Assessing cachexia in older patients: Different definitions - But which one is the most practical for clinical routine?

OBJECTIVE

Patients with chronic inflammatory diseases and malignant tumors have an increased risk of cachexia. No consistent definition exists to rapidly identify cachexia in older patients with and without cancer.

METHODS

One-hundred patients (53% male) aged 70 +  years were included in the study by a university hospital. In addition to the detection of malnutrition and determination of body composition by bioelectrical impedance analysis, cachexia was assessed according to the well-established definitions of Evans (weight loss ≥ 5% within the last 12 months plus additional clinical parameters), Fearon (weight loss > 5% in 6 months) and Bozzetti (weight loss ≥ 10% of habitual weight). After a follow-up of 3.5 years, the mortality rate was recorded.

RESULTS

Thirty-three patients had a malignant tumor disease. The patients with a non-malignant underlying disease did not differ in their mental state, physical condition and state of health compared to patients with cancer. A higher percentage of patients with underlying malignancy had cachexia. There were significant differences in the body composition between the patients with or without cachexia. Cachectic patients exhibited a significantly lower skeletal muscle mass and fat mass. The risk of death was increased in cachectic patients of all three cachexia definitions.

CONCLUSION

For clinical daily routine, the assessments by a weight loss according to Fearon and Bozzetti are suggested to be practicable methods to detect cachexia in older patients with and without cancer.

Daily and per-meal animal and plant protein intake in relation to muscle mass in healthy older adults without functional limitations: an enable study

OBJECTIVE

Animal protein sources are considered to be of higher quality than plant protein sources in terms of stimulating muscle metabolism. Our objective was to investigate whether protein intake from animal and plant sources on a daily and per-meal basis differs between healthy older adults with normal and with low muscle mass.

METHODS

In this cross-sectional study including 100 healthy, community-dwelling adults (51 women) aged 75-85 years without functional limitations dietary intake was assessed using 7-day food records. Protein intake was classified by six animal and six plant protein sources. Skeletal muscle index (SMI) was determined based on bioelectrical impedance analysis and categorized into 'normal' or 'low' (men ≤ 8.50, women ≤ 5.75 kg/m²). The absolute animal and plant protein intake and their proportion of total protein intake were compared between these groups using Mann-Whitney U test.

RESULTS

Daily protein intake was 0.96 ± 0.27 g/kg body weight (BW), 61 ± 10% hereof were from animal origin with no difference between men and women. SMI was low in 39% of men and 35% of women. No differences in absolute daily animal and plant protein intake between participants with normal vs. low SMI were observed. The proportion of animal protein was not different on neither a daily nor a per-meal basis between those with normal and those with low SMI. Women with low SMI consumed less animal protein (in g) for breakfast (4.8 ± 4.1 g vs. 8.5 ± 6.9 g, p = 0.031) and fewer meals per day with at least 50% animal protein (2.2 ± 0.9 vs. 2.7 ± 1.0, p = 0.046) compared to those with normal SMI.

CONCLUSION

On a daily basis, the absolute and relative animal protein intake does not differ between healthy older adults without functional limitations with normal vs. low SMI. However, our results indicate that in women animal protein intake on a per-meal basis might be of relevance for the maintenance of muscle mass.

Management of Malnutrition in Older Patients-Current Approaches, Evidence and Open Questions

Malnutrition is widespread in older people and represents a major geriatric syndrome with multifactorial etiology and severe consequences for health outcomes and quality of life. The aim of the present paper is to describe current approaches and evidence regarding malnutrition treatment and to highlight relevant knowledge gaps that need to be addressed. Recently published guidelines of the European Society for Clinical Nutrition and Metabolism (ESPEN) provide a summary of the available evidence and highlight the wide range of different measures that can be taken-from the identification and elimination of potential causes to enteral and parenteral nutrition-depending on the patient's abilities and needs. However, more than half of the recommendations therein are based on expert consensus because of a lack of evidence, and only three are concern patient-centred outcomes. Future research should further clarify the etiology of malnutrition and identify the most relevant causes in order to prevent malnutrition. Based on limited and partly conflicting evidence and the limitations of existing studies, it remains unclear which interventions are most effective in which patient groups, and if specific situations, diseases or etiologies of malnutrition require specific approaches. Patient-relevant outcomes such as functionality and quality of life need more attention, and research methodology should be harmonised to allow for the comparability of studies.

Measuring eating motives in older adults with and without functional impairments with The Eating Motivation Survey (TEMS)

Gaining a better understanding which motives play a role in daily eating is crucial in order to develop personalized interventions promoting adequate diet. The Eating Motivation Survey (TEMS) is a comprehensive tool to assess manifold reasons for eating but has not been specifically applied in an older sample including very old persons and persons differing in functional status. Therefore, the first step of the study was to investigate whether the basic motives of TEMS are consistent in an older sample and comparable across older adults with and without functional impairments. Second, the study aimed at describing which motives underlie eating behavior in older age most often as well as to analyze the relationship between eating motives and functional status. 376 community-dwelling older persons aged 70 years and older filled in the brief survey version (15 motives à 3 items) of TEMS. The sample comprises 149 unimpaired and 227 impaired participants in terms of physical function. Confirmatory factor analysis yielded good model fit with RMSEA 0.036 and SRMR 0.048. Furthermore, multi-group analysis revealed a generally invariant factor structure across participants with and without functional impairments. Liking was rated to underlie eating behavior most often, followed by Health and Natural Concerns. Considering gender, age and BMI, significant associations between functional status and the motive Sociability emerged. Since the results suggest that the fifteen basic eating motives are generalizable in older age and across different functional states, TEMS might be a valuable tool in nutrition-related health promotion to developing individualized approaches considering health aspects as well as hedonistic factors.

Prevalence and overlap of sarcopenia, frailty, cachexia and malnutrition in older medical inpatients

Background

Sarcopenia, frailty, cachexia and malnutrition are widespread syndromes in older people, characterized by loss of body tissue and related to poor outcome. The aim of the present cross-sectional study was to assess the prevalence of these syndromes and their overlap in older medical inpatients.

Methods

Patients aged 70 years or older who had been admitted to the internal medical department of a German university hospital were recruited. Sarcopenia, frailty, cachexia and malnutrition were assessed in a standardized manner according to current consensus definitions. Prevalence rates of these syndromes and their constituents and the concurrent occurrence of the syndromes (overlap) were calculated.

Results

One hundred patients (48 female) aged 76.5 ± 4.7 years with a BMI of 27.6 ± 5.5 kg/m² were included. The main diagnoses were gastroenterological (33%) and oncological diseases (31%). Sarcopenia was present in 42%, frailty in 33%, cachexia in 32% and malnutrition in 15% of the patients. 63% had at least one syndrome: 32% one, 11% two, 12% three and 8% all four. All four syndromes are characterized by significant weight loss during the last 12 months, which was most pronounced in malnourished patients and least pronounced in frail patients, and by significantly reduced physical performance. All syndromes were significantly pairwise related, except malnutrition and frailty. In 19% of patients sarcopenia and frailty occurred concurrently, in 20% frailty and cachexia and in 22% sarcopenia and cachexia with or without additional other syndromes. All malnourished patients except one were also cachectic (93%) and 80% of malnourished patients were also sarcopenic. 53% of malnourished patients were in addition frail, and these patients were affected by all four syndromes.

Conclusions

Nearly two thirds of older medical inpatients had at least one of the tissue loss syndromes sarcopenia, frailty, cachexia and malnutrition. The syndromes overlapped partly and were interrelated. Future studies with larger patient groups and longitudinal design are required to clarify the significance of single and concurrent occurrence of these syndromes for clinical outcome and successful therapy.

A systematic review on the influence of fear of falling on quality of life in older people: is there a role for falls?

Maintaining or improving quality of life (QoL) is a key outcome of clinical interventions in older people. Fear of falling (FoF) is associated with activity restriction as well as with poorer physical and cognitive functions and may be an important contributor to a diminished QoL. The objectives of this systematic review were to determine i) the effect of FoF on QoL in older people, ii) whether the association between these two constructs depends on the use of specific conceptualizations and measurement instruments, and iii) the role of fall events as mediating factor in this relationship. Four electronic databases (PubMed, EMBASE, CINAHL, and Cochrane Library) were searched from their inceptions to February 2018. Thirty mostly cross-sectional studies in nearly 30.000 people (weighted mean age 75.6 years (SD =6.1); 73% women) were included. FoF was associated with QoL in most studies, and this association appeared to be independent of the conceptualization of FoF. Moreover, this relationship was independent of falls people experienced which seemed to have a lower impact. FoF should be considered not only as by-product of falls and targeted interventions in parts different from those to reduce falls are likely required. Studies are needed showing that reducing FoF will lead to increased QoL.

[Diagnosis and therapy of sarcopenia-an update]

Since 2016 sarcopenia, the age-associated loss of muscle mass, strength and function, has the ICD-10-GM code M62.50 (International Statistical Classification of Diseases and Related Health Problems, 10th Revision, German Modification). The diagnosis of sarcopenia requires the combined presence of low muscle strength and low muscle mass. Well-established approaches for the prevention and therapy of sarcopenia are exercise programs-in particular strength, endurance and power training-and nutritional interventions, preferably a combination of both. Adequate protein intake is considered highly relevant, while the role of other nutrients involved in muscle metabolism (e. g. creatine, vitamin D, antioxidants, omega-3 fatty acids) is less clear, being still the subject of controversial discussions. Innovative pharmacological therapies are currently under investigation and their future relevance for this indication is unclear. In general, it has to be stated that there are still only few intervention studies available that focused specifically on sarcopenia in older individuals. More studies in this rapidly increasing population are urgently needed.

Sarcopenia: revised European consensus on definition and diagnosis

Background

in 2010, the European Working Group on Sarcopenia in Older People (EWGSOP) published a sarcopenia definition that aimed to foster advances in identifying and caring for people with sarcopenia. In early 2018, the Working Group met again (EWGSOP2) to update the original definition in order to reflect scientific and clinical evidence that has built over the last decade. This paper presents our updated findings.

Objectives

to increase consistency of research design, clinical diagnoses and ultimately, care for people with sarcopenia.

Recommendations

sarcopenia is a muscle disease (muscle failure) rooted in adverse muscle changes that accrue across a lifetime; sarcopenia is common among adults of older age but can also occur earlier in life. In this updated consensus paper on sarcopenia, EWGSOP2: (1) focuses on low muscle strength as a key characteristic of sarcopenia, uses detection of low muscle quantity and quality to confirm the sarcopenia diagnosis, and identifies poor physical performance as indicative of severe sarcopenia; (2) updates the clinical algorithm that can be used for sarcopenia case-finding, diagnosis and confirmation, and severity determination and (3) provides clear cut-off points for measurements of variables that identify and characterise sarcopenia.

Conclusions

EWGSOP2's updated recommendations aim to increase awareness of sarcopenia and its risk. With these new recommendations, EWGSOP2 calls for healthcare professionals who treat patients at risk for sarcopenia to take actions that will promote early detection and treatment. We also encourage more research in the field of sarcopenia in order to prevent or delay adverse health outcomes that incur a heavy burden for patients and healthcare systems.

The "Sarcopenia and Physical fRailty IN older people: multi-componenT Treatment strategies" (SPRINTT) randomized controlled trial: Case finding, screening and characteristics of eligible participants

BACKGROUND

The ongoing "Sarcopenia and Physical fRailty IN older people: multi-componenT Treatment strategies (SPRINTT)" randomized controlled trial (RCT) is testing the efficacy of a multicomponent intervention in the prevention of mobility disability in older adults with physical frailty & sarcopenia (PF&S). Here, we describe the procedures followed for PF&S case finding and screening of candidate participants for the SPRINTT RCT. We also illustrate the main demographic and clinical characteristics of eligible screenees.

METHODS

The identification of PF&S was based on the co-occurrence of three defining elements: (1) reduced physical performance (defined as a score on the Short Physical Performance Battery between 3 and 9); (2) low muscle mass according to the criteria released by the Foundation for the National Institutes of Health; and (3) absence of mobility disability (defined as ability to complete the 400-m walk test in 15 min). SPRINTT was advertised through a variety of means. Site-specific case finding strategies were developed to accommodate the variability across centers in catchment area characteristics and access to the target population. A quick "participant profiling" questionnaire was devised to facilitate PF&S case finding.

RESULTS

During approximately 22 months, 12,358 prescreening interviews were completed in 17 SPRINTT sites resulting in 6710 clinic screening visits. Eventually, 1566 candidates were found to be eligible for participating in the SPRINTT RCT. Eligible screenees showed substantial physical function impairment and comorbidity burden. In most centers, project advertisement through mass media was the most rewarding case finding strategy.

CONCLUSION

PF&S case finding in the community is a challenging, but feasible task. Although largely autonomous in daily life activities, older adults with PF&S suffer from significant functional impairment and comorbidity. This subset of the older population is therefore at high risk for disability and other negative health-related events. Key strategies to consider for successfully intercepting at-risk older adults should focus on mass communication methods.

[Hospital pastoral care of people with dementia : A qualitative interview study with professional hospital pastoral carers]

BACKGROUND

Communicating and interacting with persons diagnosed with dementia (PwD) present a challenge to pastoral carers, since most classical pastoral care approaches concentrate on conversation as a medium of relationship formation and do not take limited communication skills into account. This study focuses on the following question: how can hospital-based pastoral carers find appropriate methods of communication and interaction with PwD and provide them with pastoral care?

METHODS

A total of 10 professional pastoral carers participated in the study. Each of these persons had extensive experience with PwD. Data were collected with the use of guideline-based interviews. The interviews were evaluated using Mayring's method of qualitative content analysis.

RESULTS

One of the main challenges faced by the pastoral carers in interacting with PwD was to explore communication strategies based on non-verbal communication, in addition to verbal communication. Pastoral carers need to find alternative communicative approaches, such as biographical, non-verbal, and physical sense-related methods. Clinical pastoral education did not adequately equip these professionals for communicating and interacting with PwD. The interviewed pastoral carers acquired this specific knowledge through independent research of the academic literature, observation of other professionals, dementia-specific training courses, and practical experience.

CONCLUSION

Pastoral carers can make a positive contribution to the holistic care of PwD through their unique communicative and relationship approach to care. It is imperative to develop adequate pastoral care concepts and to integrate methodologies for dealing with PwD into the training curriculum of pastoral carers.

Naso- and oropharyngeal bacterial carriage in nursing home residents: Impact of multimorbidity and functional impairment

OBJECTIVE

From April 2013 to February 2014 we performed a multicentre prospective cross-sectional study in 541 German nursing home residents. We determined pharyngeal carriage of Streptococcus pneumoniae (primary objective) and other bacteria (secondary objective) in naso- and oropharyngeal swabs by culture-based standard procedures and explored the influence of multimorbidity and functional status on bacterial carriage.

METHODS

Socio-demographic data, vaccination status, multimorbidity, nutrition and functional status defined by Comprehensive Geriatric Assessment were evaluated. We estimated carriage rates with 95% confidence intervals (CI) and explored potential risk factors by logistic regression analysis.

RESULTS

Pneumococcal post-serotyping carriage rate was 0.8% (95%CI 0.2-1.9%; 4/526). Serotyping revealed serotypes 4, 7F, 23B and 23F and S. pseudopneumoniae in two other cases. Odds of carriage were higher in men (Odds ratio OR 5.3 (95%CI 0.9-29.4)), in malnourished residents (OR 4.6 (0.8-25.7)), residents living in shared rooms (OR 3.0 (0.5-16.5)) or having contact with schoolchildren (OR 2.0 (0.2-17.6)). The most frequent pathogen was Staphylococcus aureus (prevalence 29.5% (25.6-33.6%)) with meticillin-resistant Staphylococcus aureus prevalence of 1.1%. Gram-negative bacteria (GNB) were found in 22.5% (19.0-26.3%) with a prevalence of extended-spectrum beta lactamase (ESBL) producing bacteria of 0.8%. Odds of S. aureus carriage were higher for immobility (OR 1.84 (1.15-2.93)) and cognitive impairment (OR 1.54 (0.98-2.40)). Odds of GNB carriage were higher in residents with more severe comorbidity (OR 1.13 (1.00-1.28)) and malnutrition (OR 1.54 (0.81-2.91)).

CONCLUSIONS

Given the observed data, at least long-term carriage of S. pneumoniae in nursing home residents seems to be rare and rather unlikely to cause nursing home acquired pneumonia. The low rate of colonization with multi drug resistant (MDR) bacteria confirms that nursing home residency is not a risk factor for MDR pneumonia in Germany. For individual risk assessment in this susceptible population, immobility and malnutrition should be considered as signs of functional impairment as well as comorbidity.

International Clinical Practice Guidelines for Sarcopenia (ICFSR): Screening, Diagnosis and Management

OBJECTIVES

Sarcopenia, defined as an age-associated loss of skeletal muscle function and muscle mass, occurs in approximately 6 - 22 % of older adults. This paper presents evidence-based clinical practice guidelines for screening, diagnosis and management of sarcopenia from the task force of the International Conference on Sarcopenia and Frailty Research (ICSFR).

METHODS

To develop the guidelines, we drew upon the best available evidence from two systematic reviews paired with consensus statements by international working groups on sarcopenia. Eight topics were selected for the recommendations: (i) defining sarcopenia; (ii) screening and diagnosis; (iii) physical activity prescription; (iv) protein supplementation; (v) vitamin D supplementation; (vi) anabolic hormone prescription; (vii) medications under development; and (viii) research. The ICSFR task force evaluated the evidence behind each topic including the quality of evidence, the benefit-harm balance of treatment, patient preferences/values, and cost-effectiveness. Recommendations were graded as either strong or conditional (weak) as per the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Consensus was achieved via one face-to-face workshop and a modified Delphi process.

RECOMMENDATIONS

We make a conditional recommendation for the use of an internationally accepted measurement tool for the diagnosis of sarcopenia including the EWGSOP and FNIH definitions, and advocate for rapid screening using gait speed or the SARC-F. To treat sarcopenia, we strongly recommend the prescription of resistance-based physical activity, and conditionally recommend protein supplementation/a protein-rich diet. No recommendation is given for Vitamin D supplementation or for anabolic hormone prescription. There is a lack of robust evidence to assess the strength of other treatment options.

Amount, Distribution, and Quality of Protein Intake Are Not Associated with Muscle Mass, Strength, and Power in Healthy Older Adults without Functional Limitations-An enable Study

To maintain muscle mass in older age, several aspects regarding the amount and distribution of protein intake have been suggested. Our objective was to investigate single and combined associations of daily protein intake, evenness of protein distribution across the three main meals, number of meals providing ≥0.4 g protein/kg body weight (BW), and number of meals providing ≥2.5 g leucine, with muscle mass, strength, and power in successful agers. In this cross-sectional study in 97 healthy community-dwelling adults without functional limitations aged 75-85 years, protein intake was assessed using 7-day food records. Muscle mass, leg muscle strength, leg muscle power, and handgrip strength were measured according to standardized protocols. Mean daily protein intake was 0.97 ± 0.28 g/kg BW and the coefficient of variance between main meals was 0.53 ± 0.19. Per day, 0.72 ± 0.50 meals providing ≥0.4 g protein/kg BW and 1.11 ± 0.76 meals providing ≥2.5 g leucine were consumed. No correlations between single or combined aspects of protein intake and skeletal muscle index, leg muscle power, leg muscle strength, or handgrip strength were observed (Spearman's r of -0.280 to 0.291). In this sample of healthy older adults without functional limitations, aspects of protein intake were not associated with muscle mass, strength, or power.

[Is Age a Comorbidity?]

Aging is normal process, only somehow questioned by the "anti-aging wave". Normal and pathological aging are therefore separate developments. Older adults often suffer from the frailty syndrome, partly due to diminished resilience. Aging per se is not a comorbidity.

[Musculoskeletal factors, sarcopenia and falls in old age]

Falls in older adults are a major public health problem with a high incidence and severe consequences for the older individual. The age-related loss of muscle strength as well as muscle mass and muscle function (sarcopenia) are i) risk factors for falling, ii) associated with physical function and iii) markers of the frailty syndrome. Muscle function appears to play a bigger role than muscle mass. The operationalization of sarcopenia using the European Working Group on Sarcopenia in Older People (EWGSOP) algorithm is consistently associated with falling events. Structured physical exercise plays the key role in the prevention of falls and the management of functional decline caused by sarcopenia and frailty. The combined supplementation with proteins and vitamin D supports muscle protein synthesis in undersupplied persons and improves aspects of physical function.

Crystal arthritides - gout and calcium pyrophosphate arthritis : Part 3: Treatment

The treatment of gout is based on several principles. Symptom control and termination of the inflammatory process are important early goals, whereas the urate level should be lowered in the long term to prevent further gout attacks and complications. The non-pharmacological approach is based on individually informing the patient on dietary measures and changes of life style. Besides physical measures, such as cold applications on the affected joint, various medications are available for treatment of an acute gout attack. The choice of drug depends on the individual risk profile. If non-steroidal anti-inflammatory drugs (NSAID) and coxibs are chosen it should be taken into account that the use is restricted in patients with renal insufficiency. Moreover, these drugs may have gastrointestinal side effects and are associated with increased cardiovascular morbidity and mortality. Colchicine has gastrointestinal side effects at high dosages but can also be used for differential diagnostics if there is a quick response to treatment. Steroids are an effective alternative and can be given orally or parenterally in patients with dysphagia. Moreover, steroids can be used in cases of renal insufficiency. After symptoms of the acute attack have subsided, urate lowering therapy should be initiated to prevent further attacks. Low-dose urate lowering therapy can be started during an acute gout attack when acute therapy is initiated. Allopurinol is still the medication of choice but its use is restricted in patients with renal insufficiency. A rare but serious side effect is allopurinol hypersensitivity syndrome. Febuxostat can be an alternative in patients who do not tolerate allopurinol. In February 2016, lesinurad, an URAT-1 and OAT-4 inhibitor, was approved in combination with allopurinol or febuxostat. Data on the effectiveness and safety of synthetic uricases and biologicals are still sparse for elderly patients. These substances are reserved for severe cases of gout.

Nutrition, frailty, and sarcopenia

Frailty and sarcopenia are important concepts in the quest to prevent physical dependence, as geriatrics are shifting towards identifications of early stages of disability. Definitions of both sarcopenia and frailty are still developing, and both concepts clearly overlap in their physical aspects. Malnutrition (both undernutrition and obesity) plays a key role in the pathogenesis of frailty and sarcopenia. The quality of the diet along the lifespan has a close relation with the incidence of both entities, and nutritional interventions may be able to reduce the incidence or revert either of them. This brief review explores the role of energy and protein intake and other key nutrients on muscle function. Nutrition may be a key element of multimodal interventions for frailty and sarcopenia. The results of the "Sarcopenia and Physical fRailty IN older people: multi-componenT Treatment strategies" (SPRINTT) trial will offer key insights on the effect of such interventions in frail, sarcopenic older individuals.

High-Technology Based Gait Assessment in Frail People: Associations between Spatio-Temporal and Three-Dimensional Gait Characteristics with Frailty Status across Four Different Frailty Measures

OBJECTIVE

We analyzed associations between a battery of gait characteristics and frailty status across four different frailty instruments in old patients.

DESIGN

Cross-sectional study.

SETTING

Geriatric wards of a general hospital.

PARTICIPANTS

123 hospitalized patients aged ≥65 years.

MEASUREMENTS

Spatio-temporal and three-dimensional gait characteristics were assessed by an electronic walkway and a shoe-mounted, inertial sensor-based mobile gait analysis system. Frailty status was assessed by the frailty phenotype (FP), Clinical Frailty Scale (CFS), frailty index (FI), and frailty index based on a comprehensive geriatric assessment (FI-CGA).

RESULTS

A reduction in walking speed (FP, FI, FI-CGA), stride length (FP, FI, FI-CGA), maximum toe clearance (FP, CFS, FI, FI-CGA), toe off angle (FP, CFS, FI, FI-CGA), heal strike angle (FI-CGA) and greater stride length variability (FP, CFS, FI, FI-CGA), stride time variability (FP, FI), double support time (FP, FI), and stride width (CFA, FI-CGA) were associated with frailty status across the four frailty instruments (all P < 0.05, respectively). Walking speed (FP, CFS, FI, FI-CGA), stride length (FP, CFS, FI, FI-CGA), maximum toe clearance (FP, CFS, FI, FI-CGA), toe off angle (FP, CFS, FI, FI-CGA), heal strike angle (FP, FI), stride length variability (CFS, FI, FI-CGA), stride time variability (FI), double support time (FP), and stride width (FP, CFS, FI) were related with frailty severity across the four frailty instruments independent of age and sex (all P adjusted < 0.05, respectively).

CONCLUSIONS

Gait changes in frail patients include more than solely a reduction in walking speed.

Size Matters! Differences in Nutritional Care between Small, Medium and Large Nursing Homes in Germany

OBJECTIVES

The aim of this study is to comprehensively describe nutritional care in German nursing homes (NHs) and to examine if nutritional care differs between small, medium and large NHs.

DESIGN

Nationwide cross-sectional postal survey.

SETTING

Nursing homes.

PARTICIPANTS

541 NHs across Germany.

MEASUREMENTS

Information on structural NH characteristics and nutritional care (food provision and menu planning, nursing care, and management and quality assurance) was collected by means of a questionnaire addressed to the management of a random sample of German NHs. NHs were grouped by size as small (≤ 50 beds), medium (50 - 100 beds) or large (> 100 beds) institutions. Frequencies were used to describe nutritional care, and Chi2-test to identify differences in nutritional care by NH size.

RESULTS

Aspects in the domain of food provision and menu planning regarding food variety and choice were widely implemented in German NHs (77 - 100 %). Best results were achieved in the domain of nursing care, where all aspects were implemented in at least 68 % of the NHs. Aspects regarding management and quality assurance, especially those concerning staffing, i.e. the availability of an interface manager (14 %), an interdisciplinary nutrition team (12 %) and a dietician (42 %), were only rarely implemented. Differences by NH size were found between small and medium or large NHs. On the one hand, small NHs stated more often to consider individual capabilities of the residents with texture-modified food (81 % vs. 60 %, p<0.05) and produce more often hot meals at ward level on a regular base (46 % vs. 32 %, p<0.05) than large NHs. On the other hand, several aspects regarding food provision and menu planning, and management and quality assurance were significantly more often implemented in larger than smaller NHs.

CONCLUSION

Whereas kitchen and nursing-related aspects of nutritional care seem to be widely implemented in German NHs, management and quality assurance demands are often not met. The differences found by NH size support the hypothesis that the number of residents living in a NH has an impact on how nutritional care is performed.

Prevalence of low muscle mass according to body mass index in older adults

OBJECTIVE

Low muscle mass has been associated with increased morbi-mortality and should be identified for optimizing preventive and therapeutic strategies. This study evaluates the prevalence of bioelectrical impedance analysis (BIA)-derived low muscle mass in older persons using definitions found through a systematic literature search and determines the link between body mass index (BMI) and low muscle mass.

METHODS

We performed a systematic search of trials involving ≥100 persons that derived low muscle mass from BIA and reported cut-offs for low muscle mass normalized for body height or weight. These cut-offs were applied to all adults ≥65 y who underwent a BIA measurement at Geneva University Hospital between 1990 and 2011 (N = 3181). The association between BMI and low muscle mass was evaluated through multivariate logistic regressions.

RESULTS

We identified 15 cut-offs based on the fat-free mass index (FFMI), skeletal muscle index (SMI), or skeletal muscle percentage (SMP). Depending on the definition, the prevalence of low muscle mass was 17% to 68% in women and 17% to 85% in men. The risk of low muscle mass increased with a BMI <18.5 kg/m² when using cut-offs based on FFMI (odds ratio [OR] ♀ 14.28-24.04/♂ 25.42-50.64) or SMI (OR ♀ 3.56-4.56/♂ 7.07-8.87) and decreased with a BMI ≥25 kg/m² (FFMI: OR ♀ 0.03-0.04/♂ 0.01-0.04; SMI: OR ♀ 0.18-0.25/♂ 0.14-0.18). The opposite association appeared between BMI and cut-offs based on SMP.

CONCLUSION

The prevalence of low muscle mass varies widely depending on the definition, especially in persons with BMI <18.5 or ≥25 kg/m².

[Nutrition in dementia]

Older people suffering from dementia are at increased risk of malnutrition due to various nutritional problems, and the question arises which interventions are effective in maintaining adequate nutritional intake and nutritional status in the course of the disease. In an international expert group, initiated by the European Society for Clinical Nutrition and Metabolism (ESPEN), 26 evidence-based recommendations for nutritional care of older persons with dementia have been developed, covering the topics of screening and assessment of malnutrition, strategies to support oral nutrition, oral supplementation and artificial nutrition. This article is a short version of the guideline.