1. Introduction

Nutritional risk among older patients admitted to departments of internal medicine in Danish hospitals is estimated to be 25%-58% ^{[1, 2, 3]}. Older patients have increased risks of poor nutritional outcomes, such as low functional level, increased morbidity and mortality, as well as increased use of social services and hospitalisations ^{[4, 5, 6]}. Undernourished older patients are more prone to complications and the average in-hospital costs of undernourished patients are four times greater than for those who are sufficiently nourished ^[7]. Identifying nutritional risk and initiating timely nutritional therapy may prevent poor nutritional outcomes ^[8]. A decline in appetite and food intake among older people is partly due to social factors and underlying metabolic changes that impair energy regulation ^{[9, 10, 11]}. Other well documented risk factors for undernutrition include dementia, low quality of life, requiring help to eat, nausea, pain, as well as dental and swallowing problems ^{[9, 10, 11]}.

Undernutrition is not only a problem for patients during hospitalisation but also before and after, as weight loss during the six months prior to hospitalisation is regarded as a risk factor for undernutrition during hospitalisation ^{[12, 13]}. Older patients who are undernourished at admission tend to continue to lose weight during their hospitalisation ^[12]. Furthermore, hospitalisation within the previous year is associated with significant decline in body mass and hospitalisation for eight or more days is associated with lower body mass ^[15]. Previous studies on undernutrition focused on non-acutely admitted patients. To our knowledge, this study is the first to examine associations between nutritional risk at and six months after admission in acutely admitted older medical patients. These patients are prone to having a high stress metabolism that results in decreased protein syntheses and increased protein catabolism and anorexia ^[16]. Therefore, the aim of this study was to examine the association between nutritional risk at admission versus six months after discharge in acutely admitted older patients. Furthermore, we wanted to study the characteristics of patients who died or were lost to follow-up.

2. Material and Methods

Eligible patients were admitted to the Medical Section of the Emergency Department at Hvidovre Hospital, University of Copenhagen, Denmark, from December 2010 – October 2011. Consecutively, we included patients, aged older than 65 years, who were admitted from their own home and had one or more comorbidities. Patients were also excluded if they had: an inability to cooperate in an interview, inability to walk, inability to speak Danish, an expected hospitalisation of less than 48 hours, been admitted to an intensive care unit, or a terminal illness. Chronic obstructive pulmonary disease patients who were included in a disease-specific management program were also excluded. Patients who were eligible were approached on the day of their admission and included in the study. All patients gave informed consent. An admission interview took place at ward level and was conducted by two project nurses. Six months after discharge, a follow-up interview was conducted in the patient’s own home. The Danish Data Protection Agency and The Research Ethics Committees of The Capital Region approved the study (06072010/1631).

Each patient’s nutritional risk was determined using the Nutritional Risk Screening (NRS), which is utilized in Danish hospitals ^{[17, 18, 19]}. The NRS was assessed at admission by the project nurses and consisted of four items: body mass index (BMI <20.5), self-reported weight loss within the last three months, self-reported decreased appetite, and severity of disease, including severe infection. Patients were considered to be at nutritional risk if they met the conditions for one of the four items ^{[17, 18, 19]} and were categorised as at-risk or not at-risk. At the follow-up interview six months after discharge, the patients were weighed to calculate BMI and were asked about decreased appetite and weight loss.

Health-related quality of life was measured by EuroQol (EQ-5D-3L) ^{[20, 21]}. This includes five dimensions (mobility, personal care, usual activities, pain/discomfort, and anxiety/depression). Each dimension has three levels (no problems, some problems, or extreme problems/unable to) and is answered based on the patient’s current state of health. The EuroQol index ranged from 1 = fully functional quality of life to 0 = death. Patients scoring ≤ 0.8 were considered to have low quality of life ^{[20, 21]}. Cognitive status was measured by the Mini-Mental State Examination (MMSE) ^[22]. It consists of 13 items with a maximum score of 30 points. Cognitive impairment was defined as a score below 25 ^[22]. In addition, the patients were asked if they had nausea, poor dental status, swallowing problems, if they needed assistance to eat, or experienced mouth pain. We obtained information on C-reactive protein (CRP), leucocytes, albumin, haemoglobin, and comorbidities, from the hospital´s clinical systems. These data were used in the Charlson Comorbidities Index ^[23]. Patients with CRP >10 were considered to have infection.

Patients who were lost to follow-up were divided into three groups: 1) patients who died between admission and the six-month follow-up; 2) patients who were too exhausted or ill to continue in the study, i.e., patients who were transferred to the intensive care unit or were unable to cooperate; and 3) patients who declined further participation and who did not fit into group 2.

Data on function, strength, and mobility were collected in the first 30 patients. These data have previously been published by Bodilsen et al (2013) and Pedersen et al (2013) ^{[24, 25]}.

To describe the cohort, we reported medians with interquartile ranges (IQR) or percentages, depending on the variable type. To investigate the association between nutritional risk at admission and the six-month follow-up, we estimated the associations between the NRS, BMI, decreased appetite, and weight loss measured at admission with a BMI<20.5, decreased appetite, and weight loss six months after discharge using the likelihood ratio Chi-square test or Fisher’s exact test. The Fisher’s exact test was used when the number of observation in the cells were less than five in more than 20% of the cells. Similarly, the associations between the NRS, BMI, decreased appetite, weight loss, and severity of disease at admission and the reasons for being lost to follow-up were analysed using the Chi-square or Fisher’s exact test. The cases where Fisher’s exact test was used are noted in the Result section. Statistical analyses were carried out with SAS 9.3 software, and P< 0.05 was considered significant.

3. Results

One hundred and nine patients were included. Ninety patients completed the admission interview and 44 completed the six-month follow-up interview (Figure 1). Forty-six patients were lost to follow-up for the following reasons: death (n=8), being too exhausted to continue due to illness (n=10), and declining further participation (n= 28). The median age was 82 years (SD 7.46) for the 90 included patients, 50% were men and 46% had a Charlson Comorbidity Index above 1 (Table 1). Seventy-one percent of the patients were at-risk at admission.

The associations between nutritional risk at admission and six months after discharge are shown in Table 2. For the 44 patients with a follow-up interview, there was an association between BMI at admission and BMI at follow-up (P<0.0001). Otherwise, there was no significant association between the NRS, severity of disease, BMI, decreased appetite, or weight loss at admission with a BMI<20.5, decreased appetite, and weight loss at the six-month follow-up. Of the patients who were not at-risk, five (31%) reported decreased appetite and seven (44%) reported weight loss at follow-up.

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Figure 1.

Table 1. Characteristics of Older Medical Patients Acutely Admitted to a Medical Ward

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Table 2. Association Between Nutritional Risk Screening, Severe Disease, BMI, Decreased Appetite and Weight Loss on Admission and BMI<20.5, Decreased Appetite and Weight loss at Six-Month Follow-up

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The associations between the NRS, BMI, decreased appetite, weight loss, and severity of disease at admission with death, being too exhausted to continue, and declining further participation are shown in Table 3. The eight (13%) patients who died were all at-risk at admission. Sixteen patients had low BMI at admission; of these, two (13%) died before follow-up. Forty-seven patients had decreased appetite at admission; of whom, seven (15%) died before follow-up. Forty-five patients reported weight loss at admission, and five (11%) died before follow-up. Of the patients alive at follow-up, eight (14%) who were at-risk were too exhausted and 22 (39%) declined to participate. Finally, weight loss was significantly associated with declining to further participate (P=0.03), but was not significantly associated with being too exhausted to continue (P=1.00). Furthermore, five (19%) patients who did not report decreased appetite at admission and 12 (46%) who did not report weight loss at admission did so at follow-up.

Table 3. Association Between Nutritional Risk Screening, Severe Disease, BMI, Decreased Appetite and Weight Loss on Admission and Lost to Follow-up Because of Death, Too Exhausted To Continue Due To Illness or Declined To Participate

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4. Discussion

In this study, we showed that almost half of the patients who were not at nutritional risk at admission and completed the six-month follow-up, reported weight loss at follow-up. Furthermore, almost half of the patients who did not report weight loss at admission reported weight loss at follow-up. Half of the patients were lost to follow up; of these, eight died who were at nutritional risk at admission. Our results indicate that older acutely admitted medical patients, who are not at nutritional risk at admission, are still susceptible to developing nutritional risk within six months after discharge. Previous studies have showed that older non-acutely admitted patients who lost weight within six months regain some of the weight within a year ^{[12, 15]}. Moreover, another study showed a significant association between weight loss in older patients and more than eight days of hospitalisation ^[15]. We do not know how many of our patients regained their weight within a year, but half of the patients who did not report weight loss at admission did report it at follow-up. This indicates that older acutely admitted patients should be regarded as having increased catabolism and anorexia and should have nutritional therapy during and after admission based solely on age, severity of disease, and hospitalisation. Thus, a focus on nutrition during and after hospitalisation in all older acutely admitted patients, regardless of the nutritional risk screening, may prevent further hospitalisations related to the consequences of undernutrition.

From admission to six-month follow-up, a large group of our patients were lost to follow-up due to various reasons; therefore, it was important to examine their nutritional risk characteristics. To our knowledge, this has not been done before among acutely admitted older medical patients. We found a tendency for patients at nutritional risk to be lost to follow-up because of death, being too exhausted, or declining to continue. This confirms the findings of previous studies that evaluated weight loss or other nutritional variables in non-acutely admitted patients as predictors of mortality and found that decreased food intake and weight loss were associated with increased mortality ^{[26, 27, 28, 29]}. A previous study found a significant association between insufficient protein intake (<50% of requirements) and increased six month mortality ^[26]. Of the 64 patients who had nutritional risk at admission, 38 (59%) were lost at follow-up (data not shown). This indicates the problem is greater than it is possible to show in this study. Therefore, there is a need for better awareness of nutritional risk during hospitalisation. In addition, most of these patients were either too exhausted or declined to participate, factors that are important to include in the comprehensive understanding of nutritional risk.

A strength of this study was the inclusion of patients who were lost to follow-up. Another strength was the six-month follow-up period because patients were considered to be in a stable phase of the disease they were admitted for. Limitations of this study were the small sample size and the large group lost to follow-up, as these factors could have affected the results of the associations between the NRS at admission and low BMI, decreased appetite, and weight loss at follow-up. To keep these very valuable patients in a study over a long period of time is a difficult task. Patients do experience lack of energy and, therefore, are at-risk of dropping out. We believe we would have found an even higher nutritional risk at six months if more patients had participated. Furthermore, there could be recall bias in relation to the question on weight loss within the last three months. Finally, a limitation was that the full NRS was not included in the six-month follow-up; thus, we cannot compare the NRS at admission versus follow-up and determine any related associations.

5. Conclusion

A high proportion of the patients, who were not at nutritional risk at admission, developed nutritional risk over six months. Being acutely admitted seems to be a risk factor for developing nutritional risk among older medical patients. This knowledge is the first step towards determining a more comprehensive cross-sectional nutritional risk. Future research should examine which groups of patients develop nutritional risk after hospitalisation. In addition, when examining nutritional risk in acutely admitted older medical patients, it is important to include the patients that are lost to follow-up, as they have a high risk of poor nutritional status and can contribute to a comprehensive understanding of the nutritional risk for these patients.

Acknowledgement

This work was supported by the Danish Ministry of Health (grant number 9170).

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