Nutrition in care homes and home care: How to implement adequate strategies (report of the Brussels Forum (22–23 November 2007))

Restrictive diets in the elderly: never say never again?

Restrictive diets have long been an essential part of standard nutritional therapy for a wide range of diseases like obesity, diabetes, hyperlipidaemia, arterial hypertension and chronic renal failure. Although a relevant number of studies have been published in this field, most of these have concentrated on adults below age 65. Data on the effects of restrictive diets in older persons are still scarce. With increasing age, restrictive diets seem to be less effective with regard to relevant study endpoints like morbidity, quality of life and mortality. This applies in particular to chronic indications which are in most cases associated with additional co-morbidities. Here the focus shifts towards providing adequate nutritional intake rich in macro- and especially micronutrients and a diet that is also highly palatable as older individuals are at increased risk of becoming malnourished and sarcopenic. In this context, nutritional prevention and therapy are of utmost importance for maintaining quality of life. This review summarizes the present evidence for the application of restrictive diets in older persons and balances it against potential risks.

Nutrition in care homes and home care: recommendations - a summary based on the report approved by the Council of Europe

Undernutrition in home care and care home settings has been acknowledged as a situation with various causes and significant consequences on both an individual and social level. A review article exposing this problem has been recently published. Consequently, scientific experts and other stakeholders were involved in formulating recommendations to tackle undernutrition and sensitize political authorities. The forum held in Brussels and its proceedings were considered as a baseline to interview stakeholders involved in care homes and home care in order to propose solutions on different levels. A full report including guidelines was sent and accepted by the Council of Europe, and can be used as a basis for implementing strategies on a national and international level. A multidisciplinary approach is important to successfully tackle malnutrition on multiple levels: the patients, the health care workers (medical and non-medical), the public, policy makers and society stakeholders. Awareness for patients and caregivers is important; this can be obtained by information and appropriate training. Care home management and kitchen staff activities can be modified in order to promote nutrition. Policy makers should create legal frameworks to confront malnutrition as being a public health concern. Undernutrition in home care and care home settings is a considerable problem and confrontation involves a multidisciplinary approach.

Decreasing trends in malnutrition prevalence rates explained by regular audits and feedback

To our knowledge, no studies have analyzed the influence of annual audit and feedback on the prevalence rates of malnutrition. This study analyzes the trend of malnutrition prevalence rates between 2004 and 2007 and the effects of previous audits and feedback from the annual Dutch National Prevalence Measurement of Care Problems (LPZ) and the effect of the participation in Dutch national improvement programs. From 2004 to 2007, an annual multicenter study was performed in Dutch hospitals, nursing homes, and home care organizations using a standardized questionnaire involving measurements at institutional, ward, and patient levels. The data were analyzed by logistic multilevel analysis. Nutritional status was assessed by BMI, undesired weight loss, and nutritional intake. In total, 80 hospitals, 141 nursing homes, and 48 home care organizations participated. The prevalence of malnutrition tended to decrease in hospitals and home care over the years. In nursing homes, prevalence rates were stable. Furthermore, the more often hospitals and home care organizations participated in the annual LPZ audits, the lower the prevalence rate of malnutrition (P < 0.001). Participation in national improvement programs also resulted in lower prevalence rates (P = 0.027). In conclusion, malnutrition prevalence rates have decreased over the last 4 y in hospitals and home care in The Netherlands. Participation in the LPZ and involvement in national improvement programs positively influenced these malnutrition prevalence rates, possibly indicating that increasing awareness and actively working toward improvement could be important in lowering these rates.

Nutritional problems in the elderly

Despite the high prevalence of malnutrition among elderly patients, nutritional problems are still not recognized as a priority forthem by health professionals. The need for nutritional assessment and intervention is particularly crucial in this age group, in whom the incidence of chronic illness is high and a myriad of socio-economic factors enhance the likelihood of malnutrition. Malnutrition could be considered as an element of frailty among the old, leading to increased risk of many geriatric syndromes such as falls, delirium, functional decline, depressed immunity, etcetera. However, detection of nutritional risk and nutritional intervention are effective in frail patients. Nutritional assessment should be part of routine clinical practice in elderly hospitalized patients. A comprehensive screening tool for assessment of nutritional status that is clinically relevant and cost effective to perform is therefore needed. If malnutrition is suggested by such screening tests, then a supplemental conventional nutritional assessment should be performed before treatment is planned.