Abstract: PURPOSE OF REVIEW: A new nutrition-related risk assessment tool, the Geriatric Nutritional Risk Index (GNRI), has been recently proposed. The aim of this review is to summarize current evidences on the use of this tool with particular focus on the rationales of its application in elderly healthcare. RECENT FINDINGS: Structured as a dichotomous index, based on serum albumin values and the discrepancy between real and ideal weight, the GNRI seems to account for both acute and chronic reasons of nutrition-related complications. It allows us to face the frequent difficulties in obtaining a profitable participation of the old patient to nutritional assessment. Its application appears feasible in all healthcare settings in which it shows adequacy to discriminate different profiles of nutritional risk. A GNRI less than 92 might be suggested as clinical trigger for routine nutritional support. SUMMARY: In maths of nutrition 'recognize and treat' has become a clinical imperative. Actually, clinical judgement by an expert is still considered the reference standard to diagnose malnutrition but the use of simplified tools profitably assists in nutritional risk screening process. The GNRI is easy to use and preliminary results show that it is promising. Its routine application, next to the other validated tools already available, might be enforced in the assessment of the old patient.
Abstract: OBJECTIVES: To investigate whether a disease-specific nutritional approach is more beneficial than a standard dietary approach to the healing of pressure ulcers (PUs) in institutionalized elderly patients. DESIGN: Twelve-week follow-up randomized controlled trial (RCT). SETTING: Four long-term care facilities in the province of Como, Italy. PARTICIPANTS: Twenty-eight elderly subjects with Stage II, III, and IV PUs of recent onset (<1-month history). INTERVENTION: All 28 patients received 30 kcal/kg per day nutritional support; of these, 15 received standard nutrition (hospital diet or standard enteral formula; 16% calories from protein), whereas 13 were administered a disease-specific nutrition treatment consisting of the standard diet plus a 400-mL oral supplement or specific enteral formula enriched with protein (20% of the total calories), arginine, zinc, and vitamin C (P<.001 for all nutrients vs control). MEASUREMENTS: Ulcer healing was evaluated using the Pressure Ulcer Scale for Healing (PUSH; 0=complete healing, 17=greatest severity) tool and area measurement (mm(2) and %). RESULTS: The sampled groups were well matched for age, sex, nutritional status, oral intake, type of feeding, and ulcer severity. After 12 weeks, both groups showed significant improvement (P<.001). The treatment produced a higher rate of healing, the PUSH score revealing a significant difference at Week 12 (-6.1+/-2.7 vs -3.3+/-2.4; P<.05) and the reduction in ulcer surface area significantly higher in the treated patients already by Week 8 (-1,140.9+/-669.2 mm(2) vs -571.7+/-391.3 mm(2); P<.05 and approximately 57% vs approximately 33%; P<.02). CONCLUSION: The rate of PU healing appears to accelerate when a nutrition formula enriched with protein, arginine, zinc, and vitamin C is administered, making such a formula preferable to a standardized one, but the present data require further confirmation by high-quality RCTs conducted on a larger scale.
Abstract: The Mini Nutritional Assessment (MNA) is recommended for grading nutritional status in the elderly. A new index for predicting the risk of nutrition-related complications, the Geriatric Nutritional Risk Index (GNRI), was recently proposed but little is known about its possible use in the assessment of nutritional status. Thus, we aimed to investigate its ability to assess the nutritional status and predict the outcome when compared with the MNA. Anthropometry and biochemical parameters were determined in 241 institutionalised elderly (ninety-four males and 147 females; aged 80.1 (sd 8.3) years). Nutritional risk and nutritional state were graded by the GNRI and MNA, respectively. At 6 months outcomes were: death; infections; bedsores. According to the GNRI and MNA, the prevalence of high risk (GNRI < 92)/malnutrition (MNA < 17), moderate risk (GNRI 92-98)/malnutrition at-risk (MNA 17-23.5) and no risk (GNRI > 98)/good status (MNA > 24) were 20.7/12.8 %, 36.1/39 % and 43.2/48.2 %, respectively, with poor agreement in scoring the patient (Cohen's kappa test: kappa = 0.29; 95 % CI 0.19, 0.39). GNRI categories showed a stronger association (OR) with overall outcomes than MNA classes, although no difference (P>0.05) was found between malnutrition (v. 'good status', OR 6.4; 95 % CI 2.1, 71.9) and high nutritional risk (v. 'no risk', OR 9.7; 95 % CI 3.0, 130). Multivariate logistic regression revealed the GNRI as an independent predictor of complications. In overall-outcome prediction, a good sensitivity was found only for GNRI < 98 (0.86 (95 % CI 0.67, 0.96)). The combination of a GNRI > 98 with an MNA > 24 seemed to exclude adverse outcomes. The GNRI showed poor agreement with the MNA in nutritional assessment, but appeared to better predict outcome. In home-care resident elderly, outcome prediction should be performed by combining the suggestions from both these tools.
Abstract: BACKGROUND & AIMS: To possibly investigate the validity of the Geriatric Nutritional Risk Index (GNRI) in predicting muscle dysfunction among the uncomplicated elderly when coupled and compared with short dietary assessment. METHODS: A total of 130 (61 males and 69 females) stable-weight, over 70-years-old elderly patients were studied according to anthropometry, handgrip strength (HG) and simple dietary assessment, expressed as oral (percentage of food consumed to that delivered) and protein (g/kg/day) intakes. RESULTS: For the overall population, HG and strength for centimetres of arm muscle area (HG/AMA) significantly correlated with age, GNRI and nutrients intake (p<0.001). In gender-separated analyses, these associations were less evident for males than females, which were older (p<0.0001) and presented lower strength and intakes (p<0.0001). Patients in the lowest tertile of oral intake (<68%) were more likely (p<0.0001) to have low HG and HG/AMA than those at severe/moderate nutritional risk (GNRI<92; p<0.01). In multivariate models, being an aged female significantly predicted muscle dysfunction. For the overall population, HG was significantly associated with GNRI (p<0.05) and oral intake (p<0.0001), while HG/AMA was independently associated with GNRI (p<0.001) and protein intake (p<0.0001). CONCLUSIONS: The validity of GNRI in predicting muscle dysfunction is confirmed also in the uncomplicated elderly. Though, oral intake appears an even better predictor. A frequent evaluation of its changes should be considered, particularly when concomitant high risk (GNRI<92) is scored.
Abstract: BACKGROUND & AIMS: To possibly validate the use of Mini Nutritional Assessment (MNA) with respect to functional status in institutionalised elderly. METHODS: One hundred twenty-three long-term care resident elderly (85.3+/-8.4 years) were recruited. Nutritional and functional states were assessed by MNA and Barthel Index (BI), respectively. Main inclusion criterion was a MNA<23.5. Anthropometric, biochemical data and oral intake (percentage of food consumed to that delivered) were evaluated. RESULTS: MNA significantly correlated with BI (r=0.55; p<0.0001). Malnutrition (MNA<17) was characterized by lower BMI, muscle mass, poor nutritional habits and higher weight loss and disability. Similarly, poorer functional status was associated with low BMI, sarcopenia and reduced oral intake. The interrelationship between MNA and BI were investigated by multiple regression models with progressive inclusion of variables (one/analysis). The initial association between MNA and BI (p<0.0001) was masked by weight loss (p<0.02), muscle mass (p<0.03) and oral intake (p<0.05). However, when BI was included as dependent variable the association with MNA depended on sarcopenia (p<0.05) and reduced food consumption (p<0.001). CONCLUSIONS: MNA reliably identifies at-risk institutionalised elderly needing higher standards of care, particularly related to eating. Routine documentation of oral intakes and feeding assistance might be useful to prevent weight loss, sarcopenia and functional status deterioration.
Abstract: BACKGROUND & AIMS: A new tool, the Geriatric Nutritional Risk Index (GNRI), was recently proposed to predict short-term complications in elderly medical patients but no information is available when long-term follow-up periods are considered. METHODS: A 3-year follow-up study in 245 institutionalised elderly (51 M:194 F; 83.7+/-8.6 years). Nutritional risk was graded by GNRI (severe, <82; moderate, 82 to <92; mild, 92-98; no risk, >98). Main outcome was overall-cause death. RESULTS: After the follow-up 99 (26 M:73 F) events occurred. Nutritional risk prevalence was 5.7%, 24.1%, 34.7% and 35.5% and mortality rates were 71.4%, 48.6% 33.7% and 34.3% with the GNRI<82, 82 to <92, 92-98, and >98, respectively. Kaplan-Meier curves were significantly associated to GNRI (p=0.0068). GNRI<82 was consistently related to death (odds ratio, OR=5.29, [95%CI: 1.43-19.57], p=0.0127) when compared to GNRI>98. Similar results were confirmed by Cox regression (hazard ratio, HR=2.76 [95%CI: 1.89-4.03], p=0.0072). Finally, when "severe" and "moderate" risk were analysed as a single class (GNRI<92) outcome associations were: OR=2.17, [95%CI: 1.10-4.28] (p=0.0245); HR=1.76 [95%CI: 1.34-2.23] (p=0.0315). Survival analysis showed higher mortality rates by GNRI<92 (p=0.0188). CONCLUSIONS: Present data support the use of the GNRI in the evaluation of long-term nutrition-related risk of death. We suggest a GNRI<92 as clinical trigger for nutritional support in institutionalised elderly.
Abstract: OBJECTIVE: To investigate how total lymphocyte count (TLC) and the Geriatric Nutritional Risk Index (GNRI) are associated with short-term nutritional-related complications (death, infections, bedsores) in institutionalised elderly. METHODS: 220 home-care resident elderly (age +/- SD; 80.7 +/- 7.9, range: 67-98 years) were studied (anthropometry, biochemistry, food intake) and prospectively followed over a period of 3 months for the occurrence of health complications. Nutritional risk was assessed by GNRI. Patients were categorized according to GNRI (<92, 92-98, >98) and TLC (<900, 900-1499, >or=1500/mm3). RESULTS: GNRI was significantly associated with TLC according to both simple and adjusted correlation models (p < 0.001) and to multiple stepwise regression analysis (p < 0.005). TLC < 900 revealed a higher specificity (87.8%) than sensitivity (30.6%) in identifying "at-risk" patients (GNRI < 92). Adjusted multiple logistic regression revealed a significant association between overall 3-month health outcomes and both TLC and food intake. TLC was the only significant predictor for infections, while death was independently associated with GNRI and food intake. When a GNRI < 92 and a TLC < 900 were considered together, the sensitivity was 0.83 (95% confidence interval, C.I.95%: 0.66-1.0) and 0.89 (C.I.95%: 0.68-1.00) for overall complications (Odds ratio: 22.1; C.I.95%: 5.1-96.1) and infections (Odds ratio: 20.8; C.I.95%: 2.6-168.8), respectively. The association of a GNRI > 98 with a TLC >or= 1500 was able to exclude health complications. CONCLUSIONS: In the institutionalised elderly patients, GNRI confirmed its predictive value even for short-term health complications, particularly when death was considered. However, the use of TLC might improve the evaluation of nutritional risk and the identification of patients at risk of infections. Nutrition study should be considered to confirm possible risk reduction.
Abstract: BACKGROUND & AIMS: The validity of Geriatric Nutritional Risk Index (GNRI), in predicting nutrition-related risk of complications in the elderly, has been recently underscored. Malnutrition may results also in muscle function impairment. Thus, the present study aims to investigate if GNRI might be a reliable detector of muscle dysfunction in institutionalized older people. METHODS: In total, 153 institutionalized elderly (71 males, 82 females; mean age+/-SD: 75.2+/-8.4; range: 65-96) were studied in anthropometric parameters, serum albumin concentration and total score on GNRI. Muscle function was assessed by handgrip strength (HG). RESULTS: Women were significantly older than men and presented lower values of HG and arm muscle area (AMA). In overall population, GNRI was significantly correlated with AMA, HG and strength for centimeter of muscle area (HG/AMA); however, in gender-separated analysis, men presented higher degrees of correlation. After dividing patients in four categories according to GNRI, a more significant difference was detected in HG and HG/AMA rather than the other clinical and anthropometric parameters. Moreover, ANOVA analysis between HG quartiles was highly significant for GNRI, AMA and HG/AMA. CONCLUSIONS: GNRI is a good predictor of muscle dysfunction, particularly in men, and useful in identifying patients suitable for nutritional support and physical activity.
Abstract: BACKGROUND: The Geriatric Nutritional Risk Index (GNRI) is a new index recently introduced for predicting risk of nutritional-related complications in elderly patients. It combines albumin with information about body weight: GNRI = (1.489 x albumin, g/l) + (41.7 x present/ideal body weight), with ideal weight calculated according to the Lorentz formula. Because standing height (SH) is frequently difficult to obtain in older people, in Lorentz equations this parameter has been replaced by estimated height (EH) from knee height. Though, if EH is well accepted as a valid surrogate for SH, the same might not be expected for its use in ideal body weight calculation, with possible consequences in grading nutritional risk correctly. OBJECTIVE: The aim of this study was to investigate whether the use of SH rather than EH for the calculation of ideal body weight predicts similar outcomes by GNRI. METHODS: Body weight, SH and EH were obtained in 231 long-term care resident elderly (88 males and 143 females, mean age +/- SD 80.0 +/- 8.4, range 65-97 years). Blood samples were assessed for albumin concentration. Ideal body weight was derived from the Lorentz formula using both SH and EH. According to both ideal weight estimates, nutritional risk was defined by the GNRI score. RESULTS: The Pearson correlation coefficients were high for both EH (with SH; r = 0.90) and estimates of ideal body weight (r = 0.90) and all were highly significant (p < 0.0001). A statistically significant difference was found between SH and EH (p = 0.0265). Similar and expectable differences in significance have also been observed between ideal body weights (p = 0.0271). However, an accordance of 95.2% has been detected (Kendall's tau test: tau = 0.85, p < 0.0001) in grading nutritional risk by GNRI. CONCLUSION: The use of EH for ideal body weight calculation and nutritional risk assessment by GNRI is feasible. Thus, GNRI seems to have been designed in the best way and its use is really attractive, particularly when considering the low-grade participation demanded of the patient in the assessment. This simple and valid assessment tool should be taken into greater consideration.
Abstract: BACKGROUND: Nutrition problems are common in cancer patients and are frequently due to metabolic derangements. Thus, accurately assessing energy expenditure (EE) is important in planning adequate nutrition support. Indirect calorimetry (IC) represents the gold standard method but is not always available or applicable to all settings. The purpose of this study was to preliminary compare a new wearable device, the SenseWear armband (SWA), to IC in cancer patients. METHODS: Ten (6 M, 4 F) subjects (mean +/- SD: 56.6 +/- 13.3 years) affected by newly diagnosed acute myelogenous leukemia, undergoing induction chemotherapy, were prospectively enrolled. Resting EE (REE) was measured simultaneously by SWA and IC on admission (day 0) and at discharge (end). Total daily EE (TDEE) was determined by SWA 4 times during the stay (days 0, 7, 14, and end) and predicted values were calculated according to IC REE estimates (TDEE = IC x correction factor 1.2). RESULTS: Mean length of stay was 27.1 +/- 6.2 days. Bland-Altman plots revealed no significant differences between overall REE estimates (day 0 + end) performed by IC and SWA (mean +/- SD; 1645 +/- 282 vs 1705 +/- 278 kcal/d) and the correlation was high (r = 0.84; p < .0001). SWA TDEE showed a progressive reduction during the stay. No bias was detected between overall SWA TDEE (1799 +/- 153 kcal/d) and IC predicted TDEE (1974 +/- 176 kcal/d), but there was a wide 95% confidence interval (-672; +321 kcal/d). Moreover, the correlation between these values was significant (r = 0.68; p = .001). CONCLUSIONS: SWA seems to provide accurate and reliable estimation of REE and useful information on TDEE also in cancer patients. Its use appears promising. Validation studies on larger samples and different cancer types should be considered.
