Prevalence of hypoalbuminemia and nutritional issues in hospitalized elders

ABSTRACT Objective: to estimate the prevalence of hypoalbuminemia in hospitalized elders, related to socio-demographic variables, nutritional status and length of stay. Methods: crosscutting study with 200 patients hospitalized in a large hospital in the South of Brazil during three months. Evaluations, lab tests and interviews through questionnaires were performed. Results: the average albuminemia was 2,9 ± 0,5g/dL. Hypoalbuminemia was diagnosed in 173 subjects (87%) and was absent in 27 (13%) that have normal albuminemia (p=0,000). After six days of hospitalization, the prevalence of low levels grew significantly to 90% (p=0,002), average 2,7 ± 0,5g/dL. Using the Mini Nutritional Assessment, it was observed that 41 patients were malnourished and from those, 40 had hypoalbuminemia. Conclusion: the prevalence of hypoalbuminemia proved to be high, in approx. nine in ten elders, and the nutritional status and the length of stay proved to be related to the decrease of serum albumin levels. Thus, it is suggested that monitoring albumin levels should be done to evaluate the risk that the patient has to develop malnutrition and other complications during hospital stays.


Introduction
The Brazilian elderly population grew significantly in the last decades. The average life expectancy of the Brazilian was 74,8 years in 2013. This growth in the population of seniors brings to the fore a new epidemiologic profile for healthcare, and carries in itself a range of modifications and re-signification, as it demands this population to adapt in order to maintain its quality of life (1)(2) . In the view of these epidemiological shifts, hospitalization is frequently needed to cure pathologies linked to the aging process, among them the circulatory and respiratory being the most prevalent (3) .
In those hospitalized elders, a factor that worsen their health status is their nutritional condition, as it affects among others, the tissue regeneration, the inflammatory reaction and the immune function (4) .
The nutritional status is inversely associated to hospitalization and mortality risks. At the same time, the nutritional status deterioration, along with the evolution of the disease itself, may be launched by different factors related to the food supply, being key to assess the status of hospitalized elders, both to prevent malnourishment and to begin an adequate approach and intervention.
For the nutritional assessment of these patients, it is absolutely needed to know the changes that are characteristics of this process, as the progressive loss of lean body mass, and corporeal fluids, the growth in the amount of fat tissue, the reduction of some organs (kidneys, liver and lungs) and the loss of skeletal muscle mass (4) .
One way of assessing the nutritional status of the patient is through dosage of the serum albumin, that is a biochemical marker widely used in the clinical practice in this area. In geriatric patients, hypoalbuminemia may be physiologic, as the aging process is linked with lower levels of serum albumin, that is 20% lower in individuals over 70 years old. In this population, levels more than 20% under standard may signal protein malnutrition and hypercatabolism, leading to extended lengths of stay, more expensive treatments and implying risks for other kinds of clinical complications (5) .
In spite of the limits imposed by the extended half-life interfering in the detection of acute changes in nutritional status, serum albumin levels are strongly related to morbidity elevations (extension of length of stay, poor healing-up of wounds) and mortality in both acute and chronic disease patients. That is why it is one of the most frequently used variables to compose prognostic indexes, and also the best isolated predictive index of complications. The normal serum albumin concentration is between 3,5g/dL e 5,0g/dL (6) .
The serum albumin concentration depends on many factors such as: hepatic synthesis, hepatocyte function, and ingestion and absorption of protein subtracts; abnormal loss of albumin: kidney disease (Nephrotic syndrome), eclampsia, Protein-losing enteropathy, and burns; high catabolism, infection and distribution volume: affected by hydration status (7) , usual issues in hospitalized patients. That is why malnutrition, the seriousness of diseases, the drugs that are being administered, the length of stay and the age, are important factors to be monitored with regard to the prognosis of the hospitalized elder patient (6) . The number of patients to be interviewed was calculated through a sampling formula, using the following parameters: sample error 5%, level of confidence 95%, population 900 people (average of elders hospitalized each month in the hospital), 84% was the maximum percentage (as per a study performed in 2010 (8) . It was needed to have 169 elderly patients in the study plus a 10% for possible losses, a total of 186 individuals to be studied that should conform to the inclusion and exclusion criteria that will be noted below.
The inclusion criteria were: age equal or more than 60 years old (using as parameter the age classification Exclusion criteria were defined as: seniors that were discharged or deceased in the first 72 hours from hospitalization, permanently in bed, amputations, or not having a responsible person or not being able to sign the FICF, and those that did not receive a serum albumin dosage during hospitalization.

Results
The participants were 200 elderly inpatients of a hospital in the South of Brazil, in different wards. The average age was 72,6 ± 8,3 years and the majority, 120, were males. The race was white in 89% of the cases the marital status was mainly married or living with a partner and widows, 53% and 37% respectively.
The albuminemia status of the patients did not present any significant relation with any socio-economic data as recorded in this study.
The average albumin level was 2,9 ± 0,5g/dL, and the minimum and maximum values were 1,1g/dL and 4,4 g/dL (Table 1). In 87% (n=173) of the patients a diagnosis of hypoalbuminemia was found and 13% (n=27) had serum albumin levels considered to be in the normal range.
The prevalence of hypoalbuminemia in elders at the sixth day of hospitalization was 90% (n=110) and only 10% (n=12) had normal albumin levels, a statistically significant difference (p=0,000) for both classifications (Table 1). Not all the patients that measured the albumin levels for the first time also had this measure in the second time, a total of 3%, some of them being discharged or dead before the second sampling. The average of albumin dosage in the sixth day was 2,7 ± 0,5g/dL, being the minimum 1,4g/dL and maximum 4,0g/dL. There were no cases of high dosage of albumin.   (Table 3). Another anthropometric data that is relevant, the BMI, did not show significant difference when compared in its classification with the results of albumin at admission (p=0,119). As per its results, 36% of the elders were over weighted and form them 85% had hypoalbuminemia ( Table 3). The BMI average was 25,5 ± 5,5 with a minimum of 12 and a maximum of 46.
Regarding the first sample for albuminemia tests, the results showed an statistically significant difference from MNA with serum albumin profile (p=0,000) and following the post-hoc Tukey test, there is a difference between the malnourished group and those out of risk of malnutrition (p=0,000). However, this difference was not evident between the group of malnourished and the ones in risk for malnutrition (p=0,092) and between the group out of risk and those in risk for malnutrition (p=0,077). The average level of albumin of malnourished was 2,6 ± 0,5g/dL, of those in risk for malnutrition 2,9 ± 0,5g/dL and those out of risk 3,0 ± 0,4g/dL. The graphic of Figure 1 shows clearly how this relation happens. of the malnourished group, in risk, and out of risk of malnutrition were respectively 2,5 ± 0,6g/dL, 2,7 ± 0,5g/dL e 2,9 ± 0,5g/dL (Figure 1).

Discussion
This study opened the opportunity for several considerations about the aging process, malnutrition and albuminemia, fostering reflections among health practitioners that provide care for the elder patients.
The serum albumin dosage is a easy access marker, has low cost and can stratify the patients by risk during hospitalization, offering at the same time an objective indicator to support decisions when approaching these patients during hospitalization.
Some studies show how hypoalbuminemia is associated with malnourishment (5,(12)(13)(14) and that hospitalization is harmful for it, leading us to the opinion that the longer the hospitalization, larger will be the trend to a higher degree of malnutrition. This situation, ends up launching the serum albumin depletion, as shown in this study, where we can observe that the difference between results were significantly altered between admission and six days after.
In this paper, hypoalbuminemia may be found in 87% of the studied elders at admission and in 90% after six days, being the averages statistically different anthropometrics, food ingest, ADL score and physical check-up, which will make diagnosis more ample and trustworthy.
The nutritional assessment of the hospitalized patient, and specially of the elder is directed to estimate mortality and morbidity risks by malnutrition, to identify their causes and consequences, in order to guide a nutritional therapy that achieve comprehensive recovery for the patient (17) . It should be done using the adequate tools, and values and ways of testing, that take into account the old age of the patient, paying attention to the loss of autonomy, appetite, vision, olfactory capacity, troubles in chewing, among others (9) .
Using MNA as the method for assessing nutritional status, the present study found a large number of patients in malnutrition or risk for malnutrition, the same that other study that used the same method when assessing patients in a long-term institution for elders in Guaratinguetá found 28,1% of malnourished patients, 50,6% in risk and 21,3% non-malnourished. These data show that the prevalence of malnutrition and risk of malnutrition is high and represents a public health problem demanding interventions (18) .  (20) .
The present research had some limitations, mainly because it was a crosscutting study, not allowing for discrimination of causes and effects. Another limiting factor was the fact that data may be influenced by the circumstance of the elders being in a moment of frailty, that lead to the hospitalization, and it also may launched a more general worsening of the health status, even affecting the lab tests results that were analyzed.
The results of this study will help to the scientific advancement through an improvement of the knowledge of the albumin profile in relation with nutritional aspects of the elder population. These results also contribute Brock F, Bettinelli LA, Dobner T, Stobbe JC, Pomatti G, Telles CT.
through the proposal of diagnosis models and care for elders presenting hypoalbuminemia and malnutrition that should be applied from the admission moment on, for the elders, society and the work of health practitioners.

Conclusion
The prevalence of hypoalbuminemia in hospitalized elders is high and affects approx. nine in ten patients, and the length of stay is linked to the decline in serum albumin levels, not evidenced when related to sociodemographic data.
It was also observed a trend towards a decline of the serum albumin level when the nutritional status is altered, showing a direct link between nutritional and albumin worsening. In this way, if albumin dosage may not be considered a nutritional diagnostic factor, it points to a hike in its risk thus demanding a deeper nutritional diagnosis. It not only is a simple test, but also brings benefits, as it is a lab procedure that may speed-up and improves this diagnosis.
Other than the albuminemia changes, most elders showed nutritional alterations, and a expressive prevalence of malnourished, or in risk of malnutrition patients.
Under this general perspective, it is suggested that health practitioners may perform serum albumin level monitoring and the assessment of nutritional malfunction along with the associated factors in elders during hospitalization. This monitoring activity may lead to early interventions to avoid complications such as limb edema, oliguria and pressure ulcers, thus shortening the length of stay and lowering costs.
Finally, it is recommended that longitudinal studies should be performed to assess the serum albumin during hospitalization of elders, receiving or not receiving nutritional support, analyzing its relationship depending upon the length of stay and mortality rates for this population.