DOI: 10.1111/eci.

12637

ORIGINAL ARTICLE

Nutritional predictors of mortality after discharge in

elderly patients on a medical ward
Silvio Buscemi*, John A. Batsis†, Gaspare Parrinello*, Fatima M. Massenti‡, Giuseppe Rosafio*,
Vittoria Sciascia*, Flavia Costa§, Sebastiano Pollina Addario¶, Serena Mendola*, Anna M. Barile*,
Vincenza Maniaci*, Nadia Rini* and Gregorio Caimi*
*Dipartimento Biomedico di Medicina Interna e Specialistica (DIBIMIS), Laboratorio di Metabolismo e Nutrizione Clinica,
Policlinico P. Giaccone, University of Palermo, Palermo, Italy, †Section of General Internal Medicine at Dartmouth, The
Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA,
‡
Dipartimento di Scienze per la Promozione della Salute e Materno Infantile, Policlinico P. Giaccone, University of Palermo,
Palermo, Italy, §Servizio di Ingegneria Clinica, Policlinico ‘P. Giaccone’, Palermo, Italy, ¶Dipartimento Attivita

Sanitarie ed
Osservatorio Epidemiologico, Regione Siciliana, Palermo, Italy

ABSTRACT
Background Malnutrition in elderly inpatients hospitalized on medical wards is a significant public health con-
cern. The aim of this study was to investigate nutritional markers as mortality predictors following discharge in
hospitalized medical elderly patients.
Materials and methods This is a prospective observational cohort study with follow-up of 48 months. Two
hundred and twenty-five individuals aged 60 and older admitted from the hospital emergency room in the past
48 h were investigated at the medical ward in the University hospital in Palermo (Italy). Anthropometric and
clinical measurements, Mini-nutritional Assessment (MNA) questionnaire, bioelectrical (BIA) phase angle (PA),
grip strength were obtained all within 48 h of admission. Mortality data were verified by means of mortality
registry and analysed using Cox-proportional hazard models.
Results Ninety (40%) participants died at the end of follow-up. There were significant relationships between
PA, MNA score, age and gender on mortality. Patients in the lowest tertile of PA (< 4
6°) had higher mortality
estimates [I vs II tertile: hazard ratio (HR) = 3
40; 95% confidence interval (CI): 2
01–5
77; II vs III tertile:
HR = 3
83; 95% CI: 2
21–6
64; log-rank test: v2 = 43
6; P < 0
001]. Similarly, the survival curves demonstrated
low MNA scores (< 22) were associated with higher mortality estimates (HR = 1
85; 95% CI: 1
22–2
81
v2 = 8
2; P = 0
004).
Conclusions The MNA and BIA-derived phase angle are reasonable tools to identify malnourished patients at
high mortality risk and may represent useful markers in intervention trials in this high-risk subgroup.
Keywords Bioimpedance, hospitalization, malnutrition, mini-nutritional assessment, mortality, phase angle.
Eur J Clin Invest 2016; 46 (7): 609–618

malnutrition in this subset of patients and selecting biomarkers

Introduction
Malnutrition in elderly inpatients hospitalized on medical
wards is a significant public health concern [1] affecting up to
60–70% of this subpopulation [2,3]. Malnutrition is a well-
established predictor of mortality in hospitalized patients [4,5].
As a recognized independent risk factor for morbidity and
mortality [6,7], malnutrition likely contributes to the posthos-
pital syndrome [8], leading to high rates of 30-day readmissions
following hospital discharge. The cause of readmission often
differs from the original admitting diagnosis [8]. Studies have
found clinical and biochemical indicators that identify
may be useful in predicting clinical events, allowing clinicians
to target specific nutritional interventions [9–11].
Simple and reproducible methods that are clinically practical
and easily available have not been fully validated in longitu-
dinal studies. Among commonly available instruments for
malnutrition screening is the Mini-nutritional Assessment
(MNA) [12], a practical, well known questionnaire with excel-
lent external validity [13]. Alternatively, bioelectrical impe-
dance analysis (BIA) [14] has also been proposed to define a
nutritional state [15,16] based on predictive equations to cal-
culate body composition. However, the applicability of BIA

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 SILVIO BUSCEMI ET AL. www.ejci-online.com

often is questioned in multimorbid patients, [15,17] particularly
in those with disturbed hydration due to medical illness.
Recently, the use of crude BIA measures such as phase angle
(PA) or the vectorial representation of resistance and reactance
has received increasing attention as a plausible indicator of
intra/extracellular hydration and nutritional status [15].
Despite the MNA and PA being possible screening tools for
malnutrition, to our knowledge, there are no data available
about whether they predict postdischarge mortality in hospi-
talized older adults. We investigated whether these emerging
nutritional markers predict mortality following discharge in a
cohort of hospitalized medical elderly patients.
Materials and methods
Participants of this prospective observational cohort study were
recruited each Monday and Wednesday from June 2010 to May
2011, among patients admitted to the Department of Internal
Medicine, Cardiovascular and Kidney Diseases of the University
of Palermo, in Italy. Inclusion criteria consisted of subjects aged
≥ 60 years and admitted to the hospital from the hospital emer-
gency room in the past 48 h. Exclusion criteria consisted of sub-
jects hospitalized within preceding 30 days; resident of a nursing
home facility; the lack of a unique contact person to allow for
future telephone follow-up requests in case a participant expired
or was unable to provide data; lack of a telephone number; low
levels of patient or caregiver education (illiterate or below pri-
mary school level); or the inability to perform BIA due to con-
traindications such as pacemaker, metal implants, or amputation
of limbs. The study was conducted according to the guidelines
laid down in the Declaration of Helsinki, and the protocol was
approved by the Institutional Review Boards at the Biomedical
Department of Internal and Specialist Medicine (DIBIMIS) of the
University of Palermo and at Dartmouth College. Each partici-
pant approved and signed an informed consent form.
A physician not involved in patient care (GP) abstracted the
medical record of all participants. All information was obtained
through patient interview directly or, in the event they were
unable due to a health condition, a collateral history from a
family member or caregiver was obtained. The MNA was
administered by GR, SM, VM, AB, NR as described elsewhere
[9,18]. A MNA total score of < 17 was indicative of malnutrition
and a score of 17–23
5 indicative of risk of malnutrition [18].
Discharge diagnoses were classified using International Clas-
sification of Diseases-9 codes and classified by the discharging
physician [http://www.who.int/classifications/icd/en
accessed on 12 October 2013].
Clinical measurements
Systolic blood pressure and diastolic arterial blood pressure
were assessed at 5-min intervals in the seated position and
performed twice using standardized procedures (Omron M6;
Omron Healthcare Co., Matsusaka, Mie, Japan). Height, body
weight (SECA; Hamburg, Germany) and body circumferences
(nondominant arm and calf circumference) were measured
with participants lightly dressed and without shoes. Body mass
index (BMI) was calculated as body weight (kg)/height2 (m2).
In the case of patients unable to maintain the upright position,
height was obtained using a predictive equation [19] based on
the leg length measured using a calliper as the distance
between the heel and the kneecap. Grip strength was measured
using a hydraulic hand dynamometer (JAMAR SH5001, Sae-
han, Republic of Korea). Patients performed the test while sit-
ting with their shoulder adducted and forearm neutrally
rotated, elbow flexed to 90°, and forearm and wrist in a neutral
position. Patients were instructed to perform a maximal iso-
metric contraction. The test was repeated within 15–20 s, with
each hand and the average value (kg) of the three tests was
used for the analysis [20].
Bioimpedance analysis
Bioelectrical impedance analysis was performed (GR, SM, VM,
AB, NR) as previously described [21,22] using an 800 mA,
50 kHz, tetrapolar impedance plethysmograph (BIA; BIA-103,
RJL, Detroit, USA/Akern Florence, Italy) to obtain body resis-
tance (R, Ohm), reactance (Xc, Ohm) and PA (PA
degrees = arctan (Xc/R)∙(180/p).). Patients were assessed in
the morning after an overnight fast, in the supine position with
arms and legs abducted from the body. Source and sensor
electrodes were placed on the dorsum of both the hand and foot
of the dominant side of the body.
Laboratory analysis
Blood test results were abstracted from the medical record at
the time of admission. We recorded the following tests: fasting
plasma glucose, cholesterol, triglycerides, high-density
lipoprotein (HDL) cholesterol, white blood cells (WBC), hae-
moglobin, albumin. Low-density lipoprotein (LDL) cholesterol
concentration was calculated using the Friedewald’s formula.
Follow-up information
Patients were contacted by telephone at 4-month intervals
( 1 month) following discharge. A 10- to 15-min telephone
interview was conducted using a standardized template of
questions by SM and VM. The interview determined changes in
health status, new episodes of hospitalization, changes in
medications, socio-environmental and nutritional conditions.
Patients or their caregivers were interviewed face to face in the
clinic or assessments performed by telephone. Mortality was
ascertained by telephone interview by the study assistant who
obtained information from the family. Mortality data were
additionally verified by linking participants to the Sicilian

610 ª 2016 Stichting European Society for Clinical Investigation Journal Foundation
 MORTALITY AND NUTRITIONAL PREDICTORS

regional mortality registry at the Epidemiologic Observatory of Table 1 International Classification of Diseases-9 discharge
the Regional Department of Health (Palermo, Italy); this pro- diagnoses
cedure allowed also to obtain mortality data of participants that ICD-9 codes n %
were lost at telephone contact.
1–139 Infectious and parasitic diseases 2 0
9

Data analysis 140–239 Neoplasms 19 8
4

Results are presented as mean  standard deviation or counts 240–279 Endocrine, nutritional and metabolic 28 12
4
(prevalence). Variables of interest were divided into tertiles of diseases, and immunity
PA (lowest (I) tertile < 4
6°, middle (II) tertile 4
6–6
1° and
280–289 Diseases of the blood and 4 1
8
highest (III) tertile > 6
1°) and according to the median value blood-forming organs
(< 22 and ≥ 22) for MNA score. A one-way ANOVA was applied
390–459 Diseases of the circulatory system 72 32
0
to investigate differences between tertiles and Tukey’s test for
comparison between each couple of tertiles. Student’s unpaired 460–519 Diseases of the respiratory system 42 18
7
t-test or Pearson chi-square test was applied to evaluate dif- 520–579 Diseases of the digestive system 13 5
8
ferences between participants who survived and those who
580–629 Diseases of the genitourinary system 38 16
9
died. The primary outcome was all-cause mortality. We created
Cox-proportional hazard models, general and time modelled 680–709 Diseases of the skin and 2 0
9
(censoring at 4, 8, 12, 24, 36, 48 months), including the follow- subcutaneous tissue
ing covariates: age, gender, BMI, muscle strength, number of 710–739 Diseases of the musculoskeletal 3 1
3
comorbidities and total MNA score to identify the impact of PA system and connective tissue
(primary predictor) on death. Laboratory variables were 780–799 Symptoms, signs and 2 0
9
included in the general model if they were significantly dif- ill-defined conditions
ferent between participants who survived and those who died.
Total 225 100
0
There was no collinearity between our two main predictors, PA
and MNA (variance inflation factor = 1
00). Kaplan–Meier
survival curves were constructed, and outcome differences
100
were evaluated using the log-rank test. Hazard ratios with 95%
confidence intervals were presented. The referent category was 90
Survival probability (%)

lowest tertile of PA and lowest MNA score, respectively. A

80
P-value of < 0
05 was considered statistically significant. All
statistical analyses were performed using MEDCALC Statistical 70

Software version 13
3
3 (MedCalc Software bvba, Ostend, Bel- 60

HR (CI 95%) for death:

gium; http://www.medcalc.org; 2014). I vs II tertile 3·40 (2·01-5·77);

50 I vs III tertile 3·83 (2·21-6·64)
Reporting of the study conforms to STROBE statement along
with references to STROBE statement and the broader 40
EQUATOR guidelines.
30
0 10 20 30 40
Results Time (months)

Two hundred and twenty-five patients survived to hospital Time (months) 4 12 24 36 48

discharge. We present the cohort’s discharge diagnoses in Deaths (n) 18 35 62 73 88

Table 1. BIA measurements were performed in 192 patients
(85
3%). Telephone interviews were obtained at 4 months in
225 (100%) patients, in 200 (88
9%) patients at 12 months, in 162
(72
0%) patients at 24 months, in 89 (39
6%) patients at
36 months and in 48 (18
8%) patients at 48 months. Complete
mortality data at each time point, as obtained from mortality
public registry, are reflected in Figs 1 and 2. Mean survival was
31  15 months (range 1–48), and 90 participants of 225 died
(40
0%) at the end of follow-up (Figs 1 and 2). Demographic
and clinical characteristics of our included cohort are presented
Phase Angle tertiles - blue: I tertile <4·6°; green: II tertile 4·6°-6·1°; orange: III tertile >6·1°
Log-rank test: χ2 = 43·6; P< 0·001
Figure 1 Kaplan–Maier survival probability curves according to
the tertile of bioelectrical phase angle in 192 patients aged
≥ 65 years after discharge from Internal Medicine hospital wards.
in Table 2, including those who died and survived at
48 months. The prevalence of malnutrition at time of hospital
admission using the MNA was 17
3% (n = 39), while 56
4%

European Journal of Clinical Investigation Vol 46 611

 SILVIO BUSCEMI ET AL.
100
90
Survival probability (%)
80
70
60
50
40
0 10 20 30
Time (months)
Time (months) 4 12
Deaths (n) 18 35
MNA total score (< median value = blue; ≥ median value = green; median value = 22)
Log-rank test: χ2 = 8·2; P = 0·004
Figure 2 Kaplan–Maier survival probability curves according
to the median value of Mini-nutritional Assessment score in
225 patients aged ≥ 65 years after discharge from Internal
Medicine hospital wards.
(n = 127) of participants were at risk of malnutrition. Partici-
pants who died were older, had a higher number of offspring, a
lower hypertension rates and similar rates of coronary heart
disease, type 2 diabetes and chronic renal failure. Patients who
died had no different discharge diagnoses as compared to those
alive at follow-up (data not shown). The clinical characteristics
of the participants classified according to the tertile of bioelec-
tric phase angle are presented in Appendix 1. The MNA score
was significantly correlated with BMI (r = 0
26; P < 0
001).
Cox-proportional hazard model demonstrated significant
relationships for PA, MNA score, age and gender on mortality,
while BMI, number of comorbidities, muscle strength, serum
concentrations of haemoglobin and albumin had no significant
effect (Table 3). Censoring participants at each time of follow-
up resulted in different time models for death (Table 4). Age
and sex-specific interactions were tested in each model and
were not significant (data not shown). In particular, only PA
resulted significantly in associations with death at each study
time point. Figure 1 demonstrates Kaplan–Meier survival
curves suggesting that patients with the lowest tertile of PA
had higher adjusted mortality estimates. Similarly, the survival
curves demonstrated that the median MNA score discrimi-
nated survival probability (Fig. 2).
Of participants with both PA and MNA scores available
(n = 192), 25 (13%) had a readmission within 4 months after
612 ª 2016 Stichting European Society for Clinical Investigation Journal Foundation
www.ejci-online.com
discharge (no = 0; yes = 1). These individuals were examined
HR (CI 95%) for death:
using logistic regression analysis, and we demonstrated that
Low vs. High MNA score
PA (P = 0
02) and MNA scores (P = 0
006) were independently
1·85 (1·22-2·81) associated with readmission within 4 months. The OR (95%
confidence interval) for readmission was 0
69 (0
51–0
95) for PA
and 0
86 (0
78–0
96) for MNA score.
Discussion
Our data are the first to identify the importance of considering
PA as a mortality predictor following discharge in elderly
inpatients. This important finding in a population at risk of
40 50 malnutrition provides additional evidence that tools other than
MNA should be considered to identify patients at risk of death
24 36 48 posthospitalization.
Our data are consistent with other studies demonstrating that
63 74 90 PA is predictive of in-hospital mortality in geriatric patients
[23] or in conditions with persons with multimorbidity,
including cancer [24–26], haemodialysis [27], human immun-
odeficiency virus infection [28], and amyotrophic lateral scle-
rosis [29]. Our study suggests that PA independently is
associated with mortality after discharge from hospital in
patients with different clinical conditions suggesting that even
in complex patients, there may be utility in using this measure
for predictive modelling.
Considering the three groups based on the tertiles of PA
groups (Appendix 1), we did not observe any significant dif-
ference in terms of age, gender and associated comorbidities;
however, the low PA group exhibited characteristics suggestive
of malnutrition and frailty. In this group, we demonstrated
lower body weight, muscle strength and MNA score, lower
blood concentrations of albumin and haemoglobin and higher
WBC concentrations than higher PA groups. Notably, we did
not measure specific parameters of inflammation (i.e. hs-C-
reactive protein, interleukin-6, tumour necrosis factor-a). The
finding of higher WBC concentrations in patients with poorer
PA value may likely reflect a general tendency towards
inflammation that has been associated with both increased risk
of mortality [30,31] and malnutrition/frailty condition in the
elderly hospitalized patient [32,33]. The value of using PA in
highlighting both individual clinical and nutritional conditions
may be explained using the BIA theory [34]. PA is inversely
related with the extracellular/intracellular water ratio (ECW/
ICW); therefore, a low PA value is in consequence of high
ECW/ICW value, a condition that occurs when the absolute or
relative amount of ECW is increased [15,35]. An increased
ECW/ICW value may result from compromised general clini-
cal conditions due to altered cellular (i.e. membrane sodium/
potassium pumps) functioning as well as from altered nutri-
tional states characterized by loss of body cell mass and the
consequent loss of ICW. Impaired clinical or nutritional
 MORTALITY AND NUTRITIONAL PREDICTORS

Table 2 Baseline characteristics of patients aged ≥ 65 years after discharge from hospital
Participants
All (N = 225) Alive (N = 135) Dead (N = 90) P*

Age (years) 74  8 72  8 77  8 < 0
001

Gender, male sex (n, %) 165 (73
3) 95 (70
4) 70 (77
8) < 0
05
Follow-up (months) 31  15 39  10 18  12 < 0
001
Offspring (n) 2
9  1
8 2
6  1
6 3
5  2
3 0
002
Smoking
Current smoker (n, %) 22 (9
8) 14 (10
4) 8 (8
9) 0
89
Cigarettes (n/day) 1
4  4
7 1
4  4
8 1
4  4
8 0
96
Never smoker (n, %) 81 (36
0) 46 (34
1) 35 (38
9) 0
54
Comorbidity
Hypertension (%) 147 (65
3) 105 (77
8) 42 (46
7) < 0
001
Type 2 diabetes (%) 89 (39
6) 57 (42
2) 32 (35
6) 0
70
Coronary heart disease (%) 102 (45
3) 62 (45
9) 40 (44
4) 0
60
Chronic renal failure (%) 69 (30
7) 41 (30
4) 28 (31
1) 0
51
Body weight (kg) 74
8  17
7 76
8  18
6 71
1  15
3 0
02
Body mass index (kg/m ) 2
27
8  5
7 28
7  6
2 26
3  4
5 < 0
001
Body circumferences
Arm (cm) 26
0  5
0 26
7  4
7 24
8  5
2 0
008
Calf (cm) 32
5  4
2 33
3  4
3 31
2  3
7 < 0
001
Bioelectrical characteristics (n = 192)
Resistance (Ohm) 539  106 539  95 539  123 0
99
Reactance (Ohm) 54  26 56  23 51  30 0
29
Phase angle 5
5  1
9 5
9  1
8 4
8  2
0 0
03
Handgrip test (kg) 22
2  8
6 23
6  8
4 19
8  8
5 0
02
MNA (total score) 21  4 22  4 20  4 < 0
001
Laboratory parameters
Glucose (mg/dL) 121  61 119  61 124  62 0
63
Total cholesterol (mg/dL) 160  46 163  44 155  50 0
33
HDL cholesterol (mg/dL) 43  17 43  16 42  19 0
71
Triglycerides (mg/dL) 124  63 129  66 116  58 0
17
LDL cholesterol (mg/dL) 91  33 94  35 85  28 0
12
Haemoglobin (g/dL) 12
0  2
3 12
3  2
2 10
9  2
1 < 0
001
White blood cells (cells/mm
10 )
3 3
8589  4941 8302  5005 9547  4643 0
11
Albumin (g/dL) 3
5  0
7 3
6  0
7 3
2  0
7 < 0
001
HDL, high-density lipoprotein; LDL, low-density lipoprotein; MNA, Mini-nutritional Assessment (score: < 17 = malnutrition; 17–23
5 = risk of malnutrition).
Data are: mean  SD or prevalence.
Participants alive and dead at follow-up assessment.
Handgrip test represents mean value of both hands.
*Unpaired Student’s t-test or Pearson chi-square test when appropriate.

European Journal of Clinical Investigation Vol 46 613

 SILVIO BUSCEMI ET AL. www.ejci-online.com

Table 3 General-modelled Cox-proportional hazard for
mortality in 192 patients aged ≥ 65 years after discharge from
Internal Medicine hospital wards
HR
Phase angle 0
78
MNA 0
95
Age 1
04
Gender* 0
42
BMI 0
98
Muscle strength †
0
98
‡ this at-risk population, at least in the long run. Surprisingly, we
Comorbidities 0
99
Serum concentrations of
Haemoglobin 0
90
Albumin 0
82
HR, hazard ratio; CI, confidence interval; BMI, body mass index; MNA,
Mini-nutritional Assessment.
*Male = 1, female = 2.
†
Handgrip test.
‡
Total number of comorbidities: type 2 diabetes, hypertension, coronary
heart disease, congestive heart failure, chronic obstructive pulmonary dis-
ease, chronic renal failure, liver cirrhosis, malignant cancer, dementia.
conditions may be associated with low PA values and can
possibly explain our findings that PA may predict mortality
and that PA is a measure of cell mass, nutritional risk and
general health [34]. In fact, BIA is not a direct method for the
assessment of body composition and its accuracy as an indi-
cator of body composition relies largely on the use of appro-
priate regression equations that may not be applicable in
patients with disturbed hydration or altered distribution of
ECW/ICW. Our results suggest that we can bypass standard
mathematical equations and use raw parameters to elicit
hydration and body cell status [15]. Our study is based upon
posthospitalization mortality that differs from those previously
published that describe in-hospital mortality [6, 7]. Future
studies measuring the PA likely could permit to identify the
subgroup of malnourished patients with high mortality risk to
be included in nutritional intervention trials in order to
demonstrate the efficacy of treatment of illness-related malnu-
trition, a field that is still lacking of adequate evidence [36].
Our mortality estimates are not trivial and potentially may
provide a new line of research. Clinicians currently have
limited modalities in assessing malnutrition in hospitalized
adults. These results suggest that BIA has improved predictive
validity over MNA. This is important clinically in that BIA
can easily be performed in hospitalized patients, and is less
labour-intensive than the MNA. MNA requires trained staff
spending at least 15 min with patients or caregivers. Low PA
likely is a nonspecific measure suggestive of impaired home-
ostasis, a characteristic observed in frailty. Future study
should determine whether PA impacts shorter-term function
95% CI and recovery from the negative effects of hospitalizations, but
also investigate the impact on serological inflammatory
0
64–0
95
biomarkers such as C-reactive protein, interleukin-6 and
0
90–0
99 tumour necrosis factor-a.
1
01–1
07 Our results also paralleled those observed by others noting
that low MNA scores predict poor outcomes in geriatric hos-
0
24–0
74
pitalized patients [37]. While this was not surprising, the fact
0
94–1
03 that the relationship was not modified by PA at 48 months
0
94–1
02 suggests that both could potentially be biomarkers for death in
0
83–1
17
did not observe any impact of grip strength on mortality. One
possible explanation is there may be an interplay between
0
82–1
03 nutritional status and grip strength and that MNA score or PA
led to its nonsignificance. This is purely hypothetical, and we
0
58–1
15
suggest further studies to reproduce these results.
Adequate data concerning the general prevalence of hospital
malnutrition in Italy are lacking. As in other reports [38,39],
we found a high prevalence of malnutrition and risk of mal-
nutrition among the nonsurgical elderly patients included in
this study. Our results are in agreement with a study
demonstrating poor outcomes in terms of in-hospital and long-
term mortality in geriatric hospitalized patients with low
MNA score [37]. The group of patients who died during fol-
low-up exhibited poorer clinical and nutritional characteristics
(Table 2). However, PA was uniquely associated with survival
length probability. In fact, individuals with a PA < 4
6° at
admission had less chance of survival following discharge.
These values closely approximate PA values that other studies
[16,23] demonstrated to be critical for survival in similar group
of patients.
Our study also demonstrates that rate of rehospitalization
4 months after discharge was predicted by a low PA. This
result may be analysed in view of the recently described
‘posthospital syndrome’ a condition concerning patients dis-
charged from hospital that have an acute medical problem
within the subsequent 30 days necessitating another hospital-
ization often for conditions different from the initial diagnosis
[8,40–42]. The sample size of the cohort considered in this study
was too small to analyse data relative to 30-day rehospitaliza-
tion rate; however, the results concerning 4-month rehospital-
ization are in agreement with the possibility that PA may also
be a good candidate to predict 30-day posthospital syndrome.
This is a hypothesis that remains to be investigated by specifi-
cally designed trials.
Our analysis has some important limitations that should be
acknowledged. First, BIA was not performed at discharge and
this information would have greatly increased the quality of
information. We relied on BIA measurement during the

614 ª 2016 Stichting European Society for Clinical Investigation Journal Foundation
 MORTALITY AND NUTRITIONAL PREDICTORS

1
09 (0
79–1
50) hospital stay and hence factors that could impact body com-
1
23 (0
93–1
61)
1
16 (0
91–1
46)
0
96 (0
79–1
16)
0
96 (0
79–1
16)
0
96 (0
81–1
14)
Comorbidities‡
Table 4 Time-modelled Cox-proportional hazard for mortality in 192 patients aged ≥ 65 years after discharge from Internal Medicine hospital wards

Total number of comorbidities: type 2 diabetes, hypertension, coronary heart disease, congestive heart failure, chronic obstructive pulmonary disease, chronic renal failure, liver
position and fluid shifts could conceivably impact our results. It
remains unclear whether mortality rate was lower in those
patients whose PA improved at discharge. A limitation is the
heterogeneity of the patient population; however, this may be a
result of our real-life study design and likely reflects reliability.
Another limitation of the present study is that the role of
Muscle strength†

1
01 (0
93–1
11)
0
99 (0
92–1
07)
0
99 (0
92–1
07)
0
97 (0
93–1
01)
0
97 (0
93–1
01)
0
96 (0
92–1
00)
comorbidities could not be investigated as the number of cases
included was rather limited to allow an adequate analysis of
the effect of comorbidity. We attempted to overcome this lim-
itation by including the number of comorbidities in the
regression analysis which was not significant. While we had
complete mortality ascertainment, future study with adequate
0
99 (0
88–1
12)
1
01 (0
93–1
12)
0
99 (0
92–1
07)
0
98 (0
93–1
03)
0
98 (0
93–1
03)
0
99 (0
95–1
04)

deaths can allow for such an examination.

In conclusion, both malnutrition and risk of malnutrition are
important clinical aspects in hospitalized elderly patients that
should be promptly recognized. MNA and BIA-derived phase
BMI

angle are reasonable tools to identify patients at high mortality

risk and may represent useful markers in intervention trials in
this high-risk subgroup.
0
86 (0
27–2
78)
0
49 (0
16–1
47)
0
67 (0
29–1
56)
0
54 (0
29–1
01)
0
54 (0
29–1
01)
0
41 (0
24–0
68)

Acknowledgments
Gender*

We are gratefully indebted with Professor Antonio Craxi

HR, hazard ratio; CI, confidence interval; BMI, body mass index; MNA, Mini-nutritional Assessment.

(University of Palermo, Italy) for logistic support and very

stimulating comments during manuscript preparation.
1
05 (0
98–1
13)
1
04 (0
99–1
10)
1
05 (1
01–1
11)
1
06 (1
03–1
10)
1
06 (1
03–1
10)
1
02 (1
00–1
05)

Funding sources
This research was supported in part by the no profit Associ-
azione Onlus Nutrizione e Salute, Palermo, Italy.
Age

Conflict of interest statement

None to disclose.
0
89 (0
78–1
03)
0
92 (0
82–1
03)
0
95 (0
87–1
04)
0
96 (0
90–1
02)
0
96 (0
90–1
02)
0
92 (0
87–0
97)

Address
Dipartimento Biomedico di Medicina Interna e Specialistica
MNA

(DIBIMIS), Laboratorio di Metabolismo e Nutrizione Clinica,

Policlinico P. Giaccone, University of Palermo, Via del vespro
129, 90127 Palermo, Italy (S. Buscemi, G. Parrinello, G. Rosafio,
0
34 (0
22–0
62)
0
46 (0
30–0
69)
0
49 (0
35–0
69)
0
77 (0
62–0
97)
0
77 (0
62–0
97)
0
84 (0
69–0
99)

V. Sciascia, S. Mendola, A. M. Barile, V. Maniaci, N. Rini, G.

Phase angle
HR (95% CI)

Caimi); Section of General Internal Medicine at Dartmouth,

cirrhosis, malignant cancer, dementia.

Geisel School of Medicine at Dartmouth, The Dartmouth

Institute for Health Policy & Clinical Practice, Lebanon, NH
03756, USA (J. A. Batsis); Dipartimento di Scienze per la Pro-
mozione della Salute e Materno Infantile, Policlinico P. Giac-
Model 3 (12 months)
Model 4 (24 months)
Model 5 (36 months)
Model 6 (48 months)

cone, University of Palermo, Via del vespro 129, 90127 Palermo,

Model 1 (4 months)
Model 2 (8 months)

*Male = 1, female = 2.

Italy (F. M. Massenti); Servizio di Ingegneria Clinica, Policlinico

‘P. Giaccone’, Via del vespro 129, 90127 Palermo, Italy (F.
Handgrip test.

Costa); Dipartimento Attivit
a Sanitarie ed Osservatorio Epi-

demiologico, Regione Siciliana, Via del vespro 129, 90127
Palermo, Italy (S. Pollina Addario).
†
‡

European Journal of Clinical Investigation Vol 46 615

 SILVIO BUSCEMI ET AL.
Correspondence to: Silvio Buscemi, Dipartimento Biomedico di
Medicina Interna e Specialistica (DIBIMIS), Laboratorio di
Metabolismo e Nutrizione Clinica, Policlinico P. Giaccone, Via
del Vespro 129, 90127 Palermo, Italy. Tel.:+39-91-6554580; fax:
+39-91-6554580; e-mail: silbus@tin.it
Received 16 December 2015; accepted 22 April 2016
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Appendix 1 Anthropometric, demographic and clinical characteristics of the participants classified according to the tertile of bioelectric phase angle

Phase angle tertile

I (N = 61) II (N = 68) III (N = 63) P†

Age (year) 75  9 75  7 73  8 0.14

Gender, male sex (n, %) 37 (60.6) 45 (66.2) 48 (76.2) 0.18
Offspring (n) 3.3  2.0 2.9  1.8 3.1  1.9 0.72
Smoking
Current smoker (n, %) 1 (0.02) 7 (10.3) 6 (9.5) 0.20
Cigarettes (n/day) 0.2  1.3 1.3  4.8 1.6  5.3 0.19
Never smoker (n, %) 30 (49.2) 27 (39.7) 24 (38.1) 0.32
Prevalence of
Hypertension (%) 37 (60.7) 48 (70.6) 37 (58.7) 0.44
Duration of hypertension (year) 9.6  15.6 8.3  11.9 7.0  10.0 0.81
Type 2 diabetes (%) 22 (36.1) 22 (32.4) 22 (34.9) 0.90
Duration of type 2 diabetes (year) 2.6  6.6 3.8  7.6 4.1  8.5 0.81
Coronary heart disease (%) 24 (39.3) 29 (42.6) 19 (30.2) 0.59
Duration of coronary heart disease (year) 0.0  0.0 0.8  4.0 0.1  0.4 0.46
Chronic renal failure (%) 21 (34.4) 16 (23.5) 16 (25.4) 0.51
Duration of chronic renal failure (year) 0.2  0.5 1.2  4.4 0.9  2.5 0.56
Body weight (kg) 70.7  15.4 75.2  15.5 79.7  21.2 0.05
BMI (kg/m )2
27.1  5.1 28.3  5.5 29.4  6.1 0.14
Laboratory parameters
Glucose (mg/dL) 129  53 112  42 111  52 0.17
Total cholesterol (mg/dL) 155  48 162  51 162  42 0.72
HDL cholesterol (mg/dL) 43  18 42  17 47  16 0.36
Triglycerides (mg/dL) 132  73 125  69 112  54 0.43
LDL cholesterol (mg/dL) 81  32 94  35 95  37 0.26
Bioelectrical characteristics

European Journal of Clinical Investigation Vol 46 617

 SILVIO BUSCEMI ET AL. www.ejci-online.com

Appendix 1 Continued
Phase angle tertile
I (N = 61) II (N = 68) III (N = 63) P†

Resistance (Ohm) 541  116 534  97 542  93 0.92

Reactance (Ohm) 35  10 50  10* 77  29* ** ,
< 0.001
Phase angle 3.6  0.7 5.3  0.5* 8.1  2.4* ** ,
< 0.001
Handgrip test
Average (kg) 15  8 23  10*** 21  7 0.01
Mini-nutritional Assessment (score)
Total valuation 20  4 22  4* 23  4 0.002
BMI, body mass index; MNA, Mini-nutritional Assessment.
Data are: mean  SD or prevalence.
†
ANOVA or Pearson chi-square test when appropriate.
Tukey’s test:
*P < 0.001 vs. phase angle tertile I; **P < 0.001 vs. phase angle tertile II; ***P < 0.001 vs. phase angle tertile I.

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