Malnutrition is associated with severe outcome in elderly patients hospitalised with COVID-19

Introduction

The COVID-19 pandemic has brought unprecedented challenges to healthcare systems worldwide, particularly for elderly patients. Beyond the well-documented risks of severe illness and mortality, a growing body of research suggests that malnutrition plays a significant role in the outcomes of elderly patients hospitalized with COVID-19. Malnutrition, which affects up to 67% of ICU patients with COVID-19, can exacerbate the severity of the disease and lead to prolonged hospital stays, higher mortality rates, and increased risk of delirium.

The Hidden Enemy: Malnutrition

Malnutrition is a complex condition characterized by inadequate nutrition, which can result from various factors including poor dietary intake, inflammation, and prolonged hospital stays. In the context of COVID-19, symptoms such as loss of appetite and changes in taste and smell can significantly impact nutritional status. Moreover, respiratory failure and prolonged ICU admissions can further complicate the situation.

Prevalence and Impact

A recent study conducted at a single center found that 63.4% of critically ill COVID-19 patients over the age of 65 were malnourished. This high prevalence is alarming, as it directly correlates with severe outcomes. The study revealed that malnutrition was associated with a 35% higher risk of delirium and an 84% greater odds of prolonged ICU admission among elderly patients compared to those without malnutrition.

The Link Between Malnutrition and Delirium

Delirium is a common complication in ICU patients, affecting approximately 50% of them. Malnutrition can exacerbate delirium by affecting the brain's nutritional status. A study noted that only one previous study had assessed the link between malnutrition and delirium among COVID-19 patients, but it found no significant association. However, the current research indicates a clear and significant association between malnutrition and delirium in elderly COVID-19 patients.

Prolonged Hospital Stays and Mortality

Malnutrition also contributes to prolonged hospital stays and increased mortality rates. In the same study, 190 deaths were recorded among the 310 patients, with no significant association found between malnutrition and COVID-19 mortality. However, this does not downplay the critical role of nutrition in recovery and survival. The literature suggests that malnourished patients are more likely to develop severe cases of COVID-19, leading to higher mortality rates and prolonged hospital stays.

The Nursing Home Setting

Nursing home residents are particularly vulnerable to malnutrition and its associated complications. Early in the pandemic, 17.9% of nursing home residents showed symptoms of anorexia, which increased to 70.8% after 21 days. This significant decline in food intake was paralleled by a rise in delirium, from 18.6% to 56% during the same period.

Sarcopenia: The Double Threat

Sarcopenia, the loss of muscle mass, is another complication often seen in elderly COVID-19 survivors. It is exacerbated by COVID-19-associated inflammatory processes, total or partial immobilization, and malnutrition. This vicious circle of deteriorating nutritional status and declining functionality highlights the importance of regular monitoring and early intervention.

Early Intervention: The Key to Recovery

Given the critical role of nutrition in recovery and survival, early intervention is crucial. Routine monitoring of nutritional status and functionality is essential in all older COVID-19 survivors. When malnutrition and/or functional decline are identified, low-threshold provision of individualized nutritional and exercise interventions should be implemented. In severe cases, ambulatory or inpatient rehabilitation may be necessary to prevent the loss of independence.

Clinical Prediction Models

To improve patient outcomes, clinical prediction models can help identify the risk of COVID-19 re-positive cases in malnourished older adults. A recent study constructed a clinical prediction model using LASSO regression analysis, which showed good predictive performance and identified independent influencing factors such as protein intake amount, renal failure, and lymphocyte count.

Conclusion

The association between malnutrition and severe outcomes in elderly COVID-19 patients is clear. Malnutrition not only exacerbates delirium and prolongs ICU stays but also contributes to higher mortality rates. Early detection and intervention are critical to improving patient outcomes. Regular monitoring of nutritional status, early initiation of enteral and parenteral nutrition support, and individually adapted geriatric rehabilitation programs are essential components in the management of elderly COVID-19 patients.

References

• Frontiers in Medicine: Malnutrition elevates delirium and ICU stay among critically ill older COVID-19 patients.
  • https://www.frontiersin.org/journals/medicine/articles/10.3389/fmed.2024.1259320/full
• PMC - NCBI: Malnutrition and Sarcopenia in COVID-19 Survivors.
  • https://pmc.ncbi.nlm.nih.gov/articles/PMC9021037/
• Dovepress: Predicting COVID-19 Re-positive Cases in Malnourished Older Adults.
  • https://www.dovepress.com/predicting-covid-19-re-positive-cases-in-malnourished-older-adults-a-c-peer-reviewed-fulltext-article-CIA
• Nature: Long-term effects of malnutrition on severity of COVID-19.
  • https://www.nature.com/articles/s41598-021-94138-z