Hospitalized Elderly Patients Research Articles

A Study of Nurses’ Awareness of the Importance, Educational Needs, and Nursing Competence on Comprehensive Nursing Assessment for Hospitalized Elderly Patients in General Hospital

A Study of Nurses’ Awareness of the Importance, Educational Needs, and Nursing Competence on Comprehensive Nursing Assessment for Hospitalized Elderly Patients in General Hospital

Low Body Mass Index as a Significant Risk Factor for Hypoglycemia in Hospitalized Elderly Patients With Acute Pyelonephritis: A Retrospective Cohort Study

Low Body Mass Index as a Significant Risk Factor for Hypoglycemia in Hospitalized Elderly Patients With Acute Pyelonephritis: A Retrospective Cohort Study

Comparison of Sodium Zirconium Cyclosilicate to Calcium Polystyrene Sulfonate for Acute Hyperkalemia Among Hospitalized Elderly Patients

Comparison of Sodium Zirconium Cyclosilicate to Calcium Polystyrene Sulfonate for Acute Hyperkalemia Among Hospitalized Elderly Patients

Postoperative delirium among elderly elective orthopedic patients in Addis Ababa Ethiopia: a multicentere longitudinal study

BackgroundDelirium is a neurocognitive disorder characterized by an acute and relatively rapid decline in cognition, disturbance of consciousness, reduced ability to focus, and shift of attention. It mainly affects elderly patients with an incidence of about 8–23% after an operation. It frequently occurs between 24-hrs and 5 days after surgery. It results in serious medical management problems. Hence, identifying the incidence and associated factors may help prevent and manage its sequel in the elderly.ObjectiveAssessment of the incidence and associated factors of postoperative delirium(POD) among elderly elective orthopedic surgical patients in Addis Ababa public hospitals, Ethiopia, 2024.MethodsA multi-centered longitudinal study was conducted on 220 elderly (age ≥ 65 years) patients in four selected public hospitals of the study area from February 2024 to May 2024, and a systematic sampling technique was used to select the study units. Data was collected through chart review and interviews of patients, and postoperative delirium was assessed using the confusion assessment method (CAM). Both bivariable and multivariable logistic regression models were used for statistical analysis. The strength of association was determined with an adjusted odds ratio (AOR) with a 95% confidence interval(CI) at a p-value of < 0.05.ResultsA total of 220 patients were studied, and the incidence of POD among elderly elective orthopedic surgical patients was 33.7%. Age 65–75(AOR = 0.47, 95%CI (0.226–0.97)), Induction using ketamine (AOR = 1.32, 95%CI(1.109–3.87), p = 0.003)), perioperative opioid use (AOR = 2.20, 95%CI(1.073 4.5313)), intraoperative anticholinergic use(AOR = 2.24,95%CI(1.831–4.235)), recent hospitalization history (AOR = 2.24,95%CI(1.202–4.206)), and transfusion (AOR = 2.83,95%CI(1.295–6.193)) were significantly associated with POD (p < 0.05).Conclusion and recommendationsThe incidence of POD in the study area was high (33.7%); advanced age, hospitalization history, Anesthesia induction by Ketamine, perioperative anticholinergic uses, opioid use, and blood transfusion use were associated factors for postoperative delirium. We recommend giving due attention to elderly patients with advanced age, history of hospitalization, perioperative Ketamie use, perioperative anticholinergic uses, opioid use, and blood transfusion use undergoing elderly elective orthopedic surgery.

Hyponatremia Among Elderly Hospitalized Patients: An Observational Study.

Aim The aim of this study is to analyze the demographicdistribution (age and gender distribution), presenting symptoms, and evaluate the underlying etiology of hyponatremia among the study population. The presence of comorbidities and the volume status (hypovolemia, euvolemia, or hypervolemia) of elderly hyponatremic patients with varying severity of hyponatremia were assessed. Methods This cross-sectional, observational study was conducted in Dr. D. Y. Patil Hospital and Research Centre, Pune, India. After approval from the Institutional Ethics Sub-Committee (approval number: IESC/PGS/2022/09), it was conducted during the period between September 2022 and June 2024. The minimum sample size was calculated to be 96with a confidence interval of 95% using WINIPEPI software (version 11.38).The lab values of serum sodium of all patients aged above 60 years admitted in wards and intensive care units (ICUs) were studied. Out of these hyponatremic patients, a sample size of 100 patients was randomly selected. Patients above 60 years and the patients who were on diuretic therapy were excluded from the study. Results The study included 100 elderly patients with a mean age of 73.25 ± 7.03 years, ranging from 64 to 86 years. Males predominated (63%), and severe hyponatremia (<125 mEq/L) was the most common, affecting 61% of patients. Generalized weakness (22%) and disorientation (17%) were the most frequently reported symptoms. Post-operative conditions (13%) and gastroenteritis (10%) were the leading causes.Most participantshad no comorbidities (53%). Hypovolemia was present in 67% and euvolemia in 29% of the study subjects. Among hypovolemic patients, severe hyponatremia was present in 83.5% of patients. Conclusion This study highlights the significant burden of severe hyponatremia among elderly patients, particularly in male subjects andthose with hypovolemia. Majority of the participants did not have any comorbidities. Additionally, the study emphasizes the need for heightened clinical vigilance in elderly patients presenting with generalized weakness and disorientation, as these were the most common symptoms associated with hyponatremia. The identification of post-operative conditions and gastroenteritis as leading causes further supports the need for comprehensive management strategies in elderly inpatients to prevent the occurrence and complications of hyponatremia.

Exploring ICOPE's Impact on Delaying Elderly Disability Management.

The purpose of this study was to explore the initial benefits of introducing the ICOPE (Integrated care for older people) information assessment system for the management of hospitalized elderly patients in a teaching hospital in Eastern Taiwan. The ICOPE information assessment system was set up for case screening and abnormal referral through clinical ICOPE, followed by follow-up and case management. The results showed a total of 3424 screened cases, an average of 311 ICOPE screenings per month, an average of 48 abnormal screenings per month (15%), a referral rate of 79%, a rescreening rate of 91%, and a case management completion rate of 71%. Conclusion: Introducing the ICOPE information evaluation system can quickly screen for potential abnormal disability cases in hospitalized elderly patients, timely referral case management, provide appropriate intervention measures, and improve the quality of life after returning home in old age.

Analysis of hospitalization expenses and influencing factors for elderly cancer patients in a tertiary hospital in Dalian, China: a five‑year retrospective study

BackgroundBecause the proportion of elderly individuals and the incidence of cancer worldwide are continually increasing, medical costs for elderly inpatients with cancer are being significantly increasing, which puts tremendous financial pressure on their families and society. The current study described the actual direct medical costs of elderly inpatients with cancer and analyzed the influencing factors for the costs to provide advice on the prevention and control of the high medical costs of elderly patients with cancer.MethodA retrospective descriptive analysis was performed on the hospitalization expense data of 11,399 elderly inpatients with cancer at a tier-3 hospital in Dalian between June 2016 and June 2020. The differences between different groups were analyzed using univariate analysis, and the influencing factors of hospitalization expenses were explored by multiple linear regression analysis.ResultsThe hospitalization cost of elderly cancer patients showed a decreasing trend from 2016 to 2020. Specifically, the top 3 hospitalization costs were material costs, drug costs and surgery costs, which accounted for greater than 10% of all cancers according to the classification: colorectal (23.96%), lung (21.74%), breast (12.34%) and stomach cancer (12.07%). Multiple linear regression analysis indicated that cancer type, surgery, year and length of stay (LOS) had a common impact on the four types of hospitalization costs (P < 0.05).ConclusionThere were significant differences in the four types of hospitalization costs for elderly cancer patients according to the LOS, surgery, year and type of cancer. The study results suggest that the health administration department should enhance the supervision of hospital costs and elderly cancer patient treatment. Measures should be taken by relying on the hospital information system to strengthen the cost management of cancer diseases and departments, optimize the internal management system, shorten elderly cancer patients LOS, and reasonably control the costs of disease diagnosis, treatment and department operation to effectively reduce the economic burden of elderly cancer patients.

An observational study on prescription pattern of drugs and psychiatric disorders occurring in elderly patients in a tertiary care hospital

Abstract Background: Elderly age group is the most vulnerable age group for various health-related issues. Psychiatric disorders and their management are quite important, especially in this vulnerable population. With increased availability of newer drugs, rational prescription of drugs is essential. Objectives: The objectives of this study were as follows: (1) To assess the prescription pattern of antipsychotic drugs and other psychiatric drugs prescribed to elderly psychiatry patients, (2) to determine the psychiatric illness occurring among the elderly psychiatric patients, and (3) to estimate the polypharmacy and cost burden of drugs prescribed. Materials and Methods: It was an observational study conducted over a period of 6 months in “Government Hospital for Mental Care.” The prescriptions were collected from the outpatient medical records and were thoroughly analyzed to assess antipsychotics and other psychiatric drugs being prescribed and the disorders frequently came across in the elderly patients who visited the psychiatry outpatient department. Results: Two hundred and fifty prescriptions were analyzed during the study. Male patients outnumbered female patients. The majority of the patients were of age group 50–60 years. Schizophrenia was the most common disorder encountered in the study population followed by psychosis and bipolar. Among the drugs, trihexyphenidyl followed by quetiapine, olanzapine, risperidone, and so on were the most common drugs prescribed. Conclusion: In the current study the prescribing pattern of drugs is as per the norms with rational usage of more efficacious drugs. Polypharmacy is limited. Periodic drug utilization studies help to solve the issues related to polypharmacy and improve the quality of treatment given to the patients.

Incidence of Renal Impairment in Elderly Hospitalized Patients

Background: Chronic kidney disease (CKD) is increasingly prevalent among the elderly, leading to progressive kidney function decline and adversely affecting their physical and cognitive well-being. Objective: This study aimed to assess the incidence and effects of renal impairment on physical and cognitive functions in elderly hospitalized patients. Methods: A total of 420 elderly patients admitted with renal impairment to a tertiary care hospital in Karachi were included from January to August 2023. We measured the estimated glomerular filtration rate (e-GFR) and Short Physical Performance Battery (SPPB) score, and collected comprehensive demographic, socioeconomic, and clinical data, including a detailed geriatric assessment. Results: The cohort had a mean age of 78.4±5.8 years, with a nearly even gender split (51.9% male, 48.9% female). Average BMI was 24.8±4.5 Kg/m^2, mean eGFR was 56.6±18.6 mL/min per 1.73 m^2, and mean SPPB score was 4.9±3.5. High prevalence of comorbidities was noted: hypertension (68.6%), diabetes (27.6%), coronary artery disease (28.6%), and others. Renal impairment was categorized as severe (12.9%), mild (27.1%), and moderate (60%). Conclusion: There is a significant correlation between advanced age and renal failure, leading to diminished physical and cognitive capabilities in the elderly, indicating a critical need for integrated care strategies.

Silver trauma: a study of pre- and post-COVID-19 pandemic pan-CT scanning in elderly trauma patients in a large teaching hospital

The challenges posed by the assessment of elderly trauma patients increasethe reliance on emergency CT scanning to diagnose an injury. The COVID-19 pandemic posed challenges to image service delivery. We sought to assess the effect of the COVID-19 pandemic on the imaging of elderly trauma. All trauma patients aged 65 and over who underwent whole-body CT scanning in the same 3-month period (April-June) in 2019 and 2022 were included in our study. Data was collected on demographics, time of scanning, clinical request details and positive report findings. Anatomical injury distribution, abbreviated injury scale (AIS) and injury severity scores (ISS) were calculated. Consensus judgment was obtained on scan justification and significance of findings. Chi-squared test of association was applied to the categorical outcomes of interest. Associations were considered significant if p<0.05. 79 patients were scanned in the pre-pandemic assessment period versus 217 post-pandemic, an increase of 175%, including a 248% rise in fall-from-standing requests. There was a statistically significant reduction of trauma CT requests meeting fulfilment criteria post-pandemic (95% vs 83%) (p=0.008), with significantly fewer positive findings (45.6% vs 29%) (p=0.024). There was a decrease in median ISS score in the post-pandemic group (p=0.062). Despite increased scanning, there was a reduction in both the number and severity of positive traumatic imaging findings. The pandemic has increased reliance on CT without a concomitant increase in the detection of positive findings nor clinically significant findings. This single-centre study demonstrates the need to further evaluate pan-CT trauma scanning in silver trauma patients.

Utilization of Mini Nutrition Assessment-Short Form to Identify Nutritional Status of Hospitalized Elderly Patients at Dr Sardjito General Hospital, Yogyakarta

Background: Identification of nutritional status upon their admission as well as influencing factors related to changes in nutritional status during hospital treatment need to be done to prevent the risk of worsening of the patient's clinical outcomes. Objectives: This study aimed to find out the nutritional status of hospitalized elderly patients at hospital admission using the Mini Nutrition Assessment-Short Form (MNA-SF) screening tool. Methods: This study was an observational design with a cross sectional design and conducted at dr. Sardjito Yogyakarta Hospital from September-November 2021. Basic characteristic data is gathered, nutritional screening is performed using MNA-SF, and nutritional status is measured using weight, height, Mid-Upper Arm Circumferences (MUAC), calf circumference, Hand Grip Strength (HGS), total fat percentage, visceral fat, muscle mass and hemoglobin. Results: A total of 86 elderly patients, ranging in age from 60 to 80 years, were recently admitted to the hospital. The results showed the prevalence of malnutrition in the hospitalized elderly was 46.5%. According to the assessment results, malnourished elderly patients had statistically significant lower Body Mass Index (BMI) (19.4±3.1), total fat levels (20.0±10.9), visceral fat levels (4.4±4.6), muscle mass (34.4±7.7), MUAC (22.6±3.4), calf circumference (27.2±6.7) dan hemoglobin (10.7±3.2) (p&lt;0.05). Conclusions: According to MNA-SF, half of the elderly patients in hospitals were malnourished at hospital admission. Therefore, it is crucial to evaluate the nutritional state of elderly patients as soon as they are admitted and to implement the proper nutritional therapy in order to reduce its negative effects on the patients and healthcare system.

Effectiveness of Nursing Intervention Program on Prevention of Acquired Pressure Ulcers among Hospitalized Elderly Patients

Effectiveness of Nursing Intervention Program on Prevention of Acquired Pressure Ulcers among Hospitalized Elderly Patients

A-69 | Impact of Depression in Hospitalized Elderly Patients undergoing Percutaneous Coronary Intervention for Acute Coronary Syndromes: A Nationwide Study From 2016-2020

A-69 | Impact of Depression in Hospitalized Elderly Patients undergoing Percutaneous Coronary Intervention for Acute Coronary Syndromes: A Nationwide Study From 2016-2020

A Retrospective Study on Azvudine in Hospitalized Elderly Patients with COVID-19

Background:: The ongoing 2019 novel coronavirus pneumonia pandemic continues to pose a serious threat to public health and safety. In response, numerous specific anti-SARS-CoV-2 drugs have been urgently approved for use. Azvudine has been recommended as a priority treatment for COVID-19 patients, but its efficacy and safety in elderly patients remain unexplored. Methods:: In this retrospective, single-center, observational study, we assessed the impact of Azvudine treatment on elderly hospitalized patients aged over 70 years. We analyzed parameters such as the time of SARS-CoV-2 negative conversion, clinical outcomes, length of hospital stay, and respiratory support requirements. Additionally, we compared changes in blood routine indicators, liver and kidney function indicators, and the incidence of adverse events before and after Azvudine administration to provide real-world data concerning elderly patients. Results and Discussion:: The study included 36 elderly patients aged 70 to 95 years. Following Azvudine administration, the average time for SARS-CoV-2 negative conversion was 5.15 days. Clinical outcomes revealed improvement and discharge in 74.3% of the patients, exacerbation in 5.7% of the patients, and mortality in 20% of the patients. Analysis of blood routine indicators and liver function indicators before and after medication showed no clinically significant changes. However, serum creatinine levels (Scr) demonstrated a statistically significant increase (71.12 ± 44.22 vs. 87.88 ± 57.39, p &lt; 0.05). Conclusion:: Although correlation analysis was not conducted, limited by the small sample size and retrospective nature of the study, these findings underscore the importance of monitoring Azvudine’s impact on renal function.

Frequency of Potentially Inappropriate Medications in Iranian Elderly Hospitalized Patients

Background: Potentially inappropriate medications (PIMs) should not be prescribed to the elderly due to low effectiveness and adverse drug reactions. This study was conducted to determine the frequency of PIMs in the elderly admitted to educational hospitals in Kerman, in 2023. Methods: This cross-sectional study was conducted on 1500 elderly patients hospitalized in educational hospitals. The data collection forms were completed according to the health information system (HIS) of the hospital, which includes the patient’s age and gender, drug information, and the name of the hospital and ward. PIMs prescriptions were assessed according to Zhan’s criteria. Statistical analyses were performed using SPSS version 20.0. The results were presented as mean±standard deviation (SD) and frequencies (percents). Results: Nearly 17.8% (n=267) of patients were treated with at least one PIMs included in the Zhan criteria. Among 331 PIMs used for patients, 43.5% (n=144), 23.3% (n=77), and 33.2% (n=110) of drugs were classified as always avoid, rarely appropriate, and some indication, respectively. Sedative-hypnotics, opioids, and antihistamines were the most prevalent PIMs with 29.5% (n=98), 25.4% (n=84), and 23.3% (n=77) frequency. Approximately 71.4% (n=10) of patients who were admitted to the Oncology ward, and 38.9% (n=33) of patients who were admitted to the Critical Care Unit were treated with at least one PIMs. Conclusion: Today PIMs are a problem for elderly patients. Paying attention to PIMS in oncology, and critical care unit wards is important. More attention should be paid to sedative-hypnotics, opioids, and antihistamines as the most frequently prescribed PIMs.

Use of potentially inappropriate medication for elderly patients in tertiary care hospital of Riyadh, Saudi Arabia

Background and objectivesThe elderly population is affected by chronic diseases and lifelong medication. The American Geriatrics Society (AGS) Beers Criteria is a comprehensive approach to medication usage in the older population to reduce potentially inappropriate medication (PIM) use. The purpose of this study was to assess the usage of PIMs in elderly patients upon discharge from tertiary care hospital settings in Riyadh, Saudi Arabia, using the AGS Beers Criteria 2019. MethodsThe data was obtained from the medical records of 1237 patients (>65 years) who were discharged from medical or surgical wards at two hospitals affiliated with King Abdulaziz Medical City. The data was analyzed to determine the prevalence of PIM prescription, and the proportional odds of the independent factors influencing outcomes were estimated using ordinal regression analysis for criteria 1 and 2, while Binary regression analysis was conducted for criterion 3. ResultsThere were approximately equal numbers of male and female participants in our study (male: 50.8 % vs. female: 49.2 %). One-third of the patients were above the age of 80 years, with 41 % being between the ages of 70 and 80 years. Moreover, almost 70 % of the samples had chronic illnesses. The overall prevalence of PIMs was 29.2 %, with 11 % of PIMs to be avoided in elderly patients and 17 % to be used with caution in the elderly, while disease-specific PIMs were identified in 1.2 % of the patients. The most common PIM class was proton pump inhibitors (44.41 %), and patients discharged from the surgical unit were more likely to be prescribed PIMs. Proton pump inhibitors (44.41 %) were the most inappropriately prescribed drug class, and patients discharged from the surgical unit were more likely to be prescribed PIMs. ConclusionThe study noticed that male gender, the presence of multiple diseases, and obesity are associated with more than one PIM prescription. There is a need to streamline the surgical department’s prescription procedure to eliminate prescription disparities. Prescription monitoring is recommended to avoid medication errors, particularly in patients who are taking multiple medications.

Screening of Hospitalized Elderly Patients for Frailty and Associated Co-morbid Conditions in Western Gujarat in India.

Older patients admitted to hospitals have a greater impact on the healthcare system as the population ages. The relationship between the recovery of functional impairments and frailty status in geriatric care units is still not clear. Simple screening technologies are required in order to operationalize frailty management in this susceptible population due to these restrictions. Aim: The study aims to screen hospitalized older adults for frailty and associated co-morbid conditions in western Gujarat, India. This is an institutionally based cross-sectional study conducted on the elderly patients (aged 60 years or more) admitted at the tertiary-level government hospital of Jamnagar District of Gujarat State during the period of October 22 to December 22. The assessment was done with a structured questionnaire for FRAIL screen, the Rapid Cognitive Screen (RCS), Charles Co-morbidity Index, Geriatric Depression Scale-5 (GDS-5), and Short Form-12 (SF-12) Health Survey. The overall findings of this study reveal that of 124 participants 34 (27%) were frail, 52 (42%) were found to be a likelihood of depression by the GDS, and 29 (23%) were having dementia by RCS, respectively. In our study, we also found a statistically significant association between frailty and dementia (P value < 0.001). The present study implies the prevalence of frailty among old age elderly patients and its association with various socio-demographic and co-morbid conditions of the participants. Early identification of frailty and co-morbid conditions can help to prevent adverse health outcomes.

Elderly Patients at Risk of Malnutrition Presenting to a Tertiary Hospital in Nepal: A Descriptive Cross-sectional Study

Introduction: The nutritional status of elderly people is crucial for healthy aging, enabling them to maintain productive lives and reduce the progression of chronic diseases. Given that the quality of life tends to decline with age, it becomes particularly crucial for elderly individuals. Therefore, this study was aimed to find out the prevalence of elderly patients at risk of malnutrition in a tertiary hospital. Methods: This descriptive cross-sectional study was conducted among 281 elderly patients in a tertiary hospital from 2 January 2023 to 10 February 2023 after obtaining ethical approval. Non-probability purposive sampling technique was used. A face-to-face interview was conducted using a structured interview schedule with the elderly in the absence of their caregiver using a standard Mini-Nutritional Assessment tool for nutritional status, and WHOQOL_OLD quality of life for the elderly to assess the quality of life. Point estimate at 95% Confidence Interval was calculated.Results: Out of 281 elderly patients enrolled in our study, 164 (58.36%) (52.64-64.16, 95% Confidence Interval) were at risk of malnutrition. Conclusions: The study concluded that older people could be at risk of malnutrition, which could impair their quality of life.

Association between Controlling Nutritional Status (CONUT) Score and Body Composition, Inflammation and Frailty in Hospitalized Elderly Patients.

a total of 361 patients were retrospectively recruited and divided into three groups based on the CONUT score. patients with a score ≥5 exhibited significantly higher levels of inflammatory markers, such as erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), Neutrophil/Lymphocytes ratio (NLR), main platelet volume (MPV), and ferritin, compared to those with a lower score. Furthermore, these patients showed unfavorable changes in body composition, including a lower percentage of skeletal muscle mass (MM) and fat-free mass (FFM) and a higher percentage of fatty mass (FM). A positive correlation was found between the CONUT score and inflammatory markers, Geriatric Depression Scale Short Form (GDS-SF), and FM. Conversely, the Mini Nutritional Assessment (MNA), Mini-Mental Status Examination, activity daily living (ADL), instrumental activity daily living (IADL), Barthel index, FFM, and MM showed a negative correlation. Frailty was highly prevalent among patients with a higher CONUT score. The receiver operating characteristic (ROC) curve demonstrated high accuracy in identifying frail patients (sensitivity). a high CONUT score is associated with a pro-inflammatory status as well as with unfavorable body composition. Additionally, it is a good tool to identify frailty among hospitalized elderly patients.

Assessment of Nutritional Status among Elderly Hospitalized Patients in Enugu, Nigeria: A Hospital-based Study.

The ageing population worldwide presents a significant challenge for healthcare systems, with malnutrition being a common problem among elderly individuals, particularly those hospitalized. Assessing nutritional status is crucial for identifying and addressing malnutrition in this population. This study aimed to assess the prevalence of malnutrition among elderly hospitalized patients in a Nigerian tertiary healthcare setting. This was a hospital-based descriptive and cross-sectional study conducted from March to June 2023, involving 122 patients aged 60 years and above. Demographic data and anthropometric measurements were collected, and the Short-form Mini Nutritional Assessment (MNA-SF) tool was used to assess nutritional status. The reliability of the MNA-SF was assessed using Cronbach's α coefficient and item-to-total score correlations. The mean MNA score was 14.4 ± 5.3, with 71.3% of participants classified as malnourished, 22.1% at risk of malnutrition, and 6.6% well-nourished. Significant differences were observed in the body mass index (BMI) of nourished, at-risk, and malnourished individuals respectively (23.3 ± 3.6 kg/m2, 22.5 ± 3.8 kg/m2, and 19.6 ± 2.8 kg/m2, p < 0.001). The MNA-SF tool demonstrated acceptable reliability (Cronbach's α coefficient = 0.777), with significant correlations between total MNA scores and most MNA-SF questions. The high prevalence of malnutrition among elderly hospitalized patients in this Nigerian tertiary hospital emphasizes the importance of implementing routine nutritional screening protocols and targeted nutritional interventions for improved health outcomes among the elderly.