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Nutritional status in hospitalized elderly patients with mild cognitive impairment
Clinical Nutrition 28 (2009) 100–102
Contents lists available at ScienceDirect
Clinical Nutrition journal homepage: http://intl.elsevierhealth.com/journals/clnu
Short Report
Nutritional status in hospitalized elderly patients with mild cognitive impairment Giuseppe Orsitto*, Franco Fulvio, Domenico Tria, Vincenzo Turi, Amedeo Venezia, Cosimo Manca Geriatric Unit, Ospedale ‘‘Paradiso’’, Azienda Sanitaria Locale Bari, Gioia del Colle (BA), Italy
a r t i c l e i n f o
s u m m a r y
Article history: Received 22 May 2008 Accepted 2 December 2008
Background & aims: Malnutrition is prevalent in hospitalized elderly people leading to complications including cognitive deficit. However, the relationship between the nutritional status and the preclinical phase of dementia in the elderly is still unclear. The aim of this study was to evaluate the prevalence of malnutrition in older patients with mild cognitive impairment. Methods: A total of 623 hospitalized elderly patients underwent the comprehensive geriatric assessment to evaluate medical, cognitive, affective and social aspects. Nutritional status was assessed by using the mini-nutritional assessment. The cognitive function was categorized into three levels – normal cognition, mild cognitive impairment and dementia – according to the neuropsychological evaluation. Results: According to the mini-nutritional assessment classification, 18% of the sample study was assessed as well nourished, 58% at risk of malnutrition and 24% as malnourished. Patients with mild cognitive impairment and dementia had significantly lower frequency of well nourished and higher frequency of at risk of malnutrition or malnourished than patients with normal cognition. Conclusions: Malnutrition is prevalent in hospitalized elderly patients with cognitive deficit, even in those with mild cognitive impairment. It remains to be demonstrated whether improvement in nutritional status may delay progression to dementia in these patients. Ó 2008 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.
Keywords: Malnutrition Elderly Mild cognitive impairment Dementia
It is well established that malnutrition is prevalent in the frail elderly even in the industrialized countries,1 particularly in those who are hospitalized. This leads to complications during hospitalization, influencing the length of stay and increasing morbidity and mortality rates.2 Moreover poor nutritional status in the elderly is associated with several factors including cognitive deficit,3 which represents one of the most disabling health conditions in older people. Previous data have provided evidence of role of cognitive impairment as a risk factor for functional decline in the elderly,4 with a profound impact of this condition on healthcare systems. Although recent studies confirmed a higher prevalence of malnutrition in older patients with dementia,5 remains still unclear the relationship between the nutritional status and the preclinical phase of dementia, particularly mild cognitive impairment (MCI), in hospitalized elderly patients. MCI is a transitional and heterogeneous clinical syndrome that lies between normal aging and early dementia which refers to non-demented, aged persons with memory or cognitive impairment and no significant disability.6 In * Correspondence to: Unita` Operativa Geriatria, Ospedale ‘‘Paradiso’’ – ASL BA, Via Giovanni XXIII, Gioia del Colle (BA), I-70023, EU, Italy. Tel.: þ39 0803489267. E-mail address: [email protected] (G. Orsitto).
the developed world, the prevalence of MCI is more than double that of dementia and its rate of conversion to dementia is greater than that of the general older population. The aim of this study was to compare the prevalence of malnutrition in hospitalized older patients with MCI and dementia with that of control subjects without cognitive impairment (NoCI). The study population included all patients aged 65 and older consecutively admitted to the geriatric ward of the ‘‘Paradiso’’ Hospital, Azienda Sanitaria Locale Bari (ASL BA), Gioia del Colle (Ba) – Italy, from January to December 2007. At admission, a comprehensive geriatric assessment including basic and instrumental activities of daily living (ADLs, IADLs), cumulative illness rating scale comorbidity index (CIRS severity and CIRS comorbidity), mini mental state examination (MMSE), clinical dementia rating scale (CDR) and geriatric depression scale 15-item (GDS-15), was performed by the staff physician at the ward. The mini-nutritional assessment (MNA), a comprehensive tool developed for nutritional assessment in geriatric setting, was used to classify subjects as well nourished (score of 24–30), at risk for malnutrition (score of 17–23.5), or malnourished (score of <17). The cognitive function was categorized into three levels – dementia, MCI or NoCI – according to the neuropsychological evaluation, as detailed
0261-5614/$ – see front matter Ó 2008 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved. doi:10.1016/j.clnu.2008.12.001
G. Orsitto et al. / Clinical Nutrition 28 (2009) 100–102
elsewhere.7 Diagnosis of MCI was made using the Petersen criteria: presence of subjective memory loss, preferably corroborated by an informant; demonstration of a memory impairment by cognitive testing; preserved general intellectual functioning as estimated by performance on a vocabulary test; intact ability to perform activities of daily living and absence of dementia. Diagnoses of probable Alzheimer’s disease (AD), vascular dementia (VaD) and mixed dementia (MD) were made according to the criteria of the National Institute of Neurological and Communicative Disorders and Stroke/ Alzheimer’s Disease and Related Disorders Association Work Group, the National Institute of Neurological Disorders and Stroke – Association Internationale pour la Recherche et l’Einseignement en Neurosciences Work Group and the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Statistical analysis was performed using the SPSS V. 11.5 for Windows statistical software package. Pearson’s c2 test and Fisher’s exact test were used to compare frequencies of risk of malnutrition. The Kruskal–Wallis test was applied to compare demographic, cognitive, functional and nutritional characteristics as well as comorbidity of the study samples. Logistic regression analysis was also used to confirm the association between malnutrition and cognitive levels. The ANOVA post hoc analysis was used for correction in multiple comparisons. All p values were 2-tailed, with statistical significance indicated by a value of p < 0.05. During the study period, 657 subjects aged 65 and older were admitted to the hospital’s geriatric ward and were screened. In 34 subjects data were not recorded and 35 patients were excluded from the study because of a diagnosis of primary or secondary malignant brain neoplasms (n ¼ 4), hydrocephalus (n ¼ 1), shortterm prognosis tumors (n ¼ 12), alcohol abuse (n ¼ 5), head trauma (n ¼ 3), blood infections (n ¼ 2), serious anemia (n ¼ 5) and disorders of the thyroid (¼2). Thus, the final analysis included data from 588 older subjects (252 men, 336 woman, mean age 76.3 7.0, range 65–100 years): 84 patients with dementia (AD ¼ 25 patients, VaD ¼ 37, MD ¼ 22), 65 patients with MCI and 439 with NoCI. Table 1 shows the mean results of variables, expressed according to the cognitive levels. Patients with dementia had significantly lower MMSE scores (p < 0.0001), educational level (p < 0.0001) and MNA scores (p 0.004) and higher CDR scores (p < 0.0001), mean age (p 0.004) and level of disability (p < 0.0001) than patients with MCI or NoCI. No significant differences were found in CIRS
Table 1 Demographic, cognitive, functional, comorbidity and nutritional characteristics of patients according to the cognitive levels.
Age, years Male/Female Instruction MMSE CDR ADL IADL CIRS severity CIRS comorbidity GDS MNA
Dementia (n ¼ 84)
MCI (n ¼ 65)
NoCI (n ¼ 439)
79.4 6.1a,c 21/63 3.4 3.6b,c 16.6 5.4b,c 1.2 1.0b,c 3.9 2.0b,c 2.8 2.7b,c 1.5 0.2 2.3 1.6 5.9 4.0 18.6 3.9a,c
76.3 6.9 27/38 5.7 4.2 25.3 1.3d 0.5d 5.4 1.2 6.1 2.2 1.4 0.3 2.0 1.4 4.8 3.2 20.6 4.0
75.8 7.0 202/237 5.3 2.9 28.2 1.3 0 5.3 1.1 6.6 1.9 1.3 0.4 2.5 1.5 5.4 3.7 21.3 3.4
MMSE ¼ mini mental state examination, CDR ¼ clinical dementia rating scale, ADL ¼ activities of daily living, IADL ¼ instrumental activities of daily living, CIRS severity/comorbidity ¼ cumulative illness rating scale comorbidity index severity/ comorbidity, GDS ¼ geriatric depression scale, and MNA ¼ mini-nutritional assessment. Values are mean SD. The ANOVA post hoc for multiple comparison analysis confirmed the statistical significance of the p values. a Dementia vs MCI, p < 0.05. b Dementia vs MCI, p < 0.001. c Dementia vs NoCI, p < 0.001. d MCI vs NoCI, p < 0.001.
101
severity, CIRS comorbidity and GDS scores between the three groups. Moreover, MCI patients had significantly lower MMSE and higher CDR scores (p < 0.0001) than NoCI, but no significant differences were found in the level of education, mean age, level of disability and MNA scores between the two groups. Also no significant differences were found among patients with various dementia diagnoses (i.e. AD, VaD or MD) with regard to the abovementioned variables. Table 2 illustrates the distribution of the nutritional status according to the cognitive levels of the sample study. As expected, the frequency of malnourished in the patients with dementia was significantly higher than that in the 439 NoCI (p < 0.0001; OR ¼ 3.2, CI ¼ 1.6–6.2). However, the frequency of malnourished in MCI was also significantly higher than that in NoCI patients (p < 0.0001; OR ¼ 4.7, CI ¼ 2.5–9.0), and was not significantly different compared to that in patients with dementia (p ¼ 0.087; OR ¼ 1.1, CI ¼ 0.5–2.4). Similarly, the frequency of well nourished was significantly lower in the patients with dementia (p < 0.0001; OR ¼ 0.5, CI ¼ 0.3–0.8) and MCI (p ¼ 0.035; OR ¼ 1.7, CI ¼ 1.0–2.9) than that in the NoCI, but no significant differences were found between patients with MCI and dementia (p ¼ 0.853; OR ¼ 1.0, CI ¼ 0.7–1.6). Moreover the frequency of the group at risk of malnutrition was significantly lower in the patients with dementia (p < 0.0001; OR ¼ 0.4, CI ¼ 0.2– 0.8) and MCI (p ¼ 0.013; OR ¼ 3.2, CI ¼ 1.6–6.2) than that in the NoCI, but no significant differences were found between patients with MCI and dementia (p ¼ 0.09; OR ¼ 0.8, CI ¼ 0.4–1.4). At last no significant differences were found in frequencies of well nourished, at risk of malnutrition or malnourished among patients with various above-mentioned dementia diagnoses. Given the current increase of the elderly people in the industrialized countries and the occurrence of cognitive impairment in old age, it’s important to understand the factors that may contribute to developing cognitive decline. The present study evaluated the relationship between nutritional status assessed by the MNA and different grades of cognitive impairment, particularly MCI, in a sample of hospitalized older patients from the Apulia region of southern Italy. As expected, we described an extremely high prevalence of poor nutritional status in our sample study: only 18% of these patients were well nourished, while 82% of them were at risk of malnutrition and/or malnourished. This finding confirmed previous data2 in which nutritional status was found to be normal in less than one-third of newly admitted geriatric patients. In agreement with other studies2,3,5 that showed a high percentage of malnutrition in patients with deep cognitive impairment, our data confirmed a significantly greater malnutrition rate in patients with dementia. Although it has been recently reported a possible impact of malnutrition on cognitive decline and poor nutritional habits seem to be linked to disease progression in very mild AD,8 at present there is still a lack of knowledge about the
Table 2 Cognitive levels and mini-nutritional assessment.
Well-nourished (score 24) At risk of malnutrition (score 23.5 17) Malnourished (score <17)
Dementia (n ¼ 84), n (%)
MCI (n ¼ 65), n (%)
NoCI (n ¼ 439), n (%)
Total (n ¼ 588), n (%)
7 (8.5)a
6 (9)b
92 (21)
105 (18)
284 (64)
342 (58)
63 (15)
141 (24)
27 (32)
50 (59.5)
c2-test. a b c
a
Dementia vs NoCI, p < 0.001. MCI vs NoCI, p < 0.05. MCI vs NoCI, p < 0.001.
31 (47) a
28 (44)
c
102
G. Orsitto et al. / Clinical Nutrition 28 (2009) 100–102
role of malnutrition in developing dementia. This might be due to several factors, including the different nutrition habits of the study populations, varying stringency in the diagnostic criteria used, particularly in MCI, and limited sample size. Therefore the evidence in this population that nutritional status is even poor in patients with MCI is of potential clinical value and might suggest that malnutrition plays a role in the progression of cognitive decline. The major limitation of the present study lies in the small sample size, particularly of the MCI group, and so further studies on larger subsets of patients to confirm the association between rate of malnutrition and cognitive impairment are ultimately required together with intervention studies in order to address that topic adequately. In line with the findings of FaxenIrving et al.,9 our data also indicated that the nutritional status did not vary in patients with various dementia diagnoses, i.e. AD, VaD or MD. As recently shown,10 this study gave indication of a possible association between dementia and older mean age, greater disability and lower educational level. Comparing patients with dementia according to diagnosis, no significant differences were found in mean age, educational level, depression scores or level of disability. In conclusion, the results of the present study showed a high prevalence of malnutrition in hospitalized elderly patients with cognitive deficit. The major finding in this population of older people from southern Italy was the evidence of a poor nutritional status even in patients with MCI who had not progressed to dementia, compared to those with no cognitive decline. This novel finding suggested that there may be benefit in improving nutritional status in the MCI group. Further intervention studies will undoubtedly be informative in this regard. Conflict of interest All authors disclose any financial and personal relationships with other people, or organizations, that could inappropriately
influence (bias) their work, all within 3 years of the beginning the work submitted. Acknowledgements This work was supported by the ‘‘Paradiso’’ Hospital – Gioia del Colle – ASL BA. The authors are grateful to the patients who participated in the study. References 1. Izawa S, Kuzuya M, Okada K, Enoki H, Koike T, Kanda S, et al. The nutritional status of frail elderly with care needs according to the mini-nutritional assessment. Clin Nutr 2006;25(6):962–7. 2. Kagansky N, Berner Y, Koren-Morag N, Perelman L, Knobler H, Levy S. Poor nutritional habits are predictors of poor outcome in very old hospitalized patients. Am J Clin Nutr 2005;82:784–91. 3. Magri F, Borza A, Del Vecchio S, Chytiris S, Cuzzoni G, Busconi L, et al. Nutritional assessment of demented patients: a descriptive study. Aging Clin Exp Res 2003;15:148–53. 4. Orsitto G, Cascavilla L, Franceschi M, Aloia RM, Greco A, Paris F, et al. Influence of cognitive impairment and comorbidity on disability in hospitalized elderly patients. J Nutr Health Aging 2005;9:194–8. 5. Zekry D, Hermann FR, Grandjean R, Meynet MP, Michel JP, Gold G, et al. Demented versus non-demented very old inpatients: the same comorbidities but poorer functional and nutritional status. Age Ageing 2008;37(1):83–9. 6. Petersen RC, Smith GE, Waring SC, Ivnik RJ, Tangalos EG, Kokmen E. Mild cognitive impairment. Clinical characterization and outcome. Arch Neurol 1999;56:303–8. 7. Scafato E, Gandin C, Farchi G, Abete P, Baldereschi M, Di Carlo A, et al. The I.P.R.E.A. Working Group Italian Project on Epidemiology of Alzheimer’s disease (I.P.R.E.A.): study design and methodology of cross-sectional survey. Aging Clin Exp Res 2005;17:29–34. 8. Ousset PJ, Nourhashemi F, Reynish E, Vellas B. Nutritional status is associated with disease progression in very mild Alzheimer disease. Alzheimer Dis Assoc Disord 2008;22(1):66–71. 9. Faxen-Irving G, Basun H, Cederholm T. Nutritional and cognitive relationships and long-term mortality in patients with various dementia disorders. Age Ageing 2005;34(2):136–41. 10. Orsitto G, Seripa D, Panza F, Franceschi M, Cascavilla L, Placentino G, et al. Apolipoprotein E genotypes in hospitalized elderly patients with vascular dementia. Dement Geriatr Cogn Disord 2007;23(5):327–33.
Contents lists available at ScienceDirect
Clinical Nutrition journal homepage: http://intl.elsevierhealth.com/journals/clnu
Short Report
Nutritional status in hospitalized elderly patients with mild cognitive impairment Giuseppe Orsitto*, Franco Fulvio, Domenico Tria, Vincenzo Turi, Amedeo Venezia, Cosimo Manca Geriatric Unit, Ospedale ‘‘Paradiso’’, Azienda Sanitaria Locale Bari, Gioia del Colle (BA), Italy
a r t i c l e i n f o
s u m m a r y
Article history: Received 22 May 2008 Accepted 2 December 2008
Background & aims: Malnutrition is prevalent in hospitalized elderly people leading to complications including cognitive deficit. However, the relationship between the nutritional status and the preclinical phase of dementia in the elderly is still unclear. The aim of this study was to evaluate the prevalence of malnutrition in older patients with mild cognitive impairment. Methods: A total of 623 hospitalized elderly patients underwent the comprehensive geriatric assessment to evaluate medical, cognitive, affective and social aspects. Nutritional status was assessed by using the mini-nutritional assessment. The cognitive function was categorized into three levels – normal cognition, mild cognitive impairment and dementia – according to the neuropsychological evaluation. Results: According to the mini-nutritional assessment classification, 18% of the sample study was assessed as well nourished, 58% at risk of malnutrition and 24% as malnourished. Patients with mild cognitive impairment and dementia had significantly lower frequency of well nourished and higher frequency of at risk of malnutrition or malnourished than patients with normal cognition. Conclusions: Malnutrition is prevalent in hospitalized elderly patients with cognitive deficit, even in those with mild cognitive impairment. It remains to be demonstrated whether improvement in nutritional status may delay progression to dementia in these patients. Ó 2008 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.
Keywords: Malnutrition Elderly Mild cognitive impairment Dementia
It is well established that malnutrition is prevalent in the frail elderly even in the industrialized countries,1 particularly in those who are hospitalized. This leads to complications during hospitalization, influencing the length of stay and increasing morbidity and mortality rates.2 Moreover poor nutritional status in the elderly is associated with several factors including cognitive deficit,3 which represents one of the most disabling health conditions in older people. Previous data have provided evidence of role of cognitive impairment as a risk factor for functional decline in the elderly,4 with a profound impact of this condition on healthcare systems. Although recent studies confirmed a higher prevalence of malnutrition in older patients with dementia,5 remains still unclear the relationship between the nutritional status and the preclinical phase of dementia, particularly mild cognitive impairment (MCI), in hospitalized elderly patients. MCI is a transitional and heterogeneous clinical syndrome that lies between normal aging and early dementia which refers to non-demented, aged persons with memory or cognitive impairment and no significant disability.6 In * Correspondence to: Unita` Operativa Geriatria, Ospedale ‘‘Paradiso’’ – ASL BA, Via Giovanni XXIII, Gioia del Colle (BA), I-70023, EU, Italy. Tel.: þ39 0803489267. E-mail address: [email protected] (G. Orsitto).
the developed world, the prevalence of MCI is more than double that of dementia and its rate of conversion to dementia is greater than that of the general older population. The aim of this study was to compare the prevalence of malnutrition in hospitalized older patients with MCI and dementia with that of control subjects without cognitive impairment (NoCI). The study population included all patients aged 65 and older consecutively admitted to the geriatric ward of the ‘‘Paradiso’’ Hospital, Azienda Sanitaria Locale Bari (ASL BA), Gioia del Colle (Ba) – Italy, from January to December 2007. At admission, a comprehensive geriatric assessment including basic and instrumental activities of daily living (ADLs, IADLs), cumulative illness rating scale comorbidity index (CIRS severity and CIRS comorbidity), mini mental state examination (MMSE), clinical dementia rating scale (CDR) and geriatric depression scale 15-item (GDS-15), was performed by the staff physician at the ward. The mini-nutritional assessment (MNA), a comprehensive tool developed for nutritional assessment in geriatric setting, was used to classify subjects as well nourished (score of 24–30), at risk for malnutrition (score of 17–23.5), or malnourished (score of <17). The cognitive function was categorized into three levels – dementia, MCI or NoCI – according to the neuropsychological evaluation, as detailed
0261-5614/$ – see front matter Ó 2008 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved. doi:10.1016/j.clnu.2008.12.001
G. Orsitto et al. / Clinical Nutrition 28 (2009) 100–102
elsewhere.7 Diagnosis of MCI was made using the Petersen criteria: presence of subjective memory loss, preferably corroborated by an informant; demonstration of a memory impairment by cognitive testing; preserved general intellectual functioning as estimated by performance on a vocabulary test; intact ability to perform activities of daily living and absence of dementia. Diagnoses of probable Alzheimer’s disease (AD), vascular dementia (VaD) and mixed dementia (MD) were made according to the criteria of the National Institute of Neurological and Communicative Disorders and Stroke/ Alzheimer’s Disease and Related Disorders Association Work Group, the National Institute of Neurological Disorders and Stroke – Association Internationale pour la Recherche et l’Einseignement en Neurosciences Work Group and the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Statistical analysis was performed using the SPSS V. 11.5 for Windows statistical software package. Pearson’s c2 test and Fisher’s exact test were used to compare frequencies of risk of malnutrition. The Kruskal–Wallis test was applied to compare demographic, cognitive, functional and nutritional characteristics as well as comorbidity of the study samples. Logistic regression analysis was also used to confirm the association between malnutrition and cognitive levels. The ANOVA post hoc analysis was used for correction in multiple comparisons. All p values were 2-tailed, with statistical significance indicated by a value of p < 0.05. During the study period, 657 subjects aged 65 and older were admitted to the hospital’s geriatric ward and were screened. In 34 subjects data were not recorded and 35 patients were excluded from the study because of a diagnosis of primary or secondary malignant brain neoplasms (n ¼ 4), hydrocephalus (n ¼ 1), shortterm prognosis tumors (n ¼ 12), alcohol abuse (n ¼ 5), head trauma (n ¼ 3), blood infections (n ¼ 2), serious anemia (n ¼ 5) and disorders of the thyroid (¼2). Thus, the final analysis included data from 588 older subjects (252 men, 336 woman, mean age 76.3 7.0, range 65–100 years): 84 patients with dementia (AD ¼ 25 patients, VaD ¼ 37, MD ¼ 22), 65 patients with MCI and 439 with NoCI. Table 1 shows the mean results of variables, expressed according to the cognitive levels. Patients with dementia had significantly lower MMSE scores (p < 0.0001), educational level (p < 0.0001) and MNA scores (p 0.004) and higher CDR scores (p < 0.0001), mean age (p 0.004) and level of disability (p < 0.0001) than patients with MCI or NoCI. No significant differences were found in CIRS
Table 1 Demographic, cognitive, functional, comorbidity and nutritional characteristics of patients according to the cognitive levels.
Age, years Male/Female Instruction MMSE CDR ADL IADL CIRS severity CIRS comorbidity GDS MNA
Dementia (n ¼ 84)
MCI (n ¼ 65)
NoCI (n ¼ 439)
79.4 6.1a,c 21/63 3.4 3.6b,c 16.6 5.4b,c 1.2 1.0b,c 3.9 2.0b,c 2.8 2.7b,c 1.5 0.2 2.3 1.6 5.9 4.0 18.6 3.9a,c
76.3 6.9 27/38 5.7 4.2 25.3 1.3d 0.5d 5.4 1.2 6.1 2.2 1.4 0.3 2.0 1.4 4.8 3.2 20.6 4.0
75.8 7.0 202/237 5.3 2.9 28.2 1.3 0 5.3 1.1 6.6 1.9 1.3 0.4 2.5 1.5 5.4 3.7 21.3 3.4
MMSE ¼ mini mental state examination, CDR ¼ clinical dementia rating scale, ADL ¼ activities of daily living, IADL ¼ instrumental activities of daily living, CIRS severity/comorbidity ¼ cumulative illness rating scale comorbidity index severity/ comorbidity, GDS ¼ geriatric depression scale, and MNA ¼ mini-nutritional assessment. Values are mean SD. The ANOVA post hoc for multiple comparison analysis confirmed the statistical significance of the p values. a Dementia vs MCI, p < 0.05. b Dementia vs MCI, p < 0.001. c Dementia vs NoCI, p < 0.001. d MCI vs NoCI, p < 0.001.
101
severity, CIRS comorbidity and GDS scores between the three groups. Moreover, MCI patients had significantly lower MMSE and higher CDR scores (p < 0.0001) than NoCI, but no significant differences were found in the level of education, mean age, level of disability and MNA scores between the two groups. Also no significant differences were found among patients with various dementia diagnoses (i.e. AD, VaD or MD) with regard to the abovementioned variables. Table 2 illustrates the distribution of the nutritional status according to the cognitive levels of the sample study. As expected, the frequency of malnourished in the patients with dementia was significantly higher than that in the 439 NoCI (p < 0.0001; OR ¼ 3.2, CI ¼ 1.6–6.2). However, the frequency of malnourished in MCI was also significantly higher than that in NoCI patients (p < 0.0001; OR ¼ 4.7, CI ¼ 2.5–9.0), and was not significantly different compared to that in patients with dementia (p ¼ 0.087; OR ¼ 1.1, CI ¼ 0.5–2.4). Similarly, the frequency of well nourished was significantly lower in the patients with dementia (p < 0.0001; OR ¼ 0.5, CI ¼ 0.3–0.8) and MCI (p ¼ 0.035; OR ¼ 1.7, CI ¼ 1.0–2.9) than that in the NoCI, but no significant differences were found between patients with MCI and dementia (p ¼ 0.853; OR ¼ 1.0, CI ¼ 0.7–1.6). Moreover the frequency of the group at risk of malnutrition was significantly lower in the patients with dementia (p < 0.0001; OR ¼ 0.4, CI ¼ 0.2– 0.8) and MCI (p ¼ 0.013; OR ¼ 3.2, CI ¼ 1.6–6.2) than that in the NoCI, but no significant differences were found between patients with MCI and dementia (p ¼ 0.09; OR ¼ 0.8, CI ¼ 0.4–1.4). At last no significant differences were found in frequencies of well nourished, at risk of malnutrition or malnourished among patients with various above-mentioned dementia diagnoses. Given the current increase of the elderly people in the industrialized countries and the occurrence of cognitive impairment in old age, it’s important to understand the factors that may contribute to developing cognitive decline. The present study evaluated the relationship between nutritional status assessed by the MNA and different grades of cognitive impairment, particularly MCI, in a sample of hospitalized older patients from the Apulia region of southern Italy. As expected, we described an extremely high prevalence of poor nutritional status in our sample study: only 18% of these patients were well nourished, while 82% of them were at risk of malnutrition and/or malnourished. This finding confirmed previous data2 in which nutritional status was found to be normal in less than one-third of newly admitted geriatric patients. In agreement with other studies2,3,5 that showed a high percentage of malnutrition in patients with deep cognitive impairment, our data confirmed a significantly greater malnutrition rate in patients with dementia. Although it has been recently reported a possible impact of malnutrition on cognitive decline and poor nutritional habits seem to be linked to disease progression in very mild AD,8 at present there is still a lack of knowledge about the
Table 2 Cognitive levels and mini-nutritional assessment.
Well-nourished (score 24) At risk of malnutrition (score 23.5 17) Malnourished (score <17)
Dementia (n ¼ 84), n (%)
MCI (n ¼ 65), n (%)
NoCI (n ¼ 439), n (%)
Total (n ¼ 588), n (%)
7 (8.5)a
6 (9)b
92 (21)
105 (18)
284 (64)
342 (58)
63 (15)
141 (24)
27 (32)
50 (59.5)
c2-test. a b c
a
Dementia vs NoCI, p < 0.001. MCI vs NoCI, p < 0.05. MCI vs NoCI, p < 0.001.
31 (47) a
28 (44)
c
102
G. Orsitto et al. / Clinical Nutrition 28 (2009) 100–102
role of malnutrition in developing dementia. This might be due to several factors, including the different nutrition habits of the study populations, varying stringency in the diagnostic criteria used, particularly in MCI, and limited sample size. Therefore the evidence in this population that nutritional status is even poor in patients with MCI is of potential clinical value and might suggest that malnutrition plays a role in the progression of cognitive decline. The major limitation of the present study lies in the small sample size, particularly of the MCI group, and so further studies on larger subsets of patients to confirm the association between rate of malnutrition and cognitive impairment are ultimately required together with intervention studies in order to address that topic adequately. In line with the findings of FaxenIrving et al.,9 our data also indicated that the nutritional status did not vary in patients with various dementia diagnoses, i.e. AD, VaD or MD. As recently shown,10 this study gave indication of a possible association between dementia and older mean age, greater disability and lower educational level. Comparing patients with dementia according to diagnosis, no significant differences were found in mean age, educational level, depression scores or level of disability. In conclusion, the results of the present study showed a high prevalence of malnutrition in hospitalized elderly patients with cognitive deficit. The major finding in this population of older people from southern Italy was the evidence of a poor nutritional status even in patients with MCI who had not progressed to dementia, compared to those with no cognitive decline. This novel finding suggested that there may be benefit in improving nutritional status in the MCI group. Further intervention studies will undoubtedly be informative in this regard. Conflict of interest All authors disclose any financial and personal relationships with other people, or organizations, that could inappropriately
influence (bias) their work, all within 3 years of the beginning the work submitted. Acknowledgements This work was supported by the ‘‘Paradiso’’ Hospital – Gioia del Colle – ASL BA. The authors are grateful to the patients who participated in the study. References 1. Izawa S, Kuzuya M, Okada K, Enoki H, Koike T, Kanda S, et al. The nutritional status of frail elderly with care needs according to the mini-nutritional assessment. Clin Nutr 2006;25(6):962–7. 2. Kagansky N, Berner Y, Koren-Morag N, Perelman L, Knobler H, Levy S. Poor nutritional habits are predictors of poor outcome in very old hospitalized patients. Am J Clin Nutr 2005;82:784–91. 3. Magri F, Borza A, Del Vecchio S, Chytiris S, Cuzzoni G, Busconi L, et al. Nutritional assessment of demented patients: a descriptive study. Aging Clin Exp Res 2003;15:148–53. 4. Orsitto G, Cascavilla L, Franceschi M, Aloia RM, Greco A, Paris F, et al. Influence of cognitive impairment and comorbidity on disability in hospitalized elderly patients. J Nutr Health Aging 2005;9:194–8. 5. Zekry D, Hermann FR, Grandjean R, Meynet MP, Michel JP, Gold G, et al. Demented versus non-demented very old inpatients: the same comorbidities but poorer functional and nutritional status. Age Ageing 2008;37(1):83–9. 6. Petersen RC, Smith GE, Waring SC, Ivnik RJ, Tangalos EG, Kokmen E. Mild cognitive impairment. Clinical characterization and outcome. Arch Neurol 1999;56:303–8. 7. Scafato E, Gandin C, Farchi G, Abete P, Baldereschi M, Di Carlo A, et al. The I.P.R.E.A. Working Group Italian Project on Epidemiology of Alzheimer’s disease (I.P.R.E.A.): study design and methodology of cross-sectional survey. Aging Clin Exp Res 2005;17:29–34. 8. Ousset PJ, Nourhashemi F, Reynish E, Vellas B. Nutritional status is associated with disease progression in very mild Alzheimer disease. Alzheimer Dis Assoc Disord 2008;22(1):66–71. 9. Faxen-Irving G, Basun H, Cederholm T. Nutritional and cognitive relationships and long-term mortality in patients with various dementia disorders. Age Ageing 2005;34(2):136–41. 10. Orsitto G, Seripa D, Panza F, Franceschi M, Cascavilla L, Placentino G, et al. Apolipoprotein E genotypes in hospitalized elderly patients with vascular dementia. Dement Geriatr Cogn Disord 2007;23(5):327–33.