clinical and medico-economic evaluation of taken care associating nutritional support and adapted physical activity for malnourished, or at risk of undernutrition, elderly people on discharge from hospital

Conditions: Under-nutrition or Risk of Undernutrition

Summary: in the hospital, one out of every two elderly people is malnourished. this condition of undernutrition generally worsens during hospitalization, where the effects of polypathology and psychological distress are added. muscle loss due to inadequate dietary intake, hypermetabolism and immobilization results in the onset or worsening of mobility disorders and functional decline. after hospitalization, 30-50% of elderly people hospitalized in emergency in medical departments have lost autonomy in daily life. nutritional management and adaptive physical activity (apa) could have synergistic action to improve the nutritional status and mobility of elderly patients. the short duration of the average stay the acute geriatric units (10-15 days) is not enough to renew, nor to re-educate patients. it seems important to continue these actions at home. the implementation of programs combining nutrition and adapted physical activity (apa) at the hospital exit has not been studied to date. we formulate the hypothesis that in elderly people who are malnourished or at risk of undernutrition, after hospitalization, a personalized home intervention combining nutritional advice and appropriate physical activity will limit their loss of autonomy.

interventional study with minimal risk and constraints, prospective, multicentre, randomised and controlled. population of interest: * older people at least 70 years, malnourished or at risk of malnutrition, on discharge from hospital * informal caregivers of patients included in study intervention at home of professionals: mixed intervention: nutritional support, carried out by the dieticians of " saveurs et vie ", in seven sessions over three months, combined with an adapted physical activity intervention (apa), carried out by " siel bleu " professionals, also at a frequency of seven sessions over three months, for a total of fourteen sessions. control arm will benefit from usual support (depending on practices of the department, prescription or not of oral nutritional supplements and physiotherapy at home, but without home intervention of adapted physical activity professionals or dieticians). in addition to screening/inclusion visits (d0), three follow-up home visits are scheduled at d7, d45 and d90 for both study groups. inclusion visit (d0), performed in hospital in geriatric ward prior to hospital discharge. verification of inclusion criteria, collection of consent by investigator, randomization, collection of inclusion data (socio-educational level, family status, assessment of autonomy (adl, iadl, aggir) number of drugs, comorbidity (cirs-g), cognitive status, biology performed during hospitalization (albumin, crp, vitamin d) and discharge prescription (noc, nutritional advice, physiotherapy) are programmed to d7, d45 and d90 for both study arms. follow-up visits to d7, d45 and d90, carried out at home by a clinal research technician mandated by sponsor (gérond'if). assessment of autonomy (adl, iadl, aggir scale), nutritional status (weight, height, self-evaluation of appetite, mna), functional status (grinding strength, 4-metre walking speed, sppb), quality of life (eq-5d), frequency and transit time of home help workers, whether family or professional. acceptability of interventions for the home intervention arm. 2 patient/arms, a total of 372 patients divided as follows: * interventional arm : nutrition intervention with appropriate physical activity for 186 patients * control arm: standard care for 186 other patients and up to 160 informal caregivers (family members) in both groups, or 80 caregivers per group (one caregiver per patient). inclusion period: 15 months. follow-up period: 3 months/subject (patients and caregivers) total length of study: 18 months

Eligibility criteria:
inclusion criteria: * men or women aged at least 70 * hospitalized in acute geriatrics (uga), with expected return to home directly after the uga * undernourished or at risk of undernutrition (mna sf12) * able to walk 4 metres without third party assistance * able to understand and consent to the study * good understanding of the french language * living in paris (department 75) * patient affiliated with a social security scheme * having read the information note and having agreed to participate in the study by signing the consent. exclusion criteria: * life expectancy less than 6 months * chronic inflammatory pathology * progressive cancer * severe renal failure (creatinine clearance \< 30ml/min/1.73 m2) * nyha stage iii or iv dyspnea * chronic respiratory failure (oxygen therapy at home) * liver failure (tp \< 50%) * severe depression * severe dementia, according to dsm v criteria * swallowing disorders with inhalation pneumonia * corticosteroids (\> 10 mg prednisone/day long-term or equivalent) * systolic blood pressure \>200 mmhg * unstabilized acute coronary syndrome * decompensated heart failure * severe, uncontrolled ventricular rhythm disorders * high risk embolic intracardiac thrombus * presence of medium to large pericardial effusion * recent history of thrombophlebitis with or without pulmonary embolism * obstacle to severe and/or symptomatic left ventricular ejection * severe and symptomatic pulmonary hypertension * inability to perform appropriate physical activities * subject participating or having participated in a therapeutic trial within the last 3 months * refusal to participate * person under guardianship, guardianship or safeguard of justice

Keywords: autonomy nutritional support adapted physical activity undernutrition older people hospital discharge under-nutrition