Malnutrition is associated with an increased risk of falls and impaired activity in elderly patients in Dutch residential long-term care (LTC): a cross-sectional study

Validation of the Malnutrition Screening Tool for use in a Community Rehabilitation Program

AIM

The aim of the present study was to determine if the Malnutrition Screening Tool (MST) is valid for use within the Community Rehabilitation Program (CRP) setting. Secondary outcome measures were to assess malnutrition prevalence in the CRP population and to determine trends between malnutrition and age, body mass index (BMI) and falls history.

METHODS

This study used a cross-sectional design. All clients admitted to a Melbourne metropolitan CRP during the study period had the MST completed at intake. A total of 160 participants were then selected at random and a Subjective Global Assessment (SGA) was completed by an experienced dietitian. Participants were classified as well nourished or malnourished, and this result was compared to their MST score. Data analysis was completed to determine the predictive value of the MST compared to SGA, which was expressed using sensitivity, specificity, positive and negative predictive values.

RESULTS

Out of the 160 participants, 34.0% were identified as malnourished. The MST achieved a sensitivity of 72.2% and a specificity of 83.8% with positive predictive value of 69.6% and negative predictive value of 85.4% compared to the SGA. Participants in the malnourished group were older and had a lower BMI (P < 0.05).

CONCLUSIONS

Considering the demographics and needs of the CRP population group and the predictive value of the MST compared to SGA, it can be concluded that the MST is a valid screening tool for use in this population and has relatively low burden to complete. Consequently, the MST could be included in the client initial needs identification to be completed when admitted to the program.

A systematic review of feeding practices among postoperative patients: is practice in-line with evidenced-based guidelines?

BACKGROUND

Early oral feeding after surgery is best practice among adult, noncritically ill patients. Evidenced-based guidelines (EBG) recommend commencing liquid and solid feeding within 24 h of surgery to improve patient (e.g. reduced morbidity) and hospital (e.g. reduced length of stay) outcomes. Whether these EBG are adhered to in usual clinical practice remains unknown. The present study aimed to identify the time to commencement of first oral feed (liquid or solid) and first solid feed among postoperative, noncritically ill, adult patients.

METHODS

MEDLINE, CINAHL, SCOPUS and Web of Science databases were searched from inception to June 2016 for observational studies reporting liquid and/or solid feeding practices among postoperative patients. Studies reporting a mean/median time to first feed or first solid feed within 24 h of surgery or where ≥75% of patients were feeding by postoperative day one were considered in-line with EBG.

RESULTS

Of 5826 articles retrieved, 29 studies were included. Only 40% and 22% of studies reported time to first feed and time to first solid feed in-line with EBG, respectively. Clear and free liquids were the first diet types commenced in 86% of studies. When solids were commenced, 44% of studies reported using various therapeutic diet types (e.g. light) prior to the commencement of a regular diet. Patients who underwent gastrointestinal procedures appeared more likely to experience delayed postoperative feeding.

CONCLUSIONS

Our findings demonstrate a gap between postoperative feeding evidence and its practical application. This information provides a strong rationale for interventions targeting improved nutritional care following surgery.

Optimizing the electronic health record to standardize administration and documentation of nutritional supplements

Malnutrition in hospitalized patients is a major cause for hospital re-admission, pressure ulcers and increased hospital costs. Methods to improve the administration and documentation of nutritional supplements for hospitalized patients are needed to improve patient care, outcomes and resource utilization. Staff at a medium-sized academic health science center hospital in the southeastern United States noted that nutritional supplements ordered for patients at high risk for malnutrition were not offered or administered to patients in a standardized manner and/or not documented clearly in the electronic health record as per prescription. This paper reports on a process improvement project that redesigned the ordering, administration and documentation process of oral nutritional supplements in the electronic health record. By adding nutritional products to the medication order sets and adding an electronic nutrition administration record (ENAR) tab, the multidisciplinary team sought to standardize nutritional supplement ordering, documentation and administration at prescribed intervals. This process improvement project used a triangulated approach to evaluating pre- and post-process change including: medical record reviews, patient interviews, and nutrition formula room log reports. Staff education and training was carried out prior to initiation of the system changes. This process change resulted in an average decrease in the return of unused nutritional formula from 76% returned at baseline to 54% post-process change. The process change resulted in 100% of nutritional supplement orders having documentation about nutritional medication administration and/or reason for non-administration. Documentation in the ENAR showed that 41% of ONS orders were given and 59% were not given. Significantly more patients reported being offered the ONS product (p=0.0001) after process redesign and more patients (5% before ENAR and 86% after ENAR reported being offered the correct type, amount and frequency of nutritional products (p=0.0001). ENAR represented an effective strategy to improve administration and documentation of nutritional supplements for hospitalized patients.

Making the Most of Mealtimes (M3): protocol of a multi-centre cross-sectional study of food intake and its determinants in older adults living in long term care homes

BACKGROUND

Older adults living in long term care (LTC) homes are nutritionally vulnerable, often consuming insufficient energy, macro- and micronutrients to sustain their health and function. Multiple factors are proposed to influence food intake, yet our understanding of these diverse factors and their interactions are limited. The purpose of this paper is to fully describe the protocol used to examine determinants of food and fluid intake among older adults participating in the Making the Most of Mealtimes (M3) study.

METHODS

A conceptual framework that considers multi-level influences on mealtime experience, meal quality and meal access was used to design this multi-site cross-sectional study. Data were collected from 639 participants residing in 32 LTC homes in four Canadian provinces by trained researchers. Food intake was assessed with three-days of weighed food intake (main plate items), as well as estimations of side dishes, beverages and snacks and compared to the Dietary Reference Intake. Resident-level measures included: nutritional status, nutritional risk; disease conditions, medication, and diet prescriptions; oral health exam, signs of swallowing difficulty and olfactory ability; observed eating behaviours, type and number of staff assisting with eating; and food and foodservice satisfaction. Function, cognition, depression and pain were assessed using interRAI LTCF with selected items completed by researchers with care staff. Care staff completed a standardized person-directed care questionnaire. Researchers assessed dining rooms for physical and psychosocial aspects that could influence food intake. Management from each site completed a questionnaire that described the home, menu development, food production, out-sourcing of food, staffing levels, and staff training. Hierarchical regression models, accounting for clustering within province, home and dining room will be used to determine factors independently associated with energy and protein intake, as proxies for intake. Proportions of residents at risk of inadequate diets will also be determined.

DISCUSSION

This rigorous and comprehensive data collection in a large and diverse sample will provide, for the first time, the opportunity to consider important modifiable factors associated with poor food intake of residents in LTC. Identification of factors that are independently associated with food intake will help to develop effective interventions that support food intake.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT02800291 , retrospectively registered June 7, 2016.

Validation of the Photography Method for Nutritional Intake Assessment in Hospitalized Elderly Subjects

OBJECTIVE

The aim of the present study was to validate the photographic indirect method as an accurate and specific tool to assess nutritional intake in a cohort of elderly hospitalized patients.

DESIGN

this is a prospective observational study.

SETTING

hospital (geriatric acute ward and transitional care of IRCCSS AUO San Martino Hospital, Genoa, Italy).

PARTICIPANTS

255 consecutive elderly hospitalized patients.

MEASUREMENTS

assessment of malnutrition by: Mini nutritional assessment (MNA) and abbreviated Comprehensive geriatric assessment (CIRS; Barthel index, SPMSE). The direct method (Gold standard): food dish weight (before lunch) and residual (after lunch) food dish weight and estimation of the percentage of eaten food and of residual food for each dish. The percentages of food intake and residual food were calculated according to the following formula: intake %= initial weight of the dishes- residual food weight)/ initial weight dish x100. The unit of variable was the percentage. The indirect photographic method with extrapolation of the lunch food intake by photographic method confronting initial meal and residual meal (25% quartile food dish estimation).

RESULTS

The results showed a significant correlation between the direct method (weighing residual food) and the indirect photographic method(n=255; r=0.9735; p<0.001) as well as a significant positive correlation between the indirect photographic method and the food caloric estimation calculated by the direct method (n=255; r= 0.6489, p<0.001). Intraclass coefficient (ICC), showed a highly significant degree of agreement between the gold standard and the indirect photographic method (ICC: 0.69; p<0.0001). Additionally, the results showed a good inter rater agreement of the indirect photographic method (kappa-statistic measure of interrater agreement: (Z=13.04; p<0.001); agreement 70.29% e Kappa=0.5965) and a good specificity of the indirect method as it was independent on the single food item.

CONCLUSIONS

The study originally provided the validation of the indirect photographic method for the assessment of nutritional intake in a vast cohort of hospitalized elderly subjects. The present results moved a step forward in the appropriate assessment of nutrition intake in frail elderly, providing an easy to use tool that may be incorporate in routine clinical practice for early and targeted therapeutic interventions.

Rationale for Strengthening Muscle to Prevent Falls and Fractures: A Review of the Evidence

Falls represent a major public health problem in older people, predominantly due to the resulting injuries which lead to progressive disability, immobilization and resulting comorbidities, dependency, institutionalization, and death. Reduced muscle strength and power have been consistently identified as risk factors for falls and related injuries, and it is likely these associations result from the central role played by reduced muscle strength and power in poor balance recovery. In addition, muscle strength and power are involved with protective responses that reduce the risk of an injury if a fall occurs. Progressive resistance training (PRT) is the standard way to increase muscle strength and power, and this training forms one of the main components of fall prevention exercise interventions. However, PRT has rarely been implemented in routine practice due to multiple challenges inherent to frail older people. The ongoing development of drugs expected to increase muscle power offers a new opportunity to reduce the risk of falls and fall-related injuries. The intent here is not to replace exercise training with drugs but rather to offer a pharmacologic alternative when exercise is not possible or contraindicated. The target population would be those most likely to benefit from this mechanism of action, i.e., weak older people without major causes for falls independent of muscle weakness. Provided such a tailored strategy was followed, a muscle anabolic may address this major unmet need.

Impact of Nutritional Status and Sleep Quality on Hospital Utilisation in the Oldest Old with Heart Failure

OBJECTIVES

To describe three-year trends in nutritional status and sleep quality and their impact on hospital utilisation in the oldest old (80 +) with heart failure (HF).

DESIGN

Single-centred longitudinal observational study.

SETTING

South-eastern Sweden.

PARTICIPANTS

90 elderly (80+) with objectively verified HF.

MEASUREMENTS

Baseline data from the Mini Nutritional Assessment (MNA) and on sleep quality were collected through structured interviews following the HF diagnosis (n=90) and at a three-year follow-up (n=41). Data on hospital utilisation during the three years following the HF diagnosis were also collected.

RESULTS

Nineteen percent of the participants were found to have impaired nutritional status, a condition that increased hospital utilisation by four bed days per year. A majority (85%) had impaired sleep quality, but no impact on hospital utilisation was found. Nutritional status and sleep quality were stable over the three-year period.

CONCLUSION

In the oldest old with HF, impaired nutritional status and impaired sleep quality are already common at HF diagnosis. Impaired nutritional status increases hospital utilisation significantly. Therefore, it is of supreme importance to systematically evaluate nutritional status and sleep quality in the oldest old when they are diagnosed with HF, as well as to take action if impairments are present.

Pre-operative nutritional serum parameters as predictors of failure after internal fixation in undisplaced intracapsular proximal femur fractures

INTRODUCTION

Current management of undisplaced hip fractures is based on internal fixation. Reported revision rates of 12-17% for this procedure negatively impact on patient morbidity and mortality. The aim of this novel study is to examine if the nutritional status of these patients is associated with failure of internal fixation.

PATIENTS AND METHODS

A consecutive series of 111 undisplaced intracapsular hip fractures treated with cannulated screw was identified. These were retrospectively reviewed including routine admission serum investigations (lymphocyte count and albumin levels). Radiological investigations were used to assess fracture classification, posterior-tilt angle, fixation adequacy, screw configuration and failure (avascular-necrosis, non-union and screw cut-out).

RESULTS

16% of fixations failed (18 patients). Patients with fixation-failure had a significantly lower albumin (35g/l vs. 40g/l, p=0.02) and lymphocyte count (0.7×10(9)l vs. 1.4×10(9)l, p≤0.001) than non-failure patients. Lymphocyte count, albumin level and posterior-tilt angle were independent predicators of failure on binary logistic regression analysis. We suggest that routine laboratory tests can be used to identify patients at greatest risk of failure of internal fixation.

Poor nutritional status is associated with a higher risk of falling and fracture in elderly people living at home in France: the Three-City cohort study

Falling and fractures are a public health problem in elderly people. The aim of our study was to investigate whether nutritional status is associated with the risk of falling or fracture in community-dwelling elderly. Poor nutritional status was significantly associated with a higher risk of both falling and fractures.

INTRODUCTION

Nutrition could play a role to prevent falls and fractures. The purpose of this study is to investigate whether a poor nutritional status is associated with the risk of falling and of fracture in community dwelling elderly.

METHODS

Baseline nutritional status of participants was assessed using the Mini Nutritional Assessment (MNA). After a follow-up of 12 years, 6040 individuals with available data for falls and 6839 for fracture were included. People who presented the outcomes at baseline were excluded. Cox models were used to evaluate the associations between nutritional status and the risks of fall or fracture.

RESULTS

The frequency of poor nutritional status (MNA ≤ 23.5), at baseline, was respectively 12.0% in the "fall study sample" and 12.8% in the "fracture study sample." Incident fall and fracture over 12 years were reported in 55.8 and 18.5% of the respective samples, respectively. In multivariate models controlled for sociodemographic data and several baseline health indicators, poor nutritional status was significantly associated with a higher risk of falling (hazard ratio (HR) = 1.66, 95% confidence interval (95% CI) 1.35-2.04 in men and HR = 1.20, 95% CI 1.07-1.34 in women) and with a higher risk of fracture (HR = 1.28, 95% CI 1.09-1.49).

CONCLUSION

Poor nutritional status was associated with a higher risk of both falling and fractures in French elderly community-dwellers. Early screening and management of the nutritional status may be useful to reduce the frequency of these events in older people.

Malnutrition in the nursing home

PURPOSE OF REVIEW

Malnutrition in the nursing home is increasingly recognized as a major international research priority, given the expanding geriatric populations, serious consequences, and challenges conducting research in nursing homes. This review examines the recent literature and suggests implications for research and practice.

RECENT FINDINGS

Across the recent studies, approximately 20% of nursing home residents had some form of malnutrition. However, malnutrition definitions were variable and prevalence ranged from 1.5 to 66.5%. Depression, cognitive impairment, functional impairment, and swallowing difficulty were consistently associated with malnutrition. Mortality was the major consequence of malnutrition among nursing home residents, whereas higher BMIs had lower risks of mortality. Beneficial interventions to reduce malnutrition in the nursing home included dietary supplements, greater resident role in food choice, and staff training programs.

SUMMARY

To truly tackle the issue of malnutrition in the nursing home setting, a consistent definition is needed. We strongly recommend that an expert consensus panel identify a standard set of measures to more accurately compare the prevalence across countries. Given the mortality consequences of malnutrition and the paucity of intervention studies, research on interventions for malnutrition in the nursing home needs to be a higher priority for facilities, researchers, and funding agencies.

Malnutrition and risk of falling among elderly without home-help service--a cross sectional study

OBJECTIVES

The aim of this study was to explore the frequency of malnutrition risk and associated risk of falling, social and mental factors among elderly without home-help service. The aim was also to explore factors associated with risk of falling.

DESIGN

A cross-sectional design was used.

SETTING

Elderly persons own homes.

PARTICIPANTS

Data were collected during preventive home visits to 565 elderly (age range 73-90 years) without home-help service. Those with complete SCREEN II forms were included in the study (n = 465).

MEASUREMENTS

MEASUREMENTS included rating scales regarding malnutrition risk (SCREEN II) and risk of falling (Downton). In addition, single-items: general health, satisfaction with life, tiredness, low-spiritedness, worries/anxiety and sleeping were used.

RESULTS

According to the SCREEN II, 35% of the sample had no malnutrition risk, 35% had moderate risk and 30% had high malnutrition risk. In an ordinal regression analysis, increased malnutrition risk was associated with being a woman living alone (OR 4.63), male living alone (OR 6.23), lower age (OR 0.86), poorer general health (OR 2.03-5.01), often/always feeling tired (OR 2.38), and an increased risk of falling (OR 1.21). In a linear regression analysis, risk of falling was associated with higher age (B 0.020), not shopping independently (B 0.162), and low meat consumption (B 0.138).

CONCLUSION

There are complex associations between malnutrition risk and the gender-cohabitation interaction, age, general health, tiredness, and risk of falling. In clinical practice comprehensive assessments to identify those at risk of malnutrition including associated factors are needed. These have to be followed by individual nutritional interventions using a holistic perspective which may also contribute to reducing the risk of falling.

Nutritional status and falls in community-dwelling older people: a longitudinal study of a population-based random sample

Background

Falls are common in older people and may lead to functional decline, disability, and death. Many risk factors have been identified, but studies evaluating effects of nutritional status are limited. To determine whether nutritional status is a predictor of falls in older people living in the community, we analyzed data collected through the Survey of Health and Living Status of the Elderly in Taiwan (SHLSET).

Methods

SHLSET include a series of interview surveys conducted by the government on a random sample of people living in community dwellings in the nation. We included participants who received nutritional status assessment using the Mini Nutritional Assessment Taiwan Version 2 (MNA-T2) in the 1999 survey when they were 53 years or older and followed up on the cumulative incidence of falls in the one-year period before the interview in the 2003 survey.

Results

At the beginning of follow-up, the 4440 participants had a mean age of 69.5 (standard deviation  = 9.1) years, and 467 participants were “not well-nourished,” which was defined as having an MNA-T2 score of 23 or less. In the one-year study period, 659 participants reported having at least one fall. After adjusting for other risk factors, we found the associated odds ratio for falls was 1.73 (95% confidence interval, 1.23, 2.42) for “not well-nourished,” 1.57 (1.30, 1.90) for female gender, 1.03 (1.02, 1.04) for one-year older, 1.55 (1.22, 1.98) for history of falls, 1.34 (1.05, 1.72) for hospital stay during the past 12 months, 1.66 (1.07, 2.58) for difficulties in activities of daily living, and 1.53 (1.23, 1.91) for difficulties in instrumental activities of daily living.

Conclusion

Nutritional status is an independent predictor of falls in older people living in the community. Further studies are warranted to identify nutritional interventions that can help prevent falls in the elderly.

Mini Nutritional Assessment and short-form Mini Nutritional Assessment can predict the future risk of falling in older adults - results of a national cohort study

BACKGROUND & AIMS

Falling is a major issue in geriatric health. Tools that identify individuals at risk of falling can help reduce the risk of falling. The study aimed to determine whether the full and short-form Mini Nutritional Assessment (MNAs) have the ability to predict the risk of falling in older adults.

METHODS

Subjects were 3118 ≥ 53-year old Taiwanese who completed both the 1999 and 2003 "Taiwan Longitudinal Study on Aging" surveys. We rated these subjects with normalized versions of the MNA and applied the standard cut-offs to define under-nutrition (≤23.5 and ≤11 points, respectively). We used multivariate logistic regression analysis and receiver operating characteristics to evaluate the ability of these tools in predicting the risk of falling three years later.

RESULTS

Older adults rated as at risk of malnutrition with the full MNA (OR = 1.87, 95% confidence interval = 1.33-2.63, p < 0.001) or the short-form (1.39, 1.07-1.80, p = 0.014) were associated with increased risk of falling three years later. Both versions significantly predicted the risk of falling and performed slightly better in ≥65-year old persons than in younger (53-64-year old) persons. The short-form performed relatively well compared to the full scale.

CONCLUSIONS

Results suggest that the full and short-form MNAs, in addition to rating the risk of malnutrition, also predict the risk of falling in older adults. Although the short-form is slightly less effective than the full scale in predicting the future risk of falling, its simplicity, effectiveness and efficiency make it ideal as a multipurpose screening tool in clinical settings.

Geriatric syndromes increased the nutritional risk in elderly cancer patients independently from tumour site and metastatic status. The ELCAPA-05 cohort study

BACKGROUND & AIMS

We assessed the prevalence and risk factors of malnutrition in elderly cancer patients.

METHODS

We studied a prospective cohort of solid cancer patients aged ≥70 years at referral to two geriatric oncology clinics between 2007 and 2010. Nutrition was evaluated using the Mini-Nutritional Assessment (MNA) using validated cut-offs (<17: malnutrition, 17-23.5: at-risk for malnutrition). Patients with non-digestive tumours (breast, prostate, urinary tract) and with digestive (colorectal, upper digestive tract and liver) were analysed separately using multinomial logistic regression.

RESULTS

Of 643 consecutive patients, 519 had available data (median age, 80; men, 48.2%; metastases, 46.3%; digestive cancer 47.8%). In non-digestive group, 13.3% had malnutrition versus 28.6% in digestive group. The link between metastasis and malnutrition was significantly higher in non-digestive group (adjusted odds ratio [ORa ], 25.25; 95%CI: 5.97-106.8) than in digestive group (ORa, 2.59; 1.08-6.24; p for heterogeneity = 0.04). Other factors independently associated with malnutrition were cognitive impairment (ORa MMMSE ≤ 24 versus > 24 in non-digestive group: 16.68; 4.89-56.90 and in digestive group: 3.93; 1.34-11.50), and depressed mood (ORa MiniGDS ≥1 versus <1 in non-digestive group: 11.11; 3.32-37.17 and in digestive group: 3.25; 1.29-8.15) and fall risk (ORa fall risk versus no fall risk in non-digestive group: 4.68; 1.77-12.37; in digestive group: 100% of malnourished patients were faller's).

CONCLUSION

We highlighted, in elderly cancer patients, the high prevalence of malnutrition and that geriatrics syndromes (i.e. cognitive impairment, depressed mood and fall risk) were independent risk factors for malnutrition. Moreover, metastatic status was significantly much more strongly associated with malnutrition in non-digestive than digestive tumours.