The Geriatric Nutritional Risk Index predicts hospital length of stay and in-hospital weight loss in elderly patients

doi:10.1016/j.clnu.2014.01.017

Clinical Nutrition

Volume 34, Issue 1, February 2015, Pages 74-78

https://doi.org/10.1016/j.clnu.2014.01.017 Get rights and content

Summary

Background & aims

Nutritional derangements are common in elderly patients, but how nutritional risk affects outcome in this subset of hospital inpatients deserves further investigation.

We evaluated the impact of nutritional risk on length of stay (LOS) and in-hospital weight loss (WL) in elderly patients (>65yrs).

Methods

Nutritional risk was assessed by the Geriatric Nutritional Risk Index (GNRI) in a prospective multicentre hospital-based cohort study. The outcomes were LOS and in-hospital WL.

Results

In the whole sample (N = 667), the prevalence of high (GNRI < 92) and mild (GNRI: 92–98) nutritional risk were 33% and 25%, respectively. Patients with a high nutritional risk were more likely (OR = 1.89; 95%CI: 1.22–2.92) to stay longer in hospital (fourth quartile, LOS ≥ 20 days) compared to those without. Other factors associated with prolonged LOS were cancer diagnosis (OR = 2.52; 95%CI: 1.69–3.75), the presence of comorbidities (OR = 1.24; 95%CI: 1.11–1.40) and surgical setting (OR = 1.65; 95%CI: 1.10–2.47). In-hospital WL ≥ 5% was recorded in 75 ambulant patients from a representative subgroup (N = 583). It was independently associated with prolonged LOS (OR = 1.80; 95%CI: 1.03–3.06) and was more frequent among cancer patients (OR = 1.88; 95%CI: 1.09–3.24), in patients with a high nutritional risk (OR = 2.23; 95%CI: 1.20–4.14) or those admitted to surgical units (OR = 1.77; 95%CI: 1.02–3.05).

Conclusions

Nutritional risk assessed by the GNRI on admission, predicts LOS and in-hospital WL in elderly patients.

Introduction

The independent role of nutrition in affecting the prognosis of hospitalized patients is well known. Disease-related malnutrition has been shown to be associated with higher mortality and morbidity, prolonged recovery from illness and length of stay (LOS).1, 2, 3 Furthermore, nutritional status may deteriorate during hospitalization.1, 2, 4 Advanced age has been associated with poor adaptation to disease-related metabolic stress⁵ and is recognized as an independent predictor of nutritional derangements and worse clinical outcome.1, 6

The use of screening procedures to assess nutritional risk before/during hospital admission is recommended so as to identify patients who may benefit from nutritional support.⁷ To this end, different tools have been introduced in clinical practice; although they provide different information, in theory, they focus on the same issue.7, 8 Nevertheless, the use of a tool should be initially validated against prediction of outcomes. Validation should also specifically take into account the specific setting and population.⁹ As the numbers of elderly people are growing, and given the intrinsic nutritional needs among this group of patients, the validation of putatively age-specific assessment tools has a rationale.⁹ Moreover, elderly patients may frequently be unable to take part in nutritional screening procedures.

In accordance with these claims, a specific prognostic index for the elderly, the Geriatric Nutritional Risk Index (GNRI), has been proposed.10, 11 Its use appears to be promising and preliminary studies have suggested a better association with acute care outcomes.12, 13 However, most of the literature on GNRI is focused on long-term care settings. Very little research has been done on use of the GNRI in the acute setting.9, 14, 15, 16

The aim of this study was to investigate the impact of nutritional risk, as assessed by the GNRI, on length of stay (LOS) and nutritional status during hospitalization in elderly patients.

Section snippets

Methods

This was a prospective multicentre cohort study in an acute hospital setting. Assessment procedures were performed in line with principles set down by the Declaration of Helsinki. It was approved by the local Institutional Ethics Committees and all the patients were asked to provide their written informed consent.

From March 2009 to April 2012, all patients over 65 who were admitted to the hospitals were systematically screened to assess whether they met study inclusion criteria. Patients were

Assessment of the study cohort

A total number of 735 patients were assessed; 33 (4%) and 35 (5%) patients were excluded from final analysis due to LOS < 3 days and death, respectively; 667 subjects were included in the final analysis. Table 1 classifies these patients according to their main diagnoses on admission. The prevalence of high nutritional risk (GNRI < 92) was similar in patients who died during hospitalization (36.7% vs. 32.8%; P = 0.811), and no differences were detected in baseline nutritional parameters and

Discussion

Older persons are the fasted growing segment of the population and most frequently hospitalized.²¹ From a nutritional perspective, ageing is associated with poor adaptation to malnutrition and diminished anabolic response to nutritional repletion.5, 22 These factors are potentially exaggerated during hospitalization. Evidence is accumulating, however, that early nutritional screening and treatment of elderly patients may result in cost savings.19, 20, 23, 24

The current study is one of the

Funding sources

The study was supported by the Fondazione IRCCS Policlinico San Matteo (Pavia, Italy).

Statement of authorship

All the authors significantly contributed to the work, read and approved the final version of the manuscript. Particularly, contributions were as follows:

Study design: R.C., E.C., C.P.

Data collection: R.C., C.P., B.C., C.B., L.Q., S.C., A.B.

Data analyses and interpretation: E.C., R.C., C.K.

Manuscript drafting: E.C., R.C., C.P.

Critical revision of the manuscript: C.K.

Conflict of interest

All authors certify that there are no affiliations with or involvement in any organization with a direct financial interest in the subject matter or materials discussed in the manuscript.

Acknowledgements

The authors wish to thank Jennifer S Hartwig MD for assistance in editing the manuscript.

References (31)

K. Norman et al.
Prognostic impact of disease-related malnutrition
Clin Nutr
(2008)
U.G. Kyle et al.
Does nutritional risk, as assessed by nutritional risk index, increase during hospital stay? A multinational population-based study
Clin Nutr
(2005)
S.M. Schneider et al.
Lack of adaptation to severe malnutrition in elderly patients
Clin Nutr
(2002)
J. Sorensen et al.
EuroOOPS study group. EuroOOPS: an international, multicentre study to implement nutritional risk screening and evaluate clinical outcome
Clin Nutr
(2008)
J. Kondrup et al.
Educational and clinical practice committee, European society of parenteral and enteral nutrition (ESPEN). ESPEN guidelines for nutrition screening 2002
Clin Nutr
(2003)
U.G. Kyle et al.
Comparison of tools for nutritional assessment and screening at hospital admission: a population study
Clin Nutr
(2006)
O. Bouillanne et al.
Geriatric Nutritional Risk Index: a new index for evaluating at-risk elderly medical patients
Am J Clin Nutr
(2005)
E. Cereda et al.
The use of the Geriatric Nutritional Risk Index (GNRI) as a simplified nutritional screening tool
Am J Clin Nutr
(2008)
E. Cereda et al.
Nutritional screening and mortality in newly institutionalised elderly: a comparison between the geriatric nutritional risk index and the mini nutritional assessment
Clin Nutr
(2011)
M.N. Gamaletsou et al.
Nutritional risk as predictor for healthcare-associated infection among hospitalized elderly patients in the acute care setting
J Hosp Infect
(2012)

E. Cereda et al.

Geriatric Nutritional Risk Index and overall-cause mortality prediction in institutionalised elderly: a 3-year survival analysis

Clin Nutr

(2008)

D. Volkert et al.

ESPEN guidelines on enteral nutrition: geriatrics

Clin Nutr

(2006)

L. Sobotka et al.

ESPEN. ESPEN guidelines on parenteral nutrition: geriatrics

Clin Nutr

(2009)

C.S. Katsanos et al.

Aging is associated with diminished accretion of muscle proteins after the ingestion of a small bolus of essential amino acids

Am J Clin Nutr

(2005)

H.M. Kruizenga et al.

Effectiveness and cost-effectiveness of early screening and treatment of malnourished patients

Am J Clin Nutr

(2005)

Cited by (59)

The Updated Global Malnutrition Composite Score Clinical Quality Measure: Its Relevance to Improving Inpatient Clinical Outcomes and Health Equity
2024, Journal of the Academy of Nutrition and Dietetics
Quality improvement has existed in health care for centuries with a dramatic transformation over time, largely motivated by the academic health quality movement. Throughout this evolution, the Centers for Medicare and Medicaid Services have been at the forefront of the development and provision of quality measures for health care in a variety of settings, including acute care. Quality initiatives aid in the evaluation of patient care to encourage quality improvement efforts, determine pay-for-performance rates, and help patients and consumers evaluate their care providers. The addition of the Global Malnutrition Composite Score as an electronic Clinical Quality Measure in 2022 highlights the key role nutrition plays in outcomes and quality of hospitalized patients. With this, credentialed nutrition and dietetics practitioners lie front and center for the development of quality improvement processes to help promote high quality standards of nutrition care, improve length of stay, and reduce health care costs and readmissions while addressing malnutrition, health equity, and nutrition care as a human right. As the Global Malnutrition Composite Score steward, it is the obligation of the Academy of Nutrition and Dietetics and the Commission on Dietetic Registration to promote the measure and support credentialed nutrition and dietetics practitioners in advocating for the implementation of this measure. Therefore, the purpose of this practice update is to provide necessary information to credentialed nutrition and dietetics practitioners and other health care leaders related to the history and implementation of the Global Malnutrition Composite Score, along with relevant updates to the measure and practice implications.
Patient-Generated Subjective Global Assessment Short Form better predicts length of stay than Short Nutritional Assessment Questionnaire
2021, Nutrition
Citation Excerpt :
Additionally, in the present study the relationship between malnutrition risk and LOS was corrected for several covariables (e.g., age, sex, BMI, diagnosis, and comorbidities). In several studies, having multiple comorbidities and a diagnosis of cancer have been shown to be contributors to a longer LOS [26,27]. Correcting for these potential confounders better represents the actual process in patients, where the explanatory variable simultaneously influences LOS rather than separately.
Malnutrition screening instruments used in hospitals mainly include criteria to identify characteristics of malnutrition. However, to tackle malnutrition in an early stage, identifying risk factors for malnutrition in addition to characteristics may be valuable.
The aim of this study was to determine the predictive validity of the Patient-Generated Subjective Global Assessment (PG-SGA SF), which addresses malnutrition characteristics and risk factors, and the Short Nutritional Assessment Questionnaire (SNAQ), which addresses mainly malnutrition characteristics, for length of stay (LOS) in a mixed hospital population.
Patients (N = 443) were screened with the PG-SGA SF and SNAQ in the first 72 h after admission to the lung, cardiology, or surgery ward. The McNemar–Bowker test was used to investigate the symmetry between the SNAQ and PG-SGA SF categorization for low, medium, and high risk. The predictive value of the PG-SGA SF and SNAQ was assessed by γ-regression before and after adjusting for several confounders.
Of the 443 patients included, 23% and 58% were categorized as being at medium/high risk for malnutrition according to the SNAQ and PG-SGA SF, respectively. The regression analysis indicated that LOS of high-risk patients according to PG-SGA SF was 36% longer than that of low-risk patients (P = 0.001). LOS in patients at high risk according to the SNAQ did not significantly differ from that of SNAQ low-risk patients.
The PG-SGA SF, as a proactive malnutrition screening instrument, predicts LOS in various hospital wards, whereas the SNAQ, as a reactive instrument, does not. Therefore, we recommend the PG-SGA SF for proactive screening for malnutrition risk.
Impact of the Geriatric Nutritional Risk Index in Patients Undergoing Transcatheter Aortic Valve Implantation
2021, American Journal of Cardiology
Citation Excerpt :
The GNRI was developed as an indicator of nutritional status in the elderly, and it consists of 2 nutritional factors (serum albumin level and body weight). The formula is presented as [GNRI=14.89 × albumin (g/dL) + 41.7 × body weight (kg)/ideal body weight (kg)], with higher values reflecting better nutritional status.4,5 The body weight/ideal body weight ratio was set to 1 when the patient's body weight exceeded the ideal value.
Several studies have shown that nutritional indexes are associated with cardiovascular events; however, limited studies have investigated the prognostic value of the Geriatric Nutritional Risk Index (GNRI) in patients undergoing transcatheter aortic valve implantation (TAVI). We aimed to evaluate the clinical impact of GNRI in patients undergoing TAVI. This single-center retrospective study analyzed consecutive patients treated with TAVI, stratified into groups according to their median baseline GNRI. The primary endpoint was 2-year all-cause mortality. In total, 968 patients with a mean age of 82.1 years and a median Society of Thoracic Surgeons (STS) score of 4.8% who underwent TAVI were included. The median GNRI was 103. Compared with the high-GNRI group (GNRI≥103, n = 451), the low-GNRI group (GNRI<103, n = 517) had higher STS scores and renal insufficiency rates. The 2-year all-cause mortality was significantly higher in the low-GNRI group than in the high-GNRI group (24.9% vs. 9.3%, p<0.001), despite no significant differences in procedural and clinical outcomes between the groups. On multivariable analysis, lower GNRI was independently associated with higher 2-year all-cause mortality (adjusted hazard ratio: 1.07; 95% confidence interval: 1.05-1.10; p<0.001). The GNRI retained its predictive value in subgroup analyses stratified by age (>75 vs. ≤75 years) and STS score (≥4 vs. <4). In conclusion, The GNRI is an important surrogate marker for predicting prognosis and mortality in patients undergoing TAVI.
Geriatric nutritional risk index and adverse medical outcomes among Egyptian patients admitted to a geriatric hospital: a prospective cohort study
2024, BMC Geriatrics
Preoperative geriatric nutritional risk index is useful factor for predicting postoperative delirium among elderly patients with degenerative lumbar diseases
2024, European Spine Journal
Association between nutritional status scores and the 30-day mortality in patients with acute kidney injury: an analysis of MIMIC-III database
2023, BMC Nephrology

View all citing articles on Scopus

View full text

Original articleThe Geriatric Nutritional Risk Index predicts hospital length of stay and in-hospital weight loss in elderly patients

Summary

Background & aims

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Assessment of the study cohort

Discussion

Funding sources

Statement of authorship

Conflict of interest

Acknowledgements

Clin Nutr

Clin Nutr

Clin Nutr

Clin Nutr

Clin Nutr

Clin Nutr

Am J Clin Nutr

Am J Clin Nutr

Clin Nutr

J Hosp Infect

Clin Nutr

Clin Nutr

Clin Nutr

Am J Clin Nutr

Am J Clin Nutr

Original article
The Geriatric Nutritional Risk Index predicts hospital length of stay and in-hospital weight loss in elderly patients