be concluded that the role of sensory compensatory strategies in increasing products appreciation and intake in frail elderly people has been overestimated. Therefore, in the light of the results of this study it can be suggested that more effective strategies to increase product pleasantness and intake for institutionalized elderly people should definitely take into consideration other age-related factor such as psychological conditions, loneliness, reduced social interaction and limited food choice.

Acknowledgements: The authors wish to thank Dr. Barbara Neri, Dr Edda Cava, the staff and the residents of “Villa delle Querce”

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Clinical Rehabilitation Institute of Nemi (Rome- Italy)

Funding: This work was supported by a grant from the Italian Ministry of Agricultural, Food and Forestry Policies (Project Qualifu-Alieta). The products were supplied by Barilla Food Company.

References

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8. Kremer S, Mojet J, Kroeze JHA. Differences in perception of sweet and savoury waffles between elderly and young subjects. Food Qual Pref 2007; 18:106-116.

9. Mattes RD. The chemical senses and nutrition in aging: Challenging old assumptions. J Am Diet Assoc 2002;102: 192–196.

10. Laureati M, Pagliarini E, Calcinoni O, Bidoglio M. Sensory acceptability of traditional food preparations by elderly people. Food Qual Pref 2006; 17:43- 52.

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12. Griep, MI, Mets T F & Massart DL. Effects of flavor amplification of Quorns and yoghurt on food preference and consumption in relation to age. BMI and odour perception. Br J Nutr 2000;83: 105–113.

13. Mathey M-FAM, Siebelink E, De Graaf C, Van Staveren WA. Flavor enhancement of food improves dietary intake and nutritional status of elderly nursing home residents. J Gerontol 2001;56: M200–M205.

14. De Jong N, De Graaf, C, Van Staveren WA. Effect of sucrose in breakfast items on pleasantness and food intake in the elderly. Physiol Behav 1996;60:1453–1462.

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UNDERNUTRITION AND RISK OF MULTIDRUG-RESISTANT INFECTIONS IN THE ELDERLY

R. Billon¹, J.-L. Fanon², P. Thomas³

1. Pôle de Gérontologie Clinique, unité de Court Séjour Gériatrique, Centre Hospitalier de La Rochelle, France; 2. Pôle de Gérontologie Clinique, Centre Hospitalier Universitaire, Fort de France Martinique, France; 3. Psycho-Gériatrie, SHU Limoges, France

Corresponding Author: Dr Rémy Billon, unité de Court Séjour Gériatrique, Centre Hospitalier de La Rochelle, 17000 La Rochelle, France, remy.billon@ch-larochelle.fr

Abstract

Objectives: To appraise the risk of having a multi resistant bacteria infection attributable to poor nutritional status

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in the elderly. Design: Using a statement from a case-control study in an acute geriatric medical service, knowing the overall risk of infection in the studied population, it is possible from the likelihood ratio, frequency of malnourished infected by MRB, divided by frequency in malnourished infected with sensitive organisms, to calculate a probability which is a post-test assessment of this risk. Two groups of patients had a documented infection, one with both an albumin less than 25g and pre albumin levels less than 0.15g and another where values were greater than or equal to 35g and 0.15g. Setting: The geriatrics short care unit in Fort de France, Martinique, France. Participants: Patients over 75 years, hospitalized in the short care unit and who had an acute infection with a positive sample (urine, blood .. ). Measurements: The frequency of malnourished patients is increased when infected with multi-resistant Bacteria, as shown with post test probability calculation. Results: In a population averaging 85 years old, the malnourished group had almost a double risk of infection , 26.92% ( 95% CI : 22.73-30.38 ) against 13.95% ( 95% CI : 7.01-25.85) in the other group. The fraction attributable to undernutrition was 48%. Conclusion: Nearly half of the resistance can be attributed to malnutrition with a fraction attributable to exposure to 48%. It’s still possible that other factors not taken into account in this presentation partly explain this difference. The case-control statement type can also be biased and finally we relied only on the rate of albumin and pre-albumin to classify patients. But it is still unlikely that the observed result is due to chance.

Key words: Multi-resistant bacteria infection, risk, undernutrition, elderly.

What this paper adds : 1) What is already known on this subject : we know that one of the consequences of undernutrition is an increased risk of infectious episodes, more frequent and severe. 2) What does this study adds : an appraisal of the link between undernutrition in the elderly and risk of infections due to multi-resistant bacteria, that was not pointed in the current medical literature.

Introduction

The prevalence of malnutrition in elderly patients admitted to hospital is high. It varies depending on the studies and the methods of evaluation of undernutrition and may range from 16 to 90% (3, 4, 6-9, 13, 14). A consequence is the affection of the immune system and therefore an increased risk of infectious episodes more frequent and severe (10-12).

The quantitative impact of malnutrition on the excess risk of multidrug-resistant bacterial (MRB) infections is less well known. A literature search made with pubmed using the terms “multi-drugs resistant infections” and “malnutrition” revealed only a few studies of which none focuses on the elderly. We tried in this work to estimate the risk and therefore how many acute infections caused by multiresistant bacteria could be attributed to malnutrition.

Methods

Measurement of a risk of infection involves specific conditions. Ideally, the determination is made by following a malnourished population in which the incidence of infections is raised.

In a medical service, such work is not possible. Patients who arrive are often already infected and we can only assess the nutritional status of these patients. We are in terms of a case-control study that allows the measurement of an odds ratio but not a risk. But the risk is that of having a well-defined disease (MRB infection) when evaluating patients shows that they are positive for a test, which, in this presentation, is screened for malnutrition. This is a post-test probability. When you know the risk of infection resistant bacteria in the population from which is extracted the study sample (pre-test probability), then we can calculate this post-test probability that is a risk. For this we calculate the pretest odds by pre-test probability divided by 1-pretest probability, which is multiplied by the likelihood ratio, frequency of malnourished infected with resistant bacteria divided by frequency in case of infection not germ resistant. One obtains a post test odds that divided by 1 + post-test odds for the post-test probability gives the sought for risk (2).

Patients over 75 years, hospitalized in the Geriatrics Short Care Unit in Fort de France (Martinique) and who had an acute infection with a positive sample (urine, blood .. ) were included. Their consent to participate in this study was obtained in writing. Those who had on entry into the service chronic infection or acute evolving over 48 h were excluded because the inflammation could over disturb the determination albumin and pre albumin. As it was still difficult to ascertain the nature of the acute infection, to identify a possible interaction, that is to say, a different result depending on the inflammatory status, we planned to repeat the calculation for this study in two groups, one with marked inflammatory balance and one with less inflammation.

Were considered multi-resistant germ infections, those with a resistance to several classes of antibiotics and reported as such by the microbiology laboratory.

The biological nutrient assessment was done systematically in all patients with albumin, pre-albumin, C-reactive protein (CRP), orosomucoid and Prognostic Inflammatory and Nutritional Index (PINI). From our experience, we know that the prevalence of malnourished patients is very high in the hospitalized elderly populations in Martinique. It appeared to be difficult to obtain a large enough group with a really normal nutritional status. For this reason, we decided to set the cutoff for a weak or non-existant malnutrition thresholds to albumin greater than and equal to 35 grams and pre albumin greater than or equal to 0.15 grams. This group had to be compared to another having both albumin less than 25 grams and a rate of pre albumin less than 0.1 grams.

This work was done in the

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acute geriatric medicine department of the University Hospital of Fort de France, Martinique prospectively from January 2007 to July 2012.

The post-test probabilities and their confidence intervals were calculated with Winpepi module, screening and diagnostic tests (Fleiss Levin-Paik method) (1).

Results

During the study period, 405 patients had a documented acute infection and a complete nutritional assessment. One hundred and thirty had both an albumin greater than 35 g and a pre albumin greater than 0.15g, of which only six had a really normal balance and forty three had both an albumin level less than 25 g and a pre albumin less than 0.1 g. Other patients were not included for this study. One hundred and seventy three patients had the predefined criteria. Mean age was 84.86 years (n = 342, SD: 7.38), 86.08 years for females (n = 87, SD: 6.99) and 83.02 years for males (n = 57, SD: 7.62).

E. coli was the most frequent bacteria (36.8%) followed by Klebsiella (20.14%), Pseudomonas (10.42%) and to a lesser extent, Staphylococcus aureus (6.94%) and Enterobacter (6.25%) (Figure 1).

Figure 1: Distribution of bacteria found in the samples

Infections were predominantly from urine (70.34%) or found on blood cultures (19.31%) (Figure 2).

Figure 2: Origin of the positive bacterial samples

In the sample studied, 23.7% had MRB infection, which was our pre-test probability and among these, 85.37% were in the group most malnourished. 71.97% were in the non-resistant infection group.

The links between multidrug resistance and age, albumin, pre albumin, CRP, orosomucoid and PINI were studied in two predefined sub-groups (Table 1). Only age differed in the two groups (p = 0.031) with lower values in case of infection MRB (83.098 versus 86.583 years). None of the other variables obtained significance only.

Table 1: Comparison of the biological variables of the nutritional assessment according to the infection is due to a multiresistant bacterium or not

For patients with both low albumin and pre albumin, the post test probability, so the risk of infection MRB, was 26.92% (95% CI: 22.73 – 30.38). Probability was 13.95% (95% CI :7.01-25 .85) for the better nourished, which means a doubled risk.

The calculation was redone, according to whether the CRP was greater than or equal to 80 or less. In the case of intense inflammatory post-test probability is 25.27% and 26.32% in the case of

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lower value, so values close to the overall risk that is 26.92%.

The fraction attributable to exposure (malnutrition) is 26.92-13.95/26.92 = 0.48 or 48%.

The population attributable fraction was 23.7 (pretest probability our) -13.95/23.7 = 0.41 or 41%.

Discussion

In this study, the risk of infection resistant bacteria is two times higher in the group most malnourished.

Nearly half of the resistance can be related to malnutrition, a little less when risk is calculated on population (41%). This latter value is due to the high percentage of malnourished in our service. In a place where nutritional status is better, the population attributable fraction would have been lower. At the extreme, in the absence of nutritional deficiency, the post- test probability would have been 13.95% and in this case the attributable fraction is zero.

We cannot say, however, that if they had not been malnourished, they would have totally avoided the risk, which is an estimate of the maximum fraction that could have been prevented. There may be confounding factors not taken into account here.

Albumin and pre albumin levels were used to classify patients, and we know they do not have perfect sensitivity and specificity for diagnosing undernutrition (5). In particular, associated pathologies and inflammatory conditions can influence their level regardless of their actual status. Chronic infectious states were excluded, but patients arriving with a high inflammatory state may have been influenced with a consequent misclassification.

Calculations made depending on the inflammatory status are close and even with an important inflammatory syndrome, the risk of infection MRB is just near identical. So even if surprising, the value is slightly lower when there is marked inflammation, when the opposite would be expected. Yet, the samples are smaller and therefore more random. It is possible that the inflammation lowered 4 days ago … it would be degraded in fat or leastways degraded in vivid fat, then would be degraded in center and farm values of inflammatory proteins and removed from the best fed group of people who should behave been in it. The risk then declined somewhat since these patients were less susceptible.

We also note that the confidence intervals of risk depending on whether one is malnourished or not overlap: respectively 22.73-30.38 versus 7.01-25.85. It is still possible that this result is due to chance, but the odds are very low and we believe that it is rather due to a lack of power. With an effective upper, confidence intervals were narrower. One can also think that if we had had a group with a strictly normal nutritional status, the difference would have been more clear.

Finally, in this case-control study, the results may have been the effect of confounding unexpected factors.

It is also surprising that the bivariate analysis of 2 predefined groups’ variables does not show significant difference, even if there is a quantitative difference both for the albumin and for prealbumin. We estimate that this difference would have been significant for a twice as important sample, especially for albumin. Besides, we used a two-tailed test, and if we consider that the expected difference always has to go to the same direction, a one-tailed test would have been able to be used and would have divided p by 2. It is thus probably about a lack of power.

Conclusion

Despite the bias that can be attributed to this study, we conclude that malnutrition not only increases the risk of infection, but also exposes to double risk of multi resistant bacillus (26.92% against 13.95%) compared to people in better nutritional status. It remains to be confirmed on a larger scale and probably multicenter compared with a normal population nutritional status.

Acknowledgements: the authors wish to thank Steve Burrough who so graciously contributed to the achievement of this work. This work complies with the current laws of France.

Conflict of Interest Statements: We declare that we have no conflicts of interest

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