PEU in Elderly TCU Residents

Background: There is tremendous controversy regarding the adequacy/effectiveness of the
nutritional care provided in VA Transitional Care Units (TCUs). The interrelationship
between concurrent inflammatory disease, the adequacy of a resident's nutrient consumption,
the development or resolution of putative nutritional deficits, and clinical outcomes is not
established. Given the known obstacles to increasing nutrient intake (e.g. cost, resident
acceptance, associated morbidity) and the lack of proven effectiveness of all forms of
nutrition support and nutritional supplementation to improve clinical outcomes, a better
understanding of these interrelationships is needed and will be the focus of this study.

Objectives: The primary objective of this study is to determine how best to define
nutritional risk (i.e., risk for adverse clinical outcomes due to inadequate nutrient
intake) among older VA TCU residents. As part of this objective, we will seek to develop a
better understanding of the interrelationship between nutrient intake, weight change, serum
concentration of albumins, health status/illness severity, and mortality. The secondary
objective is to develop a prediction model for identifying which TCU residents are likely to
have ongoing problems with low nutrient intake. The ultimate objective is to develop a
clinically useful system to identify residents who are likely to benefit from specific
interventions aimed at improving nutritional risk.

Methods: To meet these objectives, 400 older, non-terminally ill veterans admitted to a VA
TCU (where average length of stay is approx 90 days) will be prospectively studied using the
same methodologic approach validated in prior VA hospital-based investigations. After
completing a comprehensive admission assessment, each subject will be monitored closely
throughout his/her TCU stay with serial nutrient intake and recurring metabolic, functional,
neuropsychological, cognitive, nutritional, and medical assessments. Weights,
anthropometrics, and blood for serum proteins, inflammatory markers (e.g., cytokines), and
other select lab indices will be obtained at least monthly until discharged. Resting
metabolic rate (by indirect calorimetry) will be obtained on select residents. Each subject
will remain in the study for 12 months. From discharge through the end of the subject's
study year, each subject will be monitored by phone to determine survival and days of
institutional (e.g., hospital, NH) care. At study's end, strengths of associations will be
assessed using univariable and multivariable analytic techniques including logistic and Cox
Proportional-Hazards analyses.

Findings: No results at this time.

Status: Status: Funding began 9-1-2005. Subject recruitment began 3-1-2006. To date, we have
recruited 426 subjects into the study. 421 subjects have been discharged from the inpatient
phase of the study. The average length of stay for these subjects is 32 days.

Impact: Our study will provide a clearer understanding of what factors contribute to the
apparent nutritional deficits seen in many older veterans residing in VA nursing home TCUs.
The study will also lead to the development of a clinically useful system to identify TCU
residents who are likely to benefit from specific interventions aimed at improving
nutritional risk and thus clinical outcomes.