营养相关参数对急诊老年患者衰弱的预测价值研究

Correlation between Nutrition-related Parameters and Frailty among Older Adults in the Emergency Department

背景营养作为一种可干预的重要因素与衰弱的发生密切相关,早期通过营养评价识别衰弱进而逆转其发生对于改善临床结局具有重要意义,目前关于营养指标对急诊老年患者衰弱的预测价值研究相对较少。目的探讨临床常用营养相关参数对急诊老年患者衰弱的预测价值。方法纳入2021年1—10月就诊于中国康复研究中心(北京博爱医院)急诊科的年龄≥65岁患者210例为研究对象,记录患者的人口学资料,所有患者入院24 h内采集空腹静脉血测定血常规检查指标,采用营养风险筛查2002(NRS2002)评估患者营养风险,采用巴氏指数评定表(BI)评估患者基本日常生活活动能力,采用临床衰弱量表(CFS)评估患者衰弱严重程度。依据患者CFS评级,将患者分为非衰弱组(CFS 1~4级,n=68)和衰弱组(CFS 5~9级,n=142)。采用多因素Logistic回归分析探究急诊老年患者发生衰弱的影响因素。利用Hosmer-Lemeshow检验和受试者工作特征曲线(ROC曲线)评价营养参数对急诊老年患者衰弱发生的预测价值,并采用De Long非参数检验对比各指标的ROC曲线下面积(AUC)。结果两组患者年龄、性别、BMI、冠心病占比、血红蛋白(HGB)、清蛋白(ALB)、前白蛋白(PA)、超敏C反应蛋白(hs-CRP)、25羟维生素D[25(OH)D]、NRS2002评分、BI评分、住院时间比较,差异有统计学意义(P<0.05)。多因素Logistic回归分析结果显示,PA[OR=0.943,95%CI(0.891,0.998),P=0.041]、25(OH)D[OR=0.909,95%CI(0.844,0.979),P=0.012]升高是急诊老年患者衰弱的保护因素,PA每增加100 mg/L,衰弱的患病风险下降44.6%;25(OH)D每增加10μg/L,衰弱患病风险下降61.7%。NRS2002评分[OR=1.701,95%CI(1.353,2.138),P<0.001]升高是急诊老年患者衰弱发生的危险因素,NRS2002评分每增加1分,衰弱的患病风险增加70.1%。Hosmer-Lemeshow检验结果显示,PA(χ^(2)=6.120,P=0.634)、25(OH)D(χ^(2)=5.386,P=0.716)和NRS2002评分(χ^(2)=4.758,P=0.446)的拟合优度均较好。绘制营养相关参数预测急诊老年患者发生衰弱的ROC曲线,结果显示PA、25(OH)D和NRS2002评分的最佳截断值分别为211.9 mg/L、7.06μg/L、3分,AUC分别为0.749、0.670、0.835。De Long非参数检验结果显示,NRS2002评分预测急诊老年患者发生衰弱的AUC大于PA(Z=2.241,P=0.025)和25(OH)D(Z=3.400,P<0.001)。结论衰弱患者营养状态差,营养状态的评价有助于早期识别衰弱。PA、25(OH)D、NRS2002评分能有效预测急诊老年患者衰弱的发生,其中NRS2002评分预测衰弱发生的能力较强。

Background As an important modifiable factor that can be intervened,nutrition is closely related to the occurrence of frailty.Early identification of frailty through nutrition evaluation and reversal of its occurrence is of great significance for improving clinical outcomes.There are few available studies on the predictive value of nutrition-related parameters for frailty among older patients in the emergency department(ED).Objective To evaluate the relationship between commonly used nutrition-related parameters and frailty among older adults in the ED.Methods Two hundred and ten people aged≥65 years were recruited from the Department of Emergency Medicine,China Rehabilitation Research Center(Beijing Bo'Ai Hospital)from January to October 2021.The demographic data were recorded.Fasting venous blood sample was collected within 24 hours after admission to measure routine indicators.The nutritional risk was assessed by Nutrition Risk Screening 2002(NRS2002).The basic activities of daily living were evaluated by Barthel Index(BI).The Clinical Frailty Scale(CFS)was used to assess frailty,and individuals with CFS levels 1-4(n=68)and those with CFS levels 5-9(n=142)were assigned to non-frail group and frail group,respectively.Multivariable Logistic regression was used to analyze the factors associated with frailty in older patients in the ED.Hosmer-Lemeshow test and receiver operating characteristic(ROC)curve were used to evaluate the predictive validity of nutrition-related parameters for frailty in older patients in the ED.Nonparametric DeLong test was used to compare the area under the ROC curve(AUC)of each parameter.Results There were statistically significant differences between frail and non-frail patients in mean age,sex ratio,mean body mass index(BMI),prevalence of coronary heart disease,mean levels of hemoglobin(HGB),albumin(ALB),prealbumin(PA),high-sensitivity C-reactive protein(hs-CRP)and 25-hydroxyvitamin D〔25(OH)D〕,and mean score of NRS2002,as well as mean BI and length of hospital stay(P<0.05).Multivariable Logistic regression analysis showed that higher PA〔OR=0.943,95%CI(0.891,0.998),P=0.041〕and 25(OH)D〔OR=0.909,95%CI(0.844,0.979),P=0.012〕were protective factors of frailty in older patients in the ED.The risk of frailty decreased by 44.6%for every 100 mg/L increase in PA,and decreased by 61.7%for every 10μg/L increase in 25(OH)D.However,higher NRS2002 score〔OR=1.701,95%CI(1.353,2.138),P<0.001〕was the risk factor of frailty in older patients in the ED,and the risk of frailty increased by 70.1%for every one score increase in NRS2002 score.Hosmer-Lemeshow test showed PA(χ^(2)=6.120,P=0.634),25(OH)D(χ^(2)=5.386,P=0.716)and NRS2002 score(χ^(2)=4.758,P=0.446)had good goodness of fit.ROC analysis demonstrated showed that the optimal cutoff values of PA,25(OH)D and NRS2002 score for predicting frailty in older patients in the ED were 211.9 mg/L,7.06μg/L and 3 points,respectively,and the AUCs of them were 0.749,0.670 and 0.835,respectively.Nonparametric DeLong test showed that the AUC of NRS2002 score was greater than that of PA(Z=2.241,P=0.025)and 25(OH)D(Z=3.400,P<0.001).Conclusion As frail patients have poor nutritional status,nutritional assessment contributes to early identification of frailty.Among the nutrition-related parameters,PA,25(OH)D and NRS2002 score can effectively predict frailty in older patients in the ED,and NRS2002 score may have the strongest predictive ability.