Early Nutritional Follow-up after Discharge Prevents Deterioration of Adl Functions in Malnourished, Independent, Geriatric Patients Who Live Alone – A Randomized Clinical Trial

Dear Editor,

We want to thank the respondents; Tatsuro Suzuki, Keisuke Maeda and Hidetaka Wakabayashi, for their comments on our paper. The responders search for clarification on issues related to 1) the causes of hospitalization, 2) description of the rehabilitation, 3) the power calculation.

Our study was focused on nutritional follow-up after discharge (1) and the possible changes in ADL during the first eight weeks after discharge from hospital. The population in our study was older individuals who lived independently and alone, which increases the risk of malnutrition (2). After discharge from hospital, the majority of the study population became dependent on daily help from the home care facilities and were at a major risk of losing self-care ability and independency (3) due to the consequences of disease and hospitalization. As hip fracture was the most frequent cause of admission to hospital (42%), we reported this cause. Other causes of hospitalization in our study were pneumonia (10%), urinary tract infection (8%), cardiovascular disease (8%), falls (6%), COPD (6%), other infections (4%), dehydration (2%), cerebral disease (2%), and a mixed group of patients suffering from pain, malnutrition, cancer, constipation, osteoporosis (12%). These causes were equally distributed between the randomization groups.

During hospital stay the patients received comprehensive geriatric assessment and care provided by physicians, nurses, physiotherapists, and occupational therapists. After discharge all study participants received individualized rehabilitation from the community health care, but we do not know the type, the extent and frequency of the rehabilitation. What we know is that eight weeks after discharge 26% of the participants received individualized physical training by community based physiotherapists (home visit group: 23%, telephone group: 37%, control group: 19%; p=0.08).

All patients were stratified according to the Mini Nutritional Assessment and subsequently allocated to one of three randomization groups (home visit, telephone consultation, control group). The randomization is supposed to balance the confounding factors between groups, for example in relation to rehabilitation after discharge.

Prior to commencement of the study, the number of participants needed was calculated to be 144 (48 in each of the three groups). At completion of the study, no statistical significant difference was detected between groups regarding median change in ADL (Barthel-100 score). On the other hand, we found statistical significance difference in favour of home visits in the number of participants who maintained or improved their ADL.