Elsevier

Nutrition

Volume 16, Issue 1, January 2000, Pages 1-5
Nutrition

Applied Nutritional Investigations
A multi-center trial of the effects of oral nutritional supplementation in critically ill older inpatients

https://doi.org/10.1016/S0899-9007(99)00227-0Get rights and content

Abstract

The purpose of this study was to assess the effect of nutritional supplementation on dietary intake and on pressure ulcer development in critically ill older patients. The multi-center trial involved 19 wards stratified according to speciality and recruitment for critically ill older patients; 9 wards were randomly selected for nutritional intervention (nutritional intervention group), consisting of the daily distribution of two oral supplements, with each supplement containg 200 kcal, for 15 d. Pressure ulcer incidence was prospectively recorded for grades I (erythema), II (superficial broken skin), and III (subcutaneous lesion) for 15 d. Nutritional intake was monitored by using estimates in units of quarters validated by comparison with weight measurement. There were 672 subjects older than 65 y, and 295 were in the nutritional intervention group versus 377 in the control group. The patients were similar for age, sex ratio, and C-reactive protein. In comparison with the control group, the nutritional intervention group included more patients with stroke, heart failure, and dyspnea and fewer with antecedent falls, delirium, lower limb fractures, and digestive disease. The nutritional intervention group had a lower risk of pressure ulcers according to the Norton score but was less dependent (Kuntzman score) and had a lower serum albumin level. During the trial, energy and protein intakes were higher in the nutritional intervention group (day 2: 1081 ± 595 kcal versus 957 ± 530 kcal, P = 0.006; 45.9 ± 27.8 g protein versus 38.3 ± 23.8 g protein in the control group, P < 0.001). At 15 d, the cumulative incidence of pressure ulcers was 40.6% in the nutritional intervention group versus 47.2% in the control group. The proportion of grade I cases relative to the total number of cases was 90%. Multivariate analysis, taking into account all diagnoses, potential risk factors, and the intra-ward correlation, indicated that the independent risk factors of developing a pressure ulcer during this period were: serum albumin level at baseline, for 1 g/L decrease: 1.05 (95% confidence interval: 1.02 to 1.07, P < 0.001); Kuntzmann score at baseline, for 1-point increase: 1.22 (0.32 to 4.58, P = 0.003); lower limb fracture: 2.68 (1.75 to 4.11, P < 0.001); Norton score <10 versus >14: 1.28 (1.01 to 1.62, P = 0.04); and belonging to the control group: 1.57 (1.03 to 2.38, P = 0.04). In conclusion, it was possible to increase the dietary intake of critically ill elderly subjects by systematic use of oral supplements. This intervention was associated with a decreased risk of pressure ulcer incidence.

Introduction

Elderly patients are at high risk for developing pressure ulcers.1 The cumulative incidence for pressure ulcers of grade II severity or higher could be as much as 12.9% in elderly people hospitalized for periods up to 8 wk for an acute event,2 which implies that implementation of an efficient prevention strategy is especially important in this population. A number of risk factors other than old age have been documented, the most significant being immobility, incontinence, catabolic illnesses as intrinsic factors, and pressure, moisture, shearing forces, and friction as extrinsic factors.1 In contrast, the role of malnutrition in pressure ulcer formation has not been clearly established.3 Ek et al.4 reported that malnutrition criteria were more frequent in subjects who developed pressure ulcers in a long-term setting than in those who did not during a 3-wk period. The number of new pressure ulcers was lower, although not significantly, among the subjects who underwent an oral supplementation intervention. Hypoalbuminemia has been described as a pressure ulcer risk factor.1 In elderly people, catabolic illnesses are able to induce a deep fall in serum albumin5; therefore, it is likely that these two risk factors are associated. However, controversial findings have been reported in longitudinal studies, in which malnutrition was not found to be associated with an increased risk of pressure ulcers in nursing homes6 or in the community.7 Because malnutrition is a common feature in elderly people admitted to the hospital,8 the possible beneficial role of nutritional support in the prevention of pressure ulcers needs to be assessed. Therefore, we conducted a multi-center, nutritional trial in acutely ill elderly people. The effects of systematic administration of liquid supplements given orally for 15 d after admission of patients on total energy and protein amount ingested and on the incidence of pressure ulcers were then tested.

Section snippets

Study population and design

Elderly patients involved in this study were either inpatients of hospital wards from the Centre Hospitalier Universitaire in Bordeaux or inpatients in geriatric units from elsewhere in southwest France belonging to the Groupe Aquitain Geriatrique d’Evaluation (GAGE; a group for the evaluation and improvement of health care for the elderly in Aquitania). Wards were included in the study if they satisfied the criterion that more than 40% of inpatients were older than 65 y. Thirty-five wards were

Results

Six hundred seventy-two patients were included in the study, 295 of whom were in the nutritional intervention group and 377 in the control group. The following medical conditions were found in the nutritional intervention group versus the control group: stroke (23.6% versus 6.8%; P < 0.001), falls and gait disturbance (13.7% versus 20.2%; P = 0.02), heart failure and dyspnea (13.1% versus 7.2%; P = 0.009), infectious diseases (13.7% versus 11.0%; NS), digestive diseases (3.2% versus 14.4%; P<

Discussion

The incidence of pressure ulcers occurring in the elderly during acute illnesses was high in both groups in the present study. In contrast to other studies1, 7, 17 that were limited to measurements of grade II or more severe pressure ulcers, this study included measurements of grade I pressure ulcers (erythema). The initial pressure lesion is a cellular lesion accompanied by extra-cellular swelling. A grade I ulcer induces pain as a result of localized inflammation. The proportion of grade I

Summary

The purpose of the present study was to assess the effects of nutritional supplementation (400 kcal/d) for 15 d on dietary intake and on pressure ulcer development in critically ill older patients; 672 subjects older than 65 y were included. Energy and protein intakes were higher in the nutritional intervention group. Multivariate analysis, taking into account diagnosis and potential baseline risk factors, indicated that the relative risk of developing a pressure ulcer during this period was

Acknowledgements

We thank the nurses and the dieticians in the Centre Hospitalier Universitaire, Bordeaux and the GAGE Group for their collaboration, Chantal Fontinha for manuscript preparation, and Michael Harston for editorial assistance. This research was financed by the Projet Hospitalier de Recherche Clinique, Ministère de la Santé et de l’Action Humanitaire, Direction Générale de la Santé, and the Direction des Hôpitaux.

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