Skip Navigation


Age and Ageing Advance Access originally published online on October 25, 2007
Age and Ageing 2008 37(2):214-217; doi:10.1093/ageing/afm143
This Article
Right arrow FREE Full Text (PDF) Freely available
Right arrow All Versions of this Article:
37/2/214    most recent
afm143v1
Right arrow E-letters: Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when E-letters are posted
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Scichilone, N.
Right arrow Articles by Bellia, V.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Scichilone, N.
Right arrow Articles by Bellia, V.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?

Copyright © The Author 2007. Published by Oxford University Press on behalf of the British Geriatrics Society.

The mini nutritional assessment is associated with the perception of dyspnoea in older subjects with advanced COPD

SIR—Dyspnoea is one of the cardinal features of patients with chronic obstructive pulmonary disease (COPD), and it has been shown to be strongly associated with mortality in this population [1]. The pathophysiology of dyspnoea is related to abnormalities in ventilatory demand, respiratory muscle, breathing patterns and in blood gases [2]. However, the relationship between the level of breathlessness and lung function impairment is not obvious [3, 4]. On the other hand, dyspnoea has been shown to be affected by non-respiratory factors, such as physical disability [4], nutritional status [5] and possibly age per se [6], thus supporting the multifactorial origin of this symptom [2].

COPD is a respiratory disease that is associated with systemic effects [7, 8]. Agusti et al. found that underweight patients are representative of more severe COPD [7]. A high prevalence of nutritional depletion has been demonstrated in outpatient COPD [9–11], and low body weight has been associated with severity of COPD [12]. Malnutrition affects respiratory muscle strength and endurance, which in turn contributes to worsening the respiratory function [13]. Of note, dietary supplementation has been shown to reduce the severity of dyspnoea in underweight individuals with COPD [14].

The Mini Nutritional Assessment (MNA) has been proposed to evaluate the body's nutritional status [15]. The current study aimed at investigating whether differences in nutritional status are associated with the perception of dyspnoea in individuals with COPD.

Methods

Subjects
We recruited consecutive individuals with COPD who attended the pulmonary outpatient clinic, as well as COPD inpatients at the time of discharge, in the period of April–June 2006. Patients younger than 60 years of age were excluded. Exclusion criteria were also the co-existence of malignancies or other illnesses known to alter the nutritional state. All patients were in stable condition. The study was approved by the Ethics Committee of the University of Palermo, and all patients gave written, informed consent prior to participation.

Study design
The nutritional status was evaluated through anthropometric measurements and the MNA questionnaire; the perception of dyspnoea was assessed by the Modified Medical Research Council (MMRC) Dyspnoea Scale and the degree of physical disability by the Barthel Index. Clinical and functional evaluations were performed to assess the severity of COPD [16, 17]. The number of comorbid conditions was also recorded.

Nutritional and anthropometric data: weight, height, waist and hip circumferences were measured following a standardised procedure [18]. The MNA test is an internationally validated, two-step procedure (screening for risk of malnutrition followed by global assessment of the nutritional conditions), which evaluate the overall health status of elderly subjects, by rating cognitive function, functional status, walking, balance and socio-economic status [15]. The MNA provides a total score that ranges from 0 to 30 points. According to the score achieved, patients are classified as undernourished (≤17 points), at risk of malnutrition (17.5–23.5), and well nourished (>23.5). Subjects who attained >12 points at the screening were assigned an arbitrary value of 30. To avoid inter-observer variability, the MNA evaluation was performed only by one person (GP).

The perception of dyspnoea was assessed through the MMRC Dyspnoea Scale [4] by another investigator (LM). The MMRC Dyspnoea Scale consists of five grades of physical activities that provoke dyspnoea. The Barthel Index was used to establish the degree of physical performance [19]. The final score ranges from 0 (complete dependency) to 100 (complete independence).

Data analysis
Data are presented as mean ± SD or median and range, where appropriate. Unpaired t-test or Mann–Whitney test were employed to assess differences between the two groups (‘well nourished’ versus ‘at risk of malnutrition’) for anthropometric, functional and clinical variables. An ordinal regression analysis was performed to assess independent contributors to the variance in degree of dyspnoea (MMRC score). In all analyses, P values ≤0.05 were considered statistically significant.

Results

Thirty-two individuals with COPD were enrolled (Table 1). All patients met the criteria for airflow obstruction (mean FEV1/VC: 0.48; range: 0.30–0.69). Ten patients were on long-term oxygen therapy. Ten patients were current smokers (pack-year: 67 ± 29, mean ± SD) and 22 ex-smokers (73 ± 45, mean ± SD). None of the patients was free of dyspnoea (MMRC, median: 3, range: 1–4). The Barthel Index was between 29 and 100 (median: 82), with only two patients showing complete independence (100 points). The BMI resulted in 27.8 ± 3.8 kg/m2, and the waist: hip ratio was 1.1 ± 0.1. The MNA score did not correlate with BMI (r = 0.20, P = 0.27), nor with the waist: hip ratio (r = 0.30, P = 0.15).


View this table:
[in this window]
[in a new window]

  		Table 1. Demographics and baseline lung function characteristics for all patients participating in the study. Data are expressed as mean ± SD

 
The MNA classification led to the generation of two groups: 14 patients were classified as ‘at risk of malnutrition’, and 18 regarded as ‘well nourished’. Age was not different between the two groups (at risk of malnutrition: 72 ± 5.3 years; well nourished: 71 ± 6.7 years, P = 0.58), nor was BMI (26.9 ± 4.1 kg/m2 versus 28.5 ± 3.6 kg/m2, P = 0.29). The FEV1% predicted was significantly lower in patients at risk of malnutrition (41 ± 10% versus 51 ± 12%, respectively; P = 0.02). Subjects on oxygen therapy showed lower MNA than that of individuals on pharmacological therapy (20.9 ± 3.7 versus 27.5 ± 3.9, P < 0.0001, respectively). The number of comorbid conditions did not differ between the two groups (P = 0.33), nor did the total number of medications used by the patients (P = 0.49). Similarly, the smoking habit was not different between groups (P = 0.69). The Barthel Index did not differ between the at risk (74 ± 19) and well nourished (79 ± 14) patients (P = 0.45). The severity of dyspnoea was significantly higher in patients at risk of malnutrition than in the well nourished group (3.1 ± 0.7 versus 2.3 ± 1.0, respectively; P = 0.02 by Mann–Whitney test) (Figure 1). The ordinal regression analysis, in which the MMRC represented the dependent variable, and the MNA and FEV1% predicted the independent variables yielded a P value of 0.01, with the MNA being the only factor that entered the model (P = 0.05).


Figure 1
View larger version (11K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 1. Comparison of the Dyspnoea Score between the group of patients at risk of malnutrition and the group of well–nourished patients. MMRC: Modified Medical Research Council.

 
Discussion

The present study shows that elderly patients with COPD with normal BMI but at risk for malnutrition complain of a higher degree of dyspnoea compared to well nourished patients with COPD. This suggests that early alterations of the nutritional status may play a significant role in the perception of symptoms in elderly individuals with COPD, and implies that the early detection of nutritional impairment should be included in the clinical assessment of the disease.

To the best of our knowledge, this is the first attempt to use the MNA in a population of patients with COPD. The MNA has been validated in different populations: Magri et al. [20] detected a significant risk of malnutrition in hospitalized patients with dementia. The MNA was also evaluated in orthopaedic patients [21], in surgical elderly patients [22] and in elderly, otherwise healthy subjects [23]. The reliability of the MNA in older patients was demonstrated by Barone et al. [24], who found that the MNA was superior than the global assessment of healthy status in identifying malnourished patients. Taken together, these studies provide evidence that the MNA can be safely used in the assessment of elderly populations.

The finding that the perception of increased dyspnoea is associated with the risk of malnutrition supports and extends previous observations on the pathogenetic role of low body weight in patients with COPD [5]. Interestingly, a more severe degree of dyspnoea has been observed in patients with COPD with lower MNA scores, even in the absence of reduced BMI. To explain the observed correlation between increased sensation of dyspnoea and the risk of malnutrition, at least two mechanisms can be proposed. First, it has been demonstrated that quadriceps endurance is reduced in patients with COPD, even in the mild stage of the disease [25]. This weakness of skeletal muscle causes a reduction in the ability to perform physical exercise, and this may, in turn, account for a greater degree of breathlessness [25, 26]. Second, the increased sensation of dyspnoea could be related to the presence of more severe emphysema. If this is the case, dyspnoea and the risk of malnutrition could share common pathogenetic mechanisms. It has been demonstrated that COPD associated with high-resolution computed tomography-documented emphysema is characterised by more severe lung function impairment, more intense airway inflammation, and, possibly, more serious systemic dysfunctioning, as compared with COPD free of HRCT-documented emphysema [27]. Therefore, nutritional alterations could be listed among the clinical manifestations of systemic inflammation in patients with COPD.

The study suffers from several limitations. First, the sample size is small, and consists of almost all males with severe forms of the disease. For these reasons, it cannot be regarded as representative of the COPD population. Secondly, the small number of subjects recruited might have also affected the statistical significance, or the lack of, for the findings. Therefore, a causative relationship between the malnutritional status and the perception of dyspnoea cannot be proposed. Rather, the findings of the study show an association between the two factors, which needs further elucidation.

In conclusion, the current study indicates that, even during the early phases, malnutrition is associated with increased perception of dyspnoea in older patients with COPD. The MNA can be easily performed in older patients to detect early changes in the nutritional status and, therefore, should be included in the comprehensive diagnostic assessment of COPD. Further longitudinal and interventional studies are strongly advocated.

Key points

  • Nutritional abnormalities are recognised as systemic manifestation of COPD, but their contribution to the occurrence of respiratory symptoms is still unclear. The current study aimed at investigating whether differences in nutritional status can influence the perception of dyspnea in individuals with COPD.
  • Thirty-two elderly patients with COPD underwent assessment of their nutritional status through anthropometric measurements and the MNA questionnaire; the perception of dyspnea was assessed by the MMRC Dyspnea Scale.
  • None of the patients was free of dyspnea. When patients were classified according to the level of MNA score, the severity of dyspnea was significantly greater in patients at risk of malnutrition than in the well nourished group.
  • The study shows that patients with COPD with normal BMI but at risk for malnutrition complain of a higher degree of dyspnea compared to well nourished patients with COPD. This finding suggests that early alterations in nutritional status may play a significant role in the perception of symptoms in individuals with COPD.
  • Early detection of nutritional impairment should be included in the clinical assessment of elderly individuals with COPD.

Conflicts of interest

None

Nicola Scichilone*, Giuseppe Paglino, Salvatore Battaglia, Lavinia Martino, Amelia Interrante and Vincenzo Bellia

DIMPEFINU, Università di Palermo, via Trabucco 180, 90146, Palermo, Italy

* To whom correspondence should be addressed E-mail: n.scichilone{at}libero.it

References

  1. Nishimura K, Izumi T, Tsukino M, et al. Dyspnoea is a better predictor of 5-year survival than airway obstruction in patients with COPD. Chest (2002) 121:1434–40.[CrossRef][Web of Science][Medline]
  2. American Thoracic Society. Dyspnoea. Mechanisms, assessment, and management: a consensus statement. Am J Respir Crit Care Med (1999) 159:321–40.[Free Full Text]
  3. Wolkove N, Dajczman E, Colacone A, et al. The relationship between pulmonary function and dyspnoea in obstructive lung disease. Chest (1989) 96:1247–51.[CrossRef][Web of Science][Medline]
  4. Bestall JC, Paul EA, Garrod R, et al. Usefulness of the Medical Research Council (MRC) dyspnoea scale as a measure of disability in patients with chronic obstructive pulmonary disease. Thorax (1999) 54:581–6.[Abstract/Free Full Text]
  5. Sahebjami H, Sathianpitayakul E. Influence of body weight on the severity of dyspnoea in chronic obstructive pulmonary disease. Am J Respir Crit Care Med (2000) 161:886–90.[Abstract/Free Full Text]
  6. Battaglia S, Sandrini MC, Catalano F, et al. Effects of aging on sensation of dyspnoea and health-related quality of life in elderly asthmatics. Aging Clin Exp Res (2005) 17:287–92.[Web of Science][Medline]
  7. Agusti AG, Noguera A, Sauleda J, et al. Systemic effects of chronic obstructive pulmonary disease. Eur Respir J (2003) 21:347–60.[Abstract/Free Full Text]
  8. Wouters EF. Chronic obstructive pulmonary disease. 5: systemic effects of COPD. Thorax (2002) 57:1067–70.[Abstract/Free Full Text]
  9. Schols AM, Wouters EF. Nutritional abnormalities and supplementation in chronic obstructive pulmonary disease. Clin Chest Med (2000) 21:753–62.[CrossRef][Web of Science][Medline]
  10. Schols AM, Soeters PB, Dingemans AM, et al. Prevalence and characteristics of nutritional depletion in patients with stable COPD eligible for pulmonary rehabilitation. Am Rev Respir Dis (1993) 147:1151–6.[Web of Science][Medline]
  11. Vermeeren MA, Creutzberg EC, Schols AM, et al. Prevalence of nutritional depletion in a large out-patient population of patients with COPD. Respir Med (2006) 100:1349–55.[CrossRef][Web of Science][Medline]
  12. Steuten LM, Creutzberg EC, Vrijhoef HJ, et al. COPD as a multicomponent disease: inventory of dyspnoea, underweight, obesity and fat free mass depletion in primary care. Prim Care Respir J (2006) 15:84–91.[CrossRef][Medline]
  13. Arora NS, Rochester DF. Respiratory muscle strength and maximal voluntary ventilation in undernourished patients. Am Rev Respir Dis (1982) 126:5–8.[Web of Science][Medline]
  14. Efthimiou J, Fleming J, Gomes C, et al. The effect of supplementary oral nutrition in poorly nourished patients with chronic obstructive pulmonary disease. Am Rev Respir Dis (1988) 137:1075–82.[Web of Science][Medline]
  15. Guigoz Y, Lauque S, Vellas BJ. Identifying the elderly at risk for malnutrition. The Mini Nutritional Assessment. Clin Geriatr Med (2002) 18:737–57.[CrossRef][Web of Science][Medline]
  16. NHLBI/WHO. Workshop Report: Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Update of the Management Sections. National Institutes of Health; National Heart, Lung, and Blood Institute 2001, Date updated: 1 July 2003, www.goldcopd.com.
  17. American Thoracic Society. Standardization of spirometry, 1994 Update. Am J Respir Crit Care Med (1995) 152:1107–36.[Web of Science][Medline]
  18. Incalzi RA, Bellia V, Catalano F, et al. Evaluation of health outcomes in elderly patients with asthma and COPD using disease specific and generic instruments. Chest (2001) 120:734–42.[CrossRef][Web of Science][Medline]
  19. Mahoney FI, Barthel DW. Functional evaluation: the barthel index. Md State Med J (1965) 14:61–5.[Medline]
  20. Magri F, Borza A, del Vecchio S, et al. Nutritional assessment of demented patients: a descriptive study. Aging Clin Exp Res (2003) 15:148–53.[Web of Science][Medline]
  21. Murphy MC, Brooks CN, New SA, et al. The use of the Mini-Nutritional Assessment (MNA) tool in elderly orthopaedic patients. Eur J Clin Nutr (2000) 54:555–62.[CrossRef][Web of Science][Medline]
  22. Kuzu MA, Terzioglu H, Genc V, et al. Preoperative nutritional risk assessment in predicting postoperative outcome in patients undergoing major surgery. World J Surg (2006) 30:378–90.[CrossRef][Web of Science][Medline]
  23. Soini H, Routasalo P, Lagstrom H. Characteristics of the mini-nutritional assessment in elderly home-care patients. Eur J Clin Nutr (2004) 58:64–70.[CrossRef][Web of Science][Medline]
  24. Barone L, Milosavljevic M, Gazibarich B. Assessing the older person: is the MNA a more appropriate nutritional assessment tool than the SGA? J Nutr Health Aging (2003) 7:13–7.[Medline]
  25. Coronell C, Orozco-Levi M, Mendez R, et al. Relevance of assessing quadriceps endurance in patients with COPD. Eur Respir J (2004) 24:129–36.[Abstract/Free Full Text]
  26. Killian KJ. Limitation to muscular activity in chronic obstructive pulmonary disease. Eur Respir J (2004) 24:6–7.[Free Full Text]
  27. Boschetto P, Quintavalle S, Zeni E, et al. Markers of emphysema are associated with more severe chronic obstructive pulmonary disease. Thorax (2006) 61:1037–42.[Abstract/Free Full Text]

Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us    What's this?



This Article
Right arrow FREE Full Text (PDF) Freely available
Right arrow All Versions of this Article:
37/2/214    most recent
afm143v1
Right arrow E-letters: Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when E-letters are posted
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Scichilone, N.
Right arrow Articles by Bellia, V.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Scichilone, N.
Right arrow Articles by Bellia, V.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?