ESPEN practical guideline: Clinical nutrition and hydration in geriatrics

Clean-label products: Factors affecting liking and acceptability by Portuguese older adults

Consumers are preferring more "natural" foods, made of "healthier" and "familiar" components - the "clean-label" trend. As the population ages, understanding the older adult consumer segment becomes increasingly important. This study aims to identify the factors influencing the acceptability and liking of clean-label products in older adults living in the community. A convenience sample of 100 older adults was used for this cross-sectional study. Socio-demographic data, health status, independence level, lifestyle characteristics, nutritional status, and food and nutrient intake data were collected. The acceptability and liking for clean-label products comprised two parts: Sensory analysis with overall liking evaluation of three pairs of products, using a 9-point hedonic scale and free comments; Willingness to eat and preference assessment of nine pairs of products using the Food Action scale and a simple preference test. The participants were 80% female with a mean age of 75 years old. The overall liking for clean-label versions of cookies and mayonnaise was lower than for traditional versions. However, participants were more willing to eat the clean-label versions of products, particularly ham and yogurt. Most of the participants would prefer buying the clean-label version of all nine pairs of products, especially for ham, loaf bread, sausages, and yogurt. In sum, older adults living in the community exhibit a lower liking but, a greater willingness to eat and a higher preference for buying clean-label products. Older adults who favor clean-label products have higher levels of education and are reported to have a more adequate diet.

ESPEN guideline on nutrition and hydration in dementia - Update 2024

BACKGROUND & AIMS

Dementia is accompanied by a variety of changes that result in an increased risk of malnutrition and low-intake dehydration. This guideline update aims to give evidence-based recommendations for nutritional care of persons with dementia in order to prevent and treat these syndromes.

METHODS

The previous guideline version was reviewed and expanded in accordance with the standard operating procedure for ESPEN guidelines. Based on a systematic search in three databases, strength of evidence of appropriate literature was graded by use of the SIGN system. The original recommendations were reviewed and reformulated, and new recommendations were added, which all then underwent a consensus process.

RESULTS

40 recommendations for nutritional care of older persons with dementia were developed and agreed, seven at institutional level and 33 at individual level. As a prerequisite for good nutritional care, organizations caring for persons with dementia are recommended to employ sufficient qualified staff and offer attractive food and drinks with choice in a functional and appealing environment. Nutritional care should be based on a written care concept with standardized operating procedures. At the individual level, routine screening for malnutrition and dehydration, nutritional assessment and close monitoring are unquestionable. Oral nutrition may be supported by eliminating potential causes of malnutrition and dehydration, and adequate social and nursing support (including assistance, utensils, training and oral care). Oral nutritional supplements are recommended to improve nutritional status but not to correct cognitive impairment or prevent cognitive decline. Routine use of dementia-specific ONS, ketogenic diet, omega-3 fatty acid supplementation and appetite stimulating agents is not recommended. Enteral and parenteral nutrition and hydration are temporary options in patients with mild or moderate dementia, but not in severe dementia or in the terminal phase of life. In all stages of the disease, supporting food and drink intake and maintaining or improving nutrition and hydration status requires an individualized, comprehensive approach. Due to a lack of appropriate studies, most recommendations are good practice points.

CONCLUSION

Nutritional care should be an integral part of dementia management. Numerous interventions are available that should be implemented in daily practice. Future high-quality studies are needed to clarify the evidence.

Growth differentiation factor 15 and malnutrition in older adults

OBJECTIVES

Growth differentiation factor 15 (GDF-15) levels increase due to systemic inflammation and chronic disease burden. Since these biological processes are pathogenic factors of malnutrition, we examined the prospective association between GDF-15 serum levels and subsequent malnutrition in older adults.

METHODS

We used data from 723 women and 735 men aged ≥65 years [mean age (SD): 71.3 (4.18) years] participating in the Seniors-ENRICA-2 cohort, who were followed-up for 2.2 years. Malnutrition was assessed with the Mini Nutritional Assessment-Short form (MNA-SF), where a 12-14 score indicates normal nutritional status, an 8-11 score indicates at risk of malnutrition, and a 0-7 score malnutrition. Associations of GDF-15 and malnutrition were analyzed, separately in women and men, using linear and logistic regression and adjusted for the main potential confounders.

RESULTS

The mean (SD) MNA-SF score at baseline was 13.2 (1.34) for women and 13.5 (1.13) for men. Incident malnutrition (combined endpoint "at risk of malnutrition or malnutrition") over 2.2 years was identified in 55 (9.7%) of women and 38 (5.4%) of men. In women, GDF-15 was linearly associated with a decrease in the MNA-SF score; mean differences (95% confidence interval) in the MNA-SF score were -0.07 (-0.13; -0.01) points per 25% increase in GDF-15, and -0.49 (-0.83; -0.16) for the highest versus lowest quartile of GDF-15. Also in women, GDF-15 was linearly associated with a higher malnutrition incidence, with odds ratio (95% confidence interval) of 1.24 (1.06; 1.46) per 25% increment in GDF-15 and of 3.05 (1.21; 7.65) for the highest versus lowest quartile of GDF-15. Results were similar after excluding subjects with cardiovascular disease and diabetes. No association of GDF-15 with changes in MNA score or malnutrition incidence was found in men.

CONCLUSION

Higher serum GDF-15 concentrations are associated with worsening nutritional status in older women. Further studies should elucidate the reasons for the sex differences in this association and explore the therapeutic potential of modifying GDF-15 to prevent malnutrition.

Combined systematic screening for malnutrition and dysphagia in hospitalized older adults: a scoping review

BACKGROUND

Dysphagia affects about 40% of patients admitted to acute geriatric wards, as it is closely associated with diseases that rise in prevalence with advancing age, such as stroke, Parkinson's disease, and dementia. Malnutrition is a highly associated predictive factor of dysphagia as well as one of the most common symptoms caused by dysphagia. Thus, the two conditions may exist simultaneously but also influence each other negatively and quickly cause functional decline especially in older adults. The purpose of this review was to determine whether institutions have established a protocol combining screenings for dysphagia and malnutrition on a global scale. If combined screening protocols have been implemented, the respective derived measures will be reported.

METHODS

A scoping review was conducted. A systematic database search was carried out in January and February 2024. Studies were included that examined adult hospitalized patients who were systematically screened for dysphagia and malnutrition. The results were managed through the review software tool Covidence. The screening of titles and abstracts was handled independently by two reviewers; conflicts were discussed and resolved by consensus between three authors. This procedure was retained for full-text analysis and extraction. The extraction template was piloted and revised following feedback prior to extraction, which was carried out in February 2024.

RESULTS

A total of 2014 studies were found, 1075 of which were included for abstract screening, 80 for full text screening. In the end, 27 studies were extracted and reported following the reporting guideline PRISMA with the extension for Scoping Reviews.

CONCLUSION

Most of the studies considered the prevalence and association of dysphagia and malnutrition with varying outcomes such as nutritional status, pneumonia, oral nutrition, and swallowing function. Only two studies had implemented multi-professional nutrition teams.

Adipocentric origin of the common cardiometabolic complications of obesity in the young up to the very old: pathophysiology and new therapeutic opportunities

Obesity is a multifactorial chronic disease characterized by an excess of adipose tissue, affecting people of all ages. In the last 40 years, the incidence of overweight and obesity almost tripled worldwide. The accumulation of "visceral" adipose tissue increases with aging, leading to several cardio-metabolic consequences: from increased blood pressure to overt arterial hypertension, from insulin-resistance to overt type 2 diabetes mellitus (T2DM), dyslipidemia, chronic kidney disease (CKD), and obstructive sleep apnea. The increasing use of innovative drugs, namely glucagon-like peptide-1 receptor agonists (GLP1-RA) and sodium-glucose cotransporter-2 inhibitors (SGLT2-i), is changing the management of obesity and its related cardiovascular complications significantly. These drugs, first considered only for T2DM treatment, are now used in overweight patients with visceral adiposity or obese patients, as obesity is no longer just a risk factor but a critical condition at the basis of common metabolic, cardiovascular, and renal diseases. An adipocentric vision and approach should become the cornerstone of visceral overweight and obesity integrated management and treatment, reducing and avoiding the onset of obesity-related multiple risk factors and their clinical complications. According to recent progress in basic and clinical research on adiposity, this narrative review aims to contribute to a novel clinical approach focusing on pathophysiological and therapeutic insights.

How to detect non-institutionalized older patients at risk of malnutrition during their hospitalization? Comparison of 8 screening tools for malnutrition or nutritional risk

BACKGROUND

The prevalence of malnutrition is high among the elderly population. Hospital admission is a window of opportunity for its detection.

OBJECTIVE

To assess the concordance of different nutritional scales in hospitalized patients.

METHODS

Prospective study in non-institutionalized patients over 65 years of age admitted to an internal medicine department. Five malnutrition screening surveys (MNA, MST, MUST, NRS-2000 and CONUT) and three nutritional risk screening surveys (SCREEN 3, 8 and 14) were compared. As gold standard we use the Global Malnutrition Leadership Initiative for Malnutrition (GLIM) definition of malnutrition.

RESULTS

Eighty-five patients (37% female, median age 83 years) were included. Forty-eight percent (95% CI 38-59%) of patients were classified as malnourished according to GLIM criteria. The SCREEN 3 scale was the most sensitive (93%; 95% CI 87-98) and MUST the most specific (91%; CI 85-99). The most effective scale for excluding suspected malnutrition was SCREEN 3 (LR- 0.17; 95% CI 0.05-0.53) and the best for confirming it was MST (LR+ 7.08; 95% CI 3.06-16.39). Concordance between the different scales was low or very low with kappa indices between 0.082 and 0.465.

CONCLUSIONS

A comprehensive approach is needed to detect malnutrition in hospitalized patients. More sensitive scales are more useful in initial screening. Nutritional risk tools could be effective at this stage. In a second step, malnutrition should be confirmed according to established criteria such as GLIM.

Improving geriatric outcomes through nutritional and immunonutritional strategies: Focus on surgical setting by a comprehensive evidence review

The aging population worldwide has led to an increased request for surgical interventions in older, geriatric, and frail patients. However, all the physiological changes related to aging are associated with many challenges in the perioperative period, strongly impacting surgical outcomes. Nutritional status plays a pivotal role in determining the resilience of older adults to surgical stress and their ability to recover postoperatively. It is well known that malnutrition, a prevalent concern in geriatrics, is linked to increased adverse outcomes, including morbidity and mortality. Recognizing the significance of preoperative nutritional screening, assessment, diagnosis, intervention, and monitoring is essential for optimizing surgical outcomes. In this context, immunonutrition, which involves the supplementation of specific nutrients to modulate immune responses, emerges as a promising strategy to mitigate the increased inflammatory response observed in geriatric surgical patients. This study reviews current literature on the impact of nutrition and immunonutrition on surgical outcomes in geriatrics, highlighting the potential benefits in terms of reduced complications, enhanced wound healing, and shortened hospital stays. Recognizing and addressing the specific nutritional needs of older persons undergoing surgery is essential for promoting successful surgical outcomes and improving overall quality of life in this vulnerable population.

Enhancing Elderly Nutrition: A Qualitative Evaluation of Menus in a Social Solidarity Institution in the North of Portugal

This work addresses the importance of food and nutrition in promoting the health of the elderly population, with a specific focus on the qualitative evaluation of menus provided by a social solidarity institution in Portugal. The aim of this study is to conduct a qualitative evaluation of menus furnished by a social solidarity institution situated in the northern region of Portugal in order to prevent and/or treat malnutrition in the elderly. The methodology involves the evaluation of four weekly menus, totaling 28 complete daily menus for the elderly, using the "Avaliação Qualitativa de Ementas Destinadas a Idosos" (AQEDI) tool. This assessment tool comprises six domains: general items, soup, protein suppliers, carbohydrate suppliers, vegetable suppliers, and dessert, each consisting of various parameters. The findings reveal that all menus were classified as "acceptable," with percentages ranging from 60.73% to 68.84%, and suggest that there exists room for improvement. This study emphasizes the necessity for coordinated efforts within the institution to enhance menu planning, taking into account both nutritional guidelines and sensory aspects of food. Effective coordination within the institution is crucial for maintaining positive aspects and rectifying inadequacies in menu planning.

ESPEN practical guideline: Nutritional support for polymorbid medical inpatients

BACKGROUND

Disease-related malnutrition in polymorbid medical inpatients is a highly prevalent syndrome associated with significantly increased morbidity, disability, short- and long-term mortality, impaired recovery from illness, and healthcare costs.

AIM

As there are uncertainties in applying disease-specific guidelines to patients with multiple conditions, our aim was to provide evidence-based recommendations on nutritional support for the polymorbid patient population hospitalized in medical wards.

METHODS

The 2023 update adheres to the standard operating procedures for ESPEN guidelines. We undertook a systematic literature search for 15 clinical questions in three different databases (Medline, Embase and the Cochrane Library), as well as in secondary sources (e.g., published guidelines), until July 12th, 2022. Retrieved abstracts were screened to identify relevant studies that were used to develop recommendations (including SIGN grading), which was followed by submission to Delphi voting. Here, the practical version of the guideline is presented which has been shortened and equipped with flow charts for patients care.

RESULTS

32 recommendations (7× A, 11× B, 10× O and 4× GPP), which encompass different aspects of nutritional support were included from the scientific guideline including indication, route of feeding, energy and protein requirements, micronutrient requirements, disease-specific nutrients, timing, monitoring and procedure of intervention. Here, the practical version of the guideline is presented which has been shortened and equipped with flow charts for patients care.

CONCLUSIONS

Recent high-quality trials have provided increasing evidence that nutritional support can reduce morbidity and other complications associated with malnutrition in polymorbid patients. The timely screening of patients for risk of malnutrition at hospital admission followed by individualized nutritional support interventions for at-risk patients should be part of routine clinical care and multimodal treatment in hospitals worldwide. Use of this updated practical guideline offers an evidence-based nutritional approach to polymorbid medical inpatients and may improve their outcomes.

The mode and timing of administrating nutritional treatment of critically ill elderly patients in intensive care units: a multicenter prospective study

Introduction

Critically ill patients are more susceptible to malnutrition due to their severe illness. Moreover, elderly patients who are critically ill lack specific nutrition recommendations, with nutritional care in the intensive care units (ICUs) deplorable for the elderly. This study aims to investigate nutrition treatment and its correlation to mortality in elderly patients who are critically ill in intensive care units.

Method

A multiple-center prospective cohort study was conducted in China from 128 intensive care units (ICUs). A total of 1,238 elderly patients were included in the study from 26 April 2017. We analyzed the nutrition characteristics of elderly patients who are critically ill, including initiated timing, route, ways of enteral nutrition (EN), and feeding complications, including the adverse aspects of feeding, acute gastrointestinal injury (AGI), and feeding interruption. Multivariate logistic regression analysis was used to screen out the impact of nutrition treatment on a 28-day survival prognosis of elderly patients in the ICU.

Result

A total of 1,238 patients with a median age of 76 (IQR 70-83) were enrolled in the study. The Sequential Organ Failure (SOFA) median score was 7 (interquartile range: IQR 5-10) and the median Acute Physiology and Chronic Health Evaluation (APACHE) II was 21 (IQR 16-25). The all-cause mortality score was 11.6%. The percentage of nutritional treatment initiated 24 h after ICU admission was 58%, with an EN of 34.2% and a parenteral nutrition (PN) of 16.0% in elderly patients who are critically ill. Patients who had gastrointestinal dysfunction with AGI stage from 2 to 4 were 25.2%. Compared to the survivors' group, the non-survivors group had a lower ratio of EN delivery (57% vs. 71%; p = 0.015), a higher ratio of post-pyloric feeding (9% vs. 2%; p = 0.027), and higher frequency of feeding interrupt (24% vs. 17%, p = 0.048). Multivariable logistics regression analysis showed that patients above 76 years old with OR (odds ratio) 2.576 (95% CI, 1.127-5.889), respiratory rate > 22 beats/min, and ICU admission for 24 h were independent risk predictors of the 28-day mortality study in elderly patients who are critically ill. Similarly, other independent risk predictors of the 28-day mortality study were those with an OR of 2.385 (95%CI, 1.101-5.168), lactate >1.5 mmol/L, and ICU admission for 24 h, those with an OR of 7.004 (95%CI, 2.395-20.717) and early PN delivery within 24 h of ICU admission, and finally those with an OR of 5.401 (95%CI, 1.175-24.821) with EN delivery as reference.

Conclusion

This multi-center prospective study describes clinical characteristics, the mode and timing of nutrition treatment, frequency of AGI, and adverse effects of nutrition in elderly ICU patients. According to this survey, ICU patients with early PN delivery, older age, faster respiratory rate, and higher lactate level may experience poor prognosis.

Parenteral nutrition-related complications in older patients with acute intestinal failure: A descriptive cohort study

INTRODUCTION

Reported outcomes for parenteral nutrition (PN)-related complications in older adult patients with acute intestinal failure who are receiving PN in the acute hospital setting are limited. Our study aims to compare PN-related complications between older and younger adult patients.

METHODS

A retrospective descriptive study of inpatients who were administered PN from January 1, 2019, to December 31, 2019, was performed. Patients were categorized into older (≥65 years old) and younger (<65 years old) adult groups.

RESULTS

Two hundred thirty-five patients were included. There were 103 patients in the older adult group (mean age: 73.9 [SD: 6.9] years) and 132 patients in the younger adult group (mean age: 52.4 [SD: 12.5] years). There was a significantly higher Charlson Comorbidity Index score and lower Karnofsky score in the older adult group. The older adult group received significantly lower total energy (20.8 [SD: 7.8] vs 22.8 [SD: 6.3] kcal/kg/day), dextrose (3.1 [SD: 1.4] vs 3.6 [SD: 1.4] g/kg/day), and protein (1.1 [SD: 0.4] vs 1.2 [SD: 0.3] g/kg/day) than the younger group received. The mean length of stay was significantly shorter in the older adult group (35.9 [SD: 21.3] vs 59.8 [SD: 55.3]; P < 0.05). There was no significant difference in PN-related complications and clinical outcomes (catheter-related bloodstream infections, hypoglycemia or hyperglycemia, fluid overload, or inpatient mortality) between the two groups.

CONCLUSION

Despite more comorbidities in the older adult, the usage of PN in older adult patients with acute intestinal failure was associated with neither an increased rate of PN-related complications nor worse clinical outcomes when compared with that of younger patients.

The Current Landscape of Pharmacotherapies for Sarcopenia

Sarcopenia is a skeletal muscle disorder characterized by progressive and generalized decline in muscle mass and function. Although it is mostly known as an age-related disorder, it can also occur secondary to systemic diseases such as malignancy or organ failure. It has demonstrated a significant relationship with adverse outcomes, e.g., falls, disabilities, and even mortality. Several breakthroughs have been made to find a pharmaceutical therapy for sarcopenia over the years, and some have come up with promising findings. Yet still no drug has been approved for its treatment. The key factor that makes finding an effective pharmacotherapy so challenging is the general paradigm of standalone/single diseases, traditionally adopted in medicine. Today, it is well known that sarcopenia is a complex disorder caused by multiple factors, e.g., imbalance in protein turnover, satellite cell and mitochondrial dysfunction, hormonal changes, low-grade inflammation, senescence, anorexia of aging, and behavioral factors such as low physical activity. Therefore, pharmaceuticals, either alone or combined, that exhibit multiple actions on these factors simultaneously will likely be the drug of choice to manage sarcopenia. Among various drug options explored throughout the years, testosterone still has the most cumulated evidence regarding its effects on muscle health and its safety. A mas receptor agonist, BIO101, stands out as a recent promising pharmaceutical. In addition to the conventional strategies (i.e., nutritional support and physical exercise), therapeutics with multiple targets of action or combination of multiple therapeutics with different targets/modes of action appear to promise greater benefit for the prevention and treatment of sarcopenia.

The prevalence, risk factors and clinical implications of dehydration in older patients: a cross-sectional study

OBJECTIVES

Adequate hydration is essential for the maintenance of physiological functions. Older adults may not be able to maintain adequate hydration, which is often not recognized. Our aim was to investigate the prevalence, risk factors and clinical implications of dehydration in older adults.

METHODS

This cross-sectional study included 964 older adults in one geriatric outpatient clinic in Turkey. Dehydration was defined as a calculated [1,86 × (Na+K)+1,15×glucose+urea +14] plasma osmolarity of ≥ 295 mOsm/L. Clinical characteristics and measures of comprehensive geriatric assessments of patients with dehydration and normohydration were compared. Predictors of dehydration were assessed using logistic regression analysis.

RESULTS

Mean age was 79.9 ± 7.7 years, (71.7% female). The prevalence of dehydration was 31%. Female patients, diabetes mellitus (DM), chronic renal failure (CKD), a higher risk of falling (based on Timed Up and Go test), probable sarcopenia, dependence based on basic and instrumental daily living activities (BADL and IADL) were more common in the dehydrated group (p < 0.05). After adjusting for age and gender, dependency on BADL and IADL, the risk of falling were still higher in the dehydrated group (p < 0.05). There were significant relationships between dehydration and risk of falling (OR 1.38, 95% CI 1.00-1.90; p < 0.05), after adjustment for age, gender, DM, CKD.

CONCLUSION

Dehydration is common among older adults and is associated with a dependency, probable sarcopenia, and an increased risk of falling. Screening for dehydration and taking preventive measures may be beneficial in avoiding the negative consequences associated with dehydration.

The critically ill older patient with sepsis: a narrative review

Sepsis is a significant public health concern, particularly affecting individuals above 70 years in developed countries. This is a crucial fact due to the increasing aging population, their heightened vulnerability to sepsis, and the associated high mortality rates. However, the morbidity and long-term outcomes are even more notable. While many patients respond well to timely and appropriate interventions, it is imperative to enhance efforts in identifying, documenting, preventing, and treating sepsis. Managing sepsis in older patients poses greater challenges and necessitates a comprehensive understanding of predisposing factors and a heightened suspicion for diagnosing infections and assessing the risk of sudden deterioration into sepsis. Despite age often being considered an independent risk factor for mortality and morbidity, recent research emphasizes the pivotal roles of frailty, disease severity, and comorbid conditions in influencing health outcomes. In addition, it is important to inquire about the patient's preferences and establish a personalized treatment plan that considers their potential for recovery with quality of life and functional outcomes. This review provides a summary of the most crucial aspects to consider when dealing with an old critically ill patient with sepsis.

Nutritional status of hospitalized elderly patients in Ethiopia: a cross-sectional study of an important yet neglected problem in clinical practice

Background

Malnutrition is a common geriatric syndrome affecting approximately half of the older population with a more pronounced occurrence rate in those hospitalized. It affects the physiology, and results in poor humanistic and clinical outcomes. In Africa, particularly in Ethiopia, albeit multiple studies are available on malnutrition in non-hospitalized older population, similar studies in inpatient settings are scarce. Therefore, this study was conducted with the intention to quantify the prevalence of malnutrition in older patients on inpatient admission and determine its associated factors.

Methods

A total of 157 older inpatients aged 60 years and above were included in the present study. The data collection format was developed after an in-depth review of relevant literatures. The full Mini-Nutritional Assessment (MNA) tool was employed to assess the nutritional status on admission. Data completeness was checked thoroughly. Descriptive statistics and logistic regression analysis were conducted using STATA 15.0. The area under the receiver operating characteristic curve (ROC), Hosmer-Lemeshow test, and classification table were computed to evaluate the final model goodness-of-fit.

Results

Of the total study subjects, 81% were malnourished (MNA score <17) and 17% were at risk for malnutrition (MNA score of 17.5-23.5). However, upon review of the patients' medical charts, malnutrition diagnosis was recorded in only two patients. Rural residence (AOR = 2.823, 95%CI: 1.088, 7.324), self-reported financial dependence for expenses (AOR = 4.733, 95%CI: 1.011, 22.162), and partial dependence in functional autonomy on admission (AOR = 3.689, 95%CI: 1.190, 11.433) significantly increased the risk of malnutrition. The area under the ROC curve (0.754) and the Hosmer-Lemeshow test (p = 0.7564) indicated that the final model reasonably fits the data. The model`s sensitivity is 96.85%.

Conclusion

In the present study, an alarmingly high prevalence of malnutrition was identified older inpatients. The problem went undiagnosed in a similar percentage of patients. Several available literatures indicate the presence of an association between nutritional status and patient outcomes, thus strict nutritional screening at inpatient admission and intervention are recommended with special emphasis for those from rural areas, with financial dependence, and with functional impairment on admission.

Update on the management of elderly patients with colorectal cancer

Colorectal cancer (CRC) is one of the most common tumours worldwide, and 70% of CRC patients are over 65 years of age. However, the scientific evidence available for these patients is poor, as they are underrepresented in clinical trials. Therefore, a group of experts from the Oncogeriatrics Section of the Spanish Society of Medical Oncology (SEOM), the Spanish Cooperative Group for the Treatment of Digestive Tumours, (TTD) and the Multidisciplinary Spanish Group of Digestive Cancer (GEMCAD) have reviewed the scientific evidence available in older patients with CRC. This group of experts recommends a multidisciplinary approach and geriatric assessment (GA) before making a therapeutic decision because GA predicts the risk of toxicity and survival and helps to individualize treatment. In addition, elderly patients with localized CRC should undergo standard cancer resection, preferably laparoscopically. The indication for adjuvant chemotherapy (CT) should be considered based on the potential benefit, the risk of recurrence, the life expectancy and patient comorbidities. When the disease is metastatic, the possibility of radical treatment with surgery, radiofrequency (RF) or stereotactic body radiation therapy (SBRT) should be considered. The efficacy of palliative CT is similar to that seen in younger patients, but elderly patients are at increased risk of toxicity. Clinical trials should be conducted with the elderly population and include GAs and specific treatment plans.

Management of disease-related malnutrition: a real-world experience with a novel concentrated high-protein energy-dense oral nutritional supplement

OBJECTIVE

Despite the availability of a wide range of oral nutritional supplements (ONS) offerings, individuals with malnutrition are still struggling to meet their nutritional targets. A new concentrated and high-protein energy-dense ONS (≥2.1 kcal/mL;32 g protein/200 mL) with high-quality protein (60% whey protein) has emerged as a pivotal formula to reach the patient's energy-protein requirements, enhance compliance, and maximize stimulation of muscle protein synthesis, key factors driving better nutritional, functional, and clinical outcomes. The purpose of this article is to provide our clinical experience using this new nutritionally concentrated ONS as a therapeutic strategy for patients with DRM.

METHODS

Three clinical cases have been examined using new assessment procedures and a new form of nutritional therapy, and their impact on the nutritional and functional outcomes in patients with moderate-to-severe DRM.

RESULTS

A tailored individualized nutritional interventions improved anthropometric, biochemical, and functional outcomes (Case 1,2, and 3) assessed using hand grip strength, bioimpedance and muscle ultrasound, and as well as good gastrointestinal tolerance (Case 1) and compliance to the ONS in patients with DRM (Case 1,2,3).

CONCLUSION

The use of this novel high-protein energy-dense formula with high-quality protein source (≥2.1 kcal/mL; 32 g protein/200 mL; 60% whey protein) overcome common practical challenges in the medical nutrition therapy of patients with DRM, either because these patients require a highly concentrated formulation to meet nutritional requirements due to loss of appetite, lack of interest in food, and high caloric-protein needs due to disease, and a large quantity and quality of protein to optimize muscle recovery due to sarcopenia, common in patients with moderate-severe malnutrition.

Nutritional therapy in chronic wound management for older adults

PURPOSE OF REVIEW

We provided an updated overview of recent data on the value of nutritional therapy in the management of chronic wounds in older adults.

RECENT FINDINGS

In the last years, advances in this area were limited, but new data suggest considering nutritional care (screening and assessment of malnutrition and nutritional interventions) also in patients with chronic wounds other than pressure ulcers, namely venous leg and diabetic foot ulcers, as in these patients, nutritional derangements can be present despite overweight/obesity and their management is beneficial.

SUMMARY

Chronic wounds are wounds in which the process of repair does not progress normally due to a disruption in one or more of the healing phases. Nutritional therapy is aimed at recovering the process of repair. General principles of nutritional care in geriatrics apply to these patients but disease-specific recommendations are available, particularly for pressure ulcers. Interventions should address nutritional status, comorbidities, hydration and should provide key nutrients playing an active role in the healing process (arginine, zinc, and antioxidants) but always within the context of an individual care plan addressing patients requirements, particularly protein needs. Further evidence of efficacy in vascular and diabetic foot ulcers is warranted.

Improving nutrition care and diet intake for hospitalised older people at risk of malnutrition through a nurse-driven mealtime assistance bundle

BACKGROUND

Poor dietary intake is common in hospitalised older people. A targeted mealtime intervention is needed to improve nutrition care and dietary intake, especially for those at risk of malnutrition.

OBJECTIVES

This quality improvement project designed, implemented and evaluated a mealtime assistance bundle consisting of care measures driven by the hospital nursing team. The aims were to improve the mealtime care process to promote dietary intake of the hospitalised older people and to improve nursing staff's knowledge, attitude and practice in malnutrition.

METHODS

This project adopted a pre-post design, targeting older people aged 65 years and above, who were admitted to a general medical unit in a regional hospital in Singapore. A mealtime assistance bundle consisting of seven care measures, using the acronym CANFEED, was implemented for older adults at risk of malnutrition. Outcome measures on the amount of dietary intake during meals through chart reviews and surveys of nursing staff using Malnutrition Knowledge, Attitudes and perceived Practices (M-KAP) questionnaire were performed before and after implementation.

RESULTS

There were fewer older adults with poor intake in the post-implementation group than the pre-implementation group. Among those at risk of malnutrition, older adults in the post-implementation group had higher average intake of all provided meals as well as the protein-dense main dish. Significant improvements were noted in the total scores rated by the nursing staff in both the Knowledge-Attitude subscale and Practice subscale of the M-KAP questionnaire.

CONCLUSIONS

Integrating a nurse-driven mealtime assistance bundle into usual care may have positive outcomes on nutritional intake of hospitalised older people at risk of malnutrition, and on knowledge, attitude and practice of hospital nurses in nutrition care.

IMPLICATIONS FOR PRACTICE

Nurses play a critical role in nutrition care for hospitalised older people. Continuing efforts to improve nutritional intake of hospitalised older people should focus on staff education, building a multidisciplinary food-promoting culture and patient, family and community empowerment. More efficient clinical processes incorporating information technology with the EMR to support better nutrition care of the hospitalised older people are needed.

Effects of a low-protein nutritional formula with dietary counseling in older adults with chronic kidney disease stages 3-5: a randomized controlled trial

BACKGROUND

Although combining a low-protein diet (LPD) with oral nutritional supplements increases treatment adherence and nutritional status in patients with chronic kidney disease (CKD), the effect of this combination approach in older adults remains unclear. This study examined the impact of a 6% low-protein formula (6% LPF) with diet counseling in older adults with stage 3-5 CKD.

METHODS

In this three-month randomized controlled study, 66 patients (eGFR < 60 mL/min/1.73 m2, non-dialysis, over 65 years of age) were randomly assigned to an intervention group (LPD plus a 6% LPF) or control group (LPD alone). The 6% LPF comprised 400 kcal, 6 g of protein, eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), and various micronutrients. All data were collected at baseline and after three months, including physical performance based on hand grip strength (HGS) and gait speed, nutritional status using Mini Nutritional Assessment-Short Form (MNA-SF) scores, body composition through bioelectrical impedance analysis, and dietary intake from 24-h dietary records.

RESULTS

This study incorporated 47 participants (median age, 73; median eGFR, 36 ml/min/1.73 m2; intervention group: 24; control group: 23). The intervention group exhibited significant differences in HGS and gait speed, and micronutrient analysis revealed significantly higher monounsaturated fatty acids (MUFA), EPA, DHA, calcium, iron, zinc, copper, thiamine, riboflavin, niacin, B6, B12, and folic acid intake than the control group. MNA-SF scores, macronutrient intake, and body composition did not differ significantly between the two groups.

CONCLUSIONS

Compared to LPD counseling alone, an LPD prescription with 6% LPF in older adults with CKD stages 3-5 helped relieve physical deterioration and increased micronutrient intake after three months.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05318014 (retrospectively registered on 08/04/2022).

Lactose malabsorption and intolerance: What is the correct management in older adults?

Lactose malabsorption is a very common condition due to intestinal lactase deficiency. Post weaning, a genetically programmed and irreversible reduction of lactase activity occurs in the majority of the world's population. Lactose malabsorption does not necessarily result in gastrointestinal symptoms, i.e. lactose intolerance, which occurs in approximately one third of those with lactase deficiency. In the absence of well-established guidelines, the common therapeutic approach tends to exclude milk and dairy products from the diet. However, this strategy may have serious nutritional disadvantages. Mainly in particular categories, such as the older adults, the approach to lactose malabsorption may deserve careful considerations. Milk and dairy products are an important supply of a wide range of nutrients that contribute to meet the nutritional needs in different life stages. Dietary composition can significantly impact the mechanisms leading to age-related loss of bone mineral density, skeletal muscle mass or function and overall risk of sarcopenia. Moreover, in the latest years, different lines of evidence have highlighted an association between dairy intake and prevention of chronic diseases as well as all-cause mortality. The aim of this opinion paper is to provide an overview of lactose malabsorption and intolerance in the older adults and their implications in clinical practice.

Biceps brachii muscle cross-sectional area measured by ultrasonography is independently associated with one-month mortality: A prospective observational study

PURPOSE

Studies examining mortality in palliative care units are limited. We aimed to investigate the mortality and associated factors including ultrasonographic muscle parameters in hospitalized palliative patients with a subgroup analysis of older patients.

METHODS

A prospective-observational study. We recorded the demographics, number of diseases, diagnoses, and the Charlson comorbidity index (CCI), palliative performance scale (PPS), and nutritional risk screening-2002 (NRS-2002) scores. We noted the nutritional parameters and mortality. We measured the subcutaneous fat thickness (SFT), muscle thickness (MT), and cross-sectional area (CSA) of the rectus femoris and biceps brachii using ultrasonography.

RESULTS

We enrolled 100 patients (mean age: 73.2 ± 16.4 years, 53%: female). One-month mortality was 42%. The non-survivors had significantly higher malignancy, increased CCI and NRS-2002 scores, lower required energy intake, calorie sufficiency rate, and biceps brachii SFT, MT, and CSA than the survivors. The independent mortality predictors were malignancy and biceps brachii CSA while the PPS score and malignancy were significantly associated with mortality in the older subgroup.

CONCLUSION

The malignancy and biceps brachii CSA might have prognostic value in predicting mortality in palliative patients. This was the first study investigating the mortality-associated factors including ultrasonographic muscle measurements of both the lower and upper limbs in a palliative care center.

The risk of malnutrition and its clinical implications in older patients with cancer

AIM

Malnutrition is a common geriatric syndrome with multiple negative outcomes including mortality. However, there is a scarcity of literature that focuses on the relationship between malnutrition risk and its clinical implications on geriatric syndromes and mortality among cancer patients. The aim of this study is to determine the clinical importance of malnutrition risk in geriatric oncology practice.

METHOD

180 patients with cancer who were ≥ 65 years were included in the study. All patients were questioned in terms of geriatric syndromes, including polypharmacy, frailty, probable sarcopenia, fall risk, dynapenia, depression, cognitive impairment, insomnia, and excessive daytime sleepiness. Mini Nutritional Assessment scores > 23.5 and 17-23.5 were categorized as well-nourished and malnutrition risk, respectively.

RESULTS

Of the 180 patients (mean age 73.0 ± 5.6 years, female: 50%), the prevalence of malnutrition risk was 28.9%. There was no statistically significant difference between the groups in terms of age, gender, education, marital status, body mass index, and comorbidities except for chronic obstructive pulmonary disease (p > 0.05). After adjustment for age, sex, and body mass index; polypharmacy (odds ratio [OR]: 3.17; 95% confidence interval [CI], 1.48-6.81), reduced calf circumference (OR: 3.72; 95% CI, 1.22-11.38), fall risk (OR: 2.72; 95% CI, 1.03-7.23), depression (OR: 6.24; 95% CI, 2.75-14.18), insomnia (OR: 4.89; 95% CI, 2.16-11.05), and frailty (OR: 2.44; 95% CI, 1.75-3.40) were associated with malnutrition risk compared to well-nourished patients (p < 0.05). Median survival in patients with malnutrition risk was 21.3 months (range 14.1-28.4 95% CI) and median survival in patients who were defined as well nourished was not reached (p < 0.001).

CONCLUSION

The risk of malnutrition was associated with a higher risk for all-cause mortality in older patients with cancer, and was associated with many geriatric syndromes, including polypharmacy, fall risk, frailty, insomnia, and depression.

Polypharmacy and malnutrition in older people: A narrative review

Polypharmacy is the simultaneous use of multiple medicines, usually more than five. Polypharmacy is highly prevalent among older individuals and is associated with several adverse health outcomes, including frailty. The role of polypharmacy in nutritional status seems to be crucial: although a clear association between polypharmacy and malnutrition has been widely reported in older people, the magnitude of the effect of increased number of drugs in combination with their type on the risk for malnutrition remains to be largely explored. Therefore, this review aims to discuss the association between polypharmacy and malnutrition in older people and to provide suggestions for its management. Polypharmacy is prevalent among malnourished frail patients, and the relative contribution of comorbidities and polypharmacy to malnutrition is difficult to be determined. Several mechanisms by which commonly used medications have the potential to affect nutritional status have been identified and described. Deprescribing (i.e., a systematic process of identification and discontinuation of drugs or a reduction of drug regimens) could be an essential step for minimizing the effects of polypharmacy on malnutrition. In this regard, the literature suggests that in older patients taking several medications, the best method to solve this problem is the comprehensive geriatric assessment, based on a holistic approach, including drug review, to find potential unnecessary and inappropriate medications. Nutritional and deprescribing interventions must be tailored to patient needs and to the local context to overcome barriers when applied in different settings.

Therapeutic Effect on Swallowing Function and on Hydration Status of a New Liquid Gum-Based Thickener in Independently-Living Older Patients with Oropharyngeal Dysphagia

ThickenUp® Gel Express (TUGE) is a new, xanthan- and acacia-gum-based, liquid, thickening product. In independently living older adults with oropharyngeal dysphagia (OD), we assessed: (1) the rheological properties of TUGE; (2) its therapeutic effect at four viscosity levels (achieved by 5 g, 10 g, 20 g and 30 g of TUGE in water + Omnipaque X-ray contrast) versus thin liquid; and (3) the effect on hydration status and gastrointestinal tolerance after fourteen days. Shear viscosity of TUGE was measured in SI units (mPa·s at 50 s-1). The Penetration Aspiration Scale (PAS) score and the swallow response at each viscosity level was assessed with videofluoroscopy (VFS), and in the 14-day study we assessed fluid intake, hydration, and tolerance. Thickened fluids with TUGE were unaffected (-0.3%) by α-salivary amylase (α-SA). The shear viscosity values with VFS were 49.41 ± 2.38, 154.83 ± 10.22, 439.33 ± 11.72 and 672.5 ± 35.62 mPa·s. We studied 60 independently living adults (70 ± 11.4 years) with mild OD (PAS 4.1 ± 2.2, 25% aspirations). TUGE caused a shear-viscosity-dependent improvement in PAS at 150-670 mPa·s and in safety of swallow, slightly increased oral residue, did not affect pharyngeal residue and reduced time to laryngeal vestibule closure (-27%) at 670 mPa·s. Fluid intake with TUGE (1488 mL/day) was well tolerated, and hydration status improved. In conclusion, TUGE was unaffected by α-SA and strongly improved safety of swallow in a viscosity-dependent manner without affecting pharyngeal residue. Fourteen-day treatment of thickened fluids with TUGE is safe and well tolerated and improves hydration status in older adults with dysphagia.

In vitro digestion of two protein-rich dairy products in the ageing gastrointestinal tract

It is still unclear if changes in protein digestibility and absorption kinetics in old age may affect the anabolic effect of high-protein foods. The objective of this study was to investigate the digestion of two high-protein (10% w/w) dairy products in vitro: a fermented dairy product formulated with a ratio of whey proteins to caseins of 80 to 20% (WBD) and a Skyr containing mainly caseins. The new static in vitro digestion model adapted to the general older adult population (≥65 years) proposed by the INFOGEST international consortium was implemented to investigate the digestion of these products and compared with the standard version of the protocol. Kinetics of proteolysis was compared between both models for each product, in the gastric and intestinal phases of digestion. Protein hydrolysis was studied by the OPA method, SDS-PAGE, and LC-MS/MS, and amino acids were quantified by HPLC. Protein hydrolysis by pepsin was slower with the older adult model than with the young adult model, and consequently, in spite of a longer gastric phase duration, the degree of proteolysis (DH) at the end of the gastric phase was lower. Two different scenarios were observed depending on the type of dairy product studied: -10 and -40% DH for Skyr and WBD, respectively. In the intestinal phase, lower concentrations of free leucine were observed in older adult conditions (approx. -10%), but no significant differences in proteolysis were observed overall between the models. Therefore, the digestion conditions used influenced significantly the rate and extent of proteolysis in the gastric phase but not in the intestinal phase.

Multimodal prehabilitation to improve the clinical outcomes of frail elderly patients with gastric cancer: a study protocol for a multicentre randomised controlled trial (GISSG+2201)

INTRODUCTION

Gastric cancer (GC) diagnosed in the elderly population has become a serious public health problem worldwide. Given the combined effects of frailty and the consequences of cancer treatment, older individuals with GC are more likely than young patients to suffer from postoperative complications and poor clinical outcomes. Nutrition, functional capacity and psychological state-based multimodal prehabilitation, which is dominated by Enhanced Recovery After Surgery (ERAS) pathway management, has been shown to reduce postoperative complications, promote functional recovery and decrease hospitalisation time in certain malignancies. However, no previous studies have investigated the clinical application of multimodal prehabilitation in frail older patients with GC.

METHODS AND ANALYSIS

The study is a prospective, multicentre randomised controlled trial in which a total of 368 participants who meet the inclusion criteria will be randomised into either a prehabilitation group or an ERAS group. The prehabilitation group will receive multimodal prehabilitation combined with ERAS at least 2 weeks before the gastrectomy is performed, including physical and respiratory training, nutritional support, and therapy and psychosocial treatment. The ERAS group patients will be treated according to the ERAS pathway. All interventions will be supervised by family members. The primary outcome measures are the incidence and severity of postoperative complications. Secondary outcomes include survival, functional capacity and other short-term postoperative outcomes. Overall, the multimodal prehabilitation protocol may improve functional capacity, reduce the surgical stress response and concomitant systemic inflammation, and potentially modulate the tumour microenvironment to improve short-term and long-term clinical outcomes and patients' quality of life.

ETHICS AND DISSEMINATION

All procedures and participating centres of this study were approved by their respective ethics committees (QYFYKYLL 916111920). The final study results will be published separately in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05352802.

Predictive Strategies to Reduce the Risk of Rehospitalization with a Focus on Frail Older Adults: A Narrative Review

Frailty is a geriatric syndrome that has physical, cognitive, psychological, social, and environmental components and is characterized by a decrease in physiological reserves. Frailty is associated with several adverse health outcomes such as an increase in rehospitalization rates, falls, delirium, incontinence, dependency on daily living activities, morbidity, and mortality. Older adults may become frailer with each hospitalization; thus, it is beneficial to develop and implement preventive strategies. The present review aims to highlight the epidemiological importance of frailty in rehospitalization and to compile predictive strategies and related interventions to prevent hospitalizations. Firstly, it is important to identify pre-frail and frail older adults using an instrument with high validity and reliability, which can be a practically applicable screening tool. Comprehensive geriatric assessment-based care is an important strategy known to reduce morbidity, mortality, and rehospitalization in older adults and aims to meet the needs of frail patients with a multidisciplinary approach and intervention that includes physiological, psychological, and social domains. Moreover, effective multimorbidity management, physical activity, nutritional support, preventing cognitive frailty, avoiding polypharmacy and anticholinergic drug burden, immunization, social support, and reducing the caregiver burden are other recommended predictive strategies to prevent post-discharge rehospitalization in frail older adults.

Hydration Status Assessment in Older Patients

BACKGROUND

Hydration disturbances are common in old age: the reported prevalence of dehydration in elderly patients ranges from 19% to 89%, depending on the definition and the population in question. However, the clinical assessment of patients' hydration status is difficult. In this review, we discuss the diagnostic value of currently used methods that may or may not be suitable for assessing older patients' hydration status.

METHODS

We conducted a selective literature search for relevant studies concerning patients aged 65 and above. Of the 355 articles retrieved by the initial search, a multistep selection process yielded 30 that were suitable for inclusion in this review.

RESULTS

107 different methods for the diagnostic assessment of dehydration in older persons were evaluated on the basis of the reviewed publications. High diagnostic value, especially for the determination of hyperosmolar dehydration, was found for serum osmolality, serum sodium concentration, inferior vena cava ultrasonography, a history (from the patient or another informant) of not drinking between meals, and axillary dryness. On the other hand, a variety of clinical signs such as a positive skin turgor test, sunken eyes, dry mouth, tachycardia, orthostatic dysregulation, and dark urine were found to be of inadequate diagnostic value.

CONCLUSION

Only five of the 107 methods considered appear to be suitable for determining that a patient is dehydrated. Thus, the available scientific evidence indicates that all clinicians should critically reconsider their own techniques for assessing hydration status in elderly patients. To optimize the clinical assessment of patients' hydration status, there seems to be a need for the rejection of unsuitable methods in favor of either newly developed criteria or of a combination of the best criteria already in use.

Prevalence of malnutrition among older adults in a population-based study - the HUNT Study

BACKGROUND

Malnutrition is common in older adults and is associated with increased morbidity and mortality rates.

AIM

The aim of the study is to describe the prevalence of malnutrition based on low BMI, involuntary weight loss, and reduced food intake, in a Norwegian population of community-dwelling older adults and older adults living in nursing homes.

METHODS

This population-based study is part of the fourth wave of the Trøndelag Health Study (HUNT4) and includes participants ≥70 years from the HUNT4 70+ cohort. The HUNT4 70+ cohort consist of 9930 (response rate 51.2%) participants. In the current study 8127 older people had complete dataset for inclusion in the analyses. Participants completed a self-report questionnaire and standardised interviews and clinical assessments at field stations, in participants' homes or at nursing homes. Malnutrition was defined using the following criteria: low BMI, involuntary weight loss and severely reduced food intake. The standardised prevalence of malnutrition was estimated using inverse probability weighting (IPW) with weights for sex, age and education of the total population in the catchment area of HUNT.

RESULTS

Of the 8127 included participants, 7671 (94.4%) met at field stations, 356 (4.4%) were examined in their home, and 100 (1.2%) in nursing homes. In total, 14.3% of the population were malnourished based on either low BMI, weight loss, or reduced food intake, of which low BMI was the most frequently fulfilled criterion. The prevalence of malnutrition was less common among men than among women (10.1 vs 18.0%, p < 0.001), also after adjustment for age (OR 0.53, 95% confidence interval (CI) 0.46-0.61). The prevalence increased gradually with increasing age and the regression analysis adjusted for sex showed that for each year increase in age the prevalence of malnutrition increased with 4.0% (OR 1.04, 95% CI 1.03-1.05). The prevalence was higher both among older adults examined in their homes (26.4%) and residents in nursing home (23.6%), as compared to community-dwelling older adults who met at field stations (13.5%).

CONCLUSION

The prevalence of malnutrition is high in the older population. Special attention on prevention and treatment of malnutrition should be given to older women, the oldest age groups, and care-dependent community-dwelling older adults and nursing home residents.

Smart health technologies used to support physical activity and nutritional intake in fall prevention among older adults: A scoping review

BACKGROUND

Falls are the second leading cause of accidental injury deaths globally. Older age is a key risk factors for falls. Besides older age, physical inactivity and malnutrition are identified risk factors for falls. Smart health technologies might offer a sustainable solution to prevent falls by supporting physical activity and nutritional status.

OBJECTIVE

The aim is to identify, describe, and synthesize knowledge, and identify knowledge gaps on the use of existing smart health technologies to support health behaviour in relation to physical activity and nutrition, among older (65+) in risk of falling.

METHODS

A scoping review was conducted following the PRISMA-ScR. Searches were carried out in PubMed, Scopus, and Embase using search strings on the themes; smart health technology, physical activity, nutrition, behaviour, falls and older. Identified literature was screened. Data from the included studies was extracted and synthesized.

RESULTS

2948 studies were obtained through searches. 18 studies were included. Various smart health technologies are used for fall prevention to support physical activity among older, including software and applications for smart phones, TV, and tablet. Three gaps were identified: use of smart health technologies to support nutrition in fall prevention. Inclusion of relevant stakeholders and fall prevention in low-and middle-income countries.

CONCLUSIONS

Smart health technology can offer sustainable and cost-effective fall prevention in the future. More knowledge is needed on the use of smart health technologies to support nutritional status for fall prevention, and studies involving older with physical and cognitive conditions, and studies on measures for fall prevention in low- and middle-income countries is needed.

Dietary micronutrient adequacies and adherence to the Mediterranean diet in a population of older adults with type 2 diabetes: A cross-sectional study

BACKGROUND AND AIMS

There are few data on micronutrient intake in older adults with type 2 diabetes (T2D) and their adherence to the Mediterranean diet, a dietary pattern rich in micronutrients. In this cross-sectional study, we evaluated the prevalence of adequacy in micronutrient intake according to the recommendations, and the adherence to the Mediterranean diet in older adults with T2D.

METHODS

One hundred thirty-eight patients (47 women and 91 men) with T2D aged over 65 years were included. Dietary habits were assessed by three 24-h dietary recalls. The micronutrient intake, expressed as mean daily intake, and adequacy were compared with the dietary recommendations proposed by the Italian Society of Human Nutrition (LARN) and the European Food Safety Agency (EFSA). Adherence to the Mediterranean diet was evaluated by the MEDI-quest score.

RESULTS

An extremely low proportion of participants (∼1%) adhered to the recommendations for potassium and vitamin D intake. A low proportion of participants adhered to the recommendations for calcium (∼23%), magnesium (∼16%), selenium (∼17%), vitamin E (∼14%), riboflavin (∼28%), vitamin B6 (∼29%), folate (∼25%), and niacin (∼27%) intake. More than 60% of the population adhered to the recommendations for iron, copper, vitamin A and B12 intake. Only 53% of the population showed high adherence to the Mediterranean diet.

CONCLUSIONS

Our data indicate that a very low proportion of older adults with T2D meet the recommendations for ten micronutrients (calcium, potassium, magnesium, selenium, vitamin D, vitamin E, riboflavin, vitamin B6, folate, and niacin) with an unsatisfactory adherence to the Mediterranean diet. Nutritional approaches aimed at favoring adherence to dietary recommendations and increasing the consumption of foods rich in micronutrients should be implemented in older adults.

Intrinsic capacity and risk of death: Focus on the impact of using different diagnostic criteria for the nutritional domain

OBJECTIVE

We aimed to estimate the ability of intrinsic capacity (IC) to predict death in community-dwelling older people using different diagnostic criteria to define the nutritional domain.

METHODS

Participants from the Belgian SarcoPhAge cohort were followed from 2013 to the present. Four IC domains were assessed at baseline (data on the sensorial domain were not collected), and considered unsatisfactory below some specific thresholds. The nutritional domain was considered unsatisfactory if baseline malnutrition was present, defined by: 1) MNA-SF ≤11 points; 2) seven versions of the GLIM criteria, varying by the technique used to identify a reduced muscle mass; or 3) the combination of MNA-SF ≤11 points + GLIM criteria. The association between baseline unsatisfactory IC and 9-year mortality was calculated using the odds ratio (OR) adjusted for cofounders.

RESULTS

Among the 534 participants (73.5 ± 6.2 years old; 60.3 % women at baseline), 157 (29.4 %) were dead after 9.3 ± 0.3 years of follow-up. Patients with baseline unsatisfactory IC in the locomotor domain (adjusted OR = 2.31 [95%CI 1.38-3.86]) or psychological domain (adjusted OR = 1.78 [1.12-2.83]) were at higher mortality risk. Regarding malnutrition, unsatisfactory IC in the nutrition domain was strongly associated with a higher mortality risk, whatever the criteria used to identify a reduced muscle mass. The highest association with mortality was found in participants with a baseline unsatisfactory nutritional domain defined by the combination of MNA-SF + GLIM criteria (adjusted OR = 3.27 [95%CI 1.72-6.23]).

CONCLUSIONS

Presenting any unsatisfactory IC at baseline was associated with a higher 9-year mortality risk in community-dwelling older people. The sequential incorporation of MNA-SF and GLIM criteria as the IC nutritional domain would be helpful to guide public health actions towards healthy ageing.

Significant Published Articles in 2022 for Pharmacy Nutrition Support Practice

Purpose: The purpose of this article is to assist the pharmacist engaged in nutrition support therapy in staying current with pertinent literature. Methods: Several clinical pharmacists engaged in nutrition support therapy compiled a list of articles published in 2022 considered important to their clinical practice. The citation list was compiled into a spreadsheet where the author participants were asked to assess whether the article was considered important to nutrition support pharmacy practice. A culled list of publications was then identified whereby at least 5 out of the 8 author participants considered the article to be important. Guideline and consensus papers, important to practice but not ranked, were also included. Results: A total of 162 articles were identified; 8 from the primary literature were voted by the group to be of high importance. An additional 10 guidelines, position, recommendation, or consensus papers were also identified. The top-ranked articles from the primary literature were summarized and a narrative regarding its implications to pharmacy nutrition support practice were provided. Conclusion: We recommend that pharmacists engaged in nutrition support therapy be familiar with these articles as it pertains to their practice.

ESPEN guideline on nutritional support for polymorbid medical inpatients

BACKGROUND

Disease-related malnutrition in polymorbid medical inpatients is a highly prevalent syndrome associated with significantly increased morbidity, disability, short- and long-term mortality, impaired recovery from illness, and cost of care.

AIM

As there are uncertainties in applying disease-specific guidelines to patients with multiple conditions, our aim was to provide evidence-based recommendations on nutritional support for the polymorbid patient population hospitalized in medical wards.

METHODS

This update adheres to the standard operating procedures for ESPEN guidelines. We did a systematic literature search for 15 clinical questions in three different databases (Medline, Embase and the Cochrane Library), as well as in secondary sources (e.g. published guidelines), until July 12th. Retrieved abstracts were screened to identify relevant studies that were used to develop recommendations (incl. SIGN grading), which was followed by submission to Delphi voting.

RESULTS

From a total of 3527 retrieved abstracts, 60 new relevant studies were analyzed and used to generate a guideline draft that proposed 32 recommendations (7x A, 11x B, 10x O and 4x GPP), which encompass different aspects of nutritional support including indication, route of feeding, energy and protein requirements, micronutrient requirements, disease-specific nutrients, timing, monitoring and procedure of intervention. The results of the first online voting showed a strong consensus (agreement of >90%) on 100% of the recommendations. Therefore, no final consensus conference was needed.

CONCLUSIONS

Recent high-quality trials have provided increasing evidence that nutritional support can reduce morbidity and other complications associated with malnutrition in polymorbid patients. The timely screening of patients for risk of malnutrition at hospital admission followed by individualized nutritional support interventions for at-risk patients should be part of routine clinical care and multimodal treatment in hospitals worldwide. Use of this updated guideline offers an evidence-based nutritional approach to the polymorbid medical inpatients and may improve their outcomes.

Management of Type 2 Diabetes in Frail Older Adults

Aging is one of the most important factors associated with the dramatic increase in the prevalence of type 2 diabetes mellitus (T2DM) globally. In addition to traditional micro- and macrovascular complications, diabetes mellitus (DM) in older adults is of great importance due to its independent relationship with frailty, which is defined as a decline in functional reserves and vulnerability to stressors. Frailty assessment enables the determination of biological age, thus predicting potential complications in older adults and identifying tailored treatment strategies. Although the latest guidelines have acknowledged the frailty concept and provided recommendations specific to this subgroup of older adults, frail older adults are particularly considered only as anorexic, malnourished people for whom relaxed treatment targets should be set. However, this approach bypasses other metabolic phenotypes in the context of diabetes and frailty. Recently, a spectrum of metabolic phenotypes in the context of frailty in DM was suggested, and the two edges of this spectrum were defined as "anorexic malnourished (AM)" and "sarcopenic obese (SO)." These two edges were suggested to require different strategies: Opposite to the AM phenotype requiring less stringent targets and de-intensification of treatments, tight blood glucose control with agents promoting weight loss was recommended in the SO group. Our suggestion is that, regardless of their phenotype, weight loss should not be the primary goal in DM management in older adults who are overweight or obese, because of the increased malnutrition prevalence in older adults suffering from DM compared with standard older adults. Furthermore, overweight older adults have been reported to have the lowest risk of mortality compared with other groups. On the other hand, obese older individuals may benefit from intensive lifestyle interventions including caloric restriction and regular exercise with the assurance of at least 1 g/kg/day high-quality protein intake. Besides metformin (MF), sodium-glucose cotransporter-2 inhibitors (SGLT-2i) or glucagon-like peptide-1 receptor agonists (GLP-1RA) should be considered in appropriate SO cases, due to high evidence of cardiorenal benefits. MF should be avoided in the AM phenotype due to their weight loss property. Although weight loss is not desired in AM phenotype, SGLT-2i may still be preferred with close follow-up in certain individuals demonstrating high cardiovascular disease (CVD) risk. Of note, SGLT-2i should be considered earlier in the diabetes treatment in both groups due to their multiple benefits, i.e., organ protective effects, the potential to reduce polypharmacy, and improve frailty status. The concept of different metabolic phenotypes in frail older adults with diabetes once again shows "one size fits all" cannot be applied in geriatric medicine, and a tailored, individualized approach should be adopted to get the highest benefit from treatments.

Short-Term Effects of Dietary Protein Supplementation on Physical Recovery in Older Patients at Risk of Malnutrition during Inpatient Rehabilitation: A Pilot, Randomized, Controlled Trial

It is estimated that about 50% of geriatric rehabilitation patients suffer from sarcopenia. Thereby, malnutrition is frequently associated with sarcopenia, and dietary intake is the main modifiable risk factor. During hospitalization, older adults are recommended to consume more dietary protein than the current recommended dietary allowance of 0.8 g/kg body weight per day to optimize the recovery of muscular strength and physical function. This prospective pilot study examined the feasibility and preliminary efficacy of short-term protein supplementation with protein-enriched foods and drinks on the hand-grip strength, nutritional status, and physical function of older patients at risk of malnutrition during a three-week inpatient orthopedic rehabilitation stay. The Mini Nutritional Assessment (MNA) tool was used to assess malnutrition. Patients with an MNA score ≤ 23.5 points were randomly assigned to an intervention group (goal: to consume 1.2-1.5 g protein/kg body weight per day) or a control group (standard care). Both groups carried out the same rehabilitation program. Physical recovery parameters were determined at admission and discharge. A trend was recognized for participants in the intervention group to consume more protein than the control group (p = 0.058): 95.3 (SD 13.2) g/day as compared to 77.2 (SD 24.2) g/day, which corresponds to a mean protein intake of 1.6 (SD 0.3) g/kg/day vs. 1.3 (SD 0.5) g/kg/day. Dietary protein supplementation increased body weight by an average of 0.9 (SD 1.1) kg and fat mass by an average of 0.9 (SD 1.2) kg as compared to the baseline (p = 0.039 and p = 0.050, respectively). No significant change in hand-grip strength, body composition, or physical function was observed. In conclusion, short-term intervention with protein-enriched foods and drinks enabled older patients at risk of malnutrition to increase their protein intake to levels that are higher than their required intake. In these older individuals with appropriate protein intake, dietary protein supplementation did not result in a greater improvement in physical recovery outcomes during short-term inpatient rehabilitation. The intervention improved dietary protein intake, but further research (e.g., a full-scale, randomized, controlled trial with sufficient power) is required to determine the effects on physical function outcomes.

Survival and factors affecting the survival of older adult patients in palliative care

PURPOSE

Investigate the survival and risk factors that affect the survival of aged patients in a palliative care center (PCC).

METHODS

A total of 180 inpatients (aged ≥ 65 years) who were admitted to a PCC from January 2018 to March 2020 were included. Information regarding patients' demographic characteristics, chronic diseases, length of hospital stay, nutrition provided at the first hospital stay, pressure wound, pain, and laboratory results were evaluated.

RESULTS

The patients 50% were women (n = 90). The mean age, mean comorbidity, and mean follow-up duration was 77.6 years, 3.4, and 115 days (median: 29 days), respectively. The mean NRS2002 score of patients was 4.0 ± 1.0 and the risk of malnutrition was 93%. The mortality rate of the patients was 91.7%. The life expectancy of patients without malignancy was higher than those with malignancy (p < 0.001). Enteral nutrition (EN) via percutaneous endoscopic gastrostomy (PEG) was associated with up to two-fold increase in the survival rates of patients with PCC (p = 0.049, HR: 2.029). High neutrophil/lymphocyte ratio (p = 0.002, HR: 1.017) and high ferritin (p = 0.001, HR: 1.000) and C-reactive protein (CRP) levels (p < 0.001, HR: 1.006) were adverse risk factors affecting life expectancy. Malignity reduced the survival rate of aged patients with PCC by 40% (p = 0.008).

CONCLUSION

EN via PEG was found to be a positive factor affecting survival rates of older adult patients in palliative care, whereas malignity, high neutrophil/lymphocyte ratio, high CRP and ferritin levels, and prolonged hospital stays were negative risk factors.

Are Energy and Protein Intakes Lower Than Requirements in Older Adults? An Urgent Issue in Hospitals and Nursing Homes

Energy and protein intakes lower than requirements are associated with worsening health outcomes. Here we set out to evaluate gaps between energy and protein intakes and requirements in older adults in hospitals and in nursing homes (NH). A cross-sectional study included 360 inpatients and residents aged 75 years and older in two acute care wards; i.e., a multidisciplinary care unit (MCU) and a geriatric care unit (GCU), a geriatric rehabilitation unit (GRU), and two NH. Intakes were measured for three days. Requirements were based on French National Health Authority recommendations. Energy and protein intakes were under the minimum requirement of 30 kcal/kg/day and 1.2 g/kg/day in 89.5% and 100% of MCU patients, respectively, 75.5% and 64.2% of GCU patients, 92.7% and 90.9% of GRU patients, and 83.8% and 83.8 of NH residents. Intake-to-requirement gaps were not significantly associated with malnutrition, except in the GCU group where non-malnourished patients had higher energy gaps than malnourished patients. Intakes fell dramatically short of requirements in older adults in both hospital and NH settings irrespective of malnutrition status. A new paradigm based on a patient-centered approach should be developed to adapt meals served in hospital and in NH.

Healthy Eating for Elective Major Orthopedic Surgery: Quality, Quantity, and Timing

Improvements to enhanced recovery pathways in orthopedic surgery are reducing the time that patients spend in the hospital, giving an increasingly vital role to prehabilitation and/or rehabilitation after surgery. Nutritional support is an important tenant of perioperative medicine, with the aim to integrate the patient's diet with food components that are needed in greater amounts to support surgical fitness. Regardless of the time available between the time of contemplation of surgery and the day of admission, a patient who eats healthy is reasonably more suitable for surgery than a patient who does not meet the daily requirements for energy and nutrients. Moreover, a successful education for healthy food choices is one possible way to sustain the exercise therapy, improve recovery, and thus contribute to the patient's long-term health. The expected benefits presuppose that the patient follows a healthy diet, but it is unclear which advice is needed to improve dietary choices. We present the principles of healthy eating for patients undergoing major orthopedic surgery to lay the foundations of rational and valuable perioperative nutritional support programs. We discuss the concepts of nutritional use of food, requirements, portion size, dietary target, food variety, time variables of feeding, and the practical indications on what the last meal to be consumed six hours before the induction of anesthesia may be together with what is meant by clear fluids to be consumed until two hours before. Surgery may act as a vital "touch point" for some patients with the health service and is therefore a valuable opportunity for members of the perioperative team to promote optimal lifestyle choices, such as the notion and importance of healthy eating not just for surgery but also for long-term health benefit.

Obesity in Nursing Home Patients: Association with Common Care Problems

(1) Background: There is not much research about obesity in nursing homes although knowledge will help us to develop customized treatment plans and prevention strategies, which may help to decrease the burden for all persons involved. The objective of conducting this study was to describe the prevalence of obesity and the association between obesity and care problems in nursing home patients. (2) Methods: This study is a secondary data analysis of data collected in an annually performed cross-sectional study called "Nursing Quality Measurement 2.0". A standardized and tested questionnaire was used to collect data. (3) Results: In total, 1236 nursing home patients took part, and 16.7% of them were obese. The multivariate logistic regression analysis results show that urinary incontinence is significantly associated with the presence of obesity (OR 2.111). The other care problems of pressure injuries, fecal and double incontinence, physical restraints, falls, and pain were not associated with obesity. (4) Conclusions: The results indicate that, in the nursing home setting, healthcare staff should pay special attention to the patients' nutritional status and help patients to maintain a healthy weight and prevent a loss of muscle mass and function. Conducting more studies with larger sample sizes is recommended, as this will allow for differentiation among different obesity classes.

A task force for diagnosis and treatment of people with Alzheimer's disease in Latin America

Alzheimer's disease (AD) represents a substantial burden to patients, their caregivers, health systems, and society in Latin America and the Caribbean (LAC). This impact is exacerbated by limited access to diagnosis, specialized care, and therapies for AD within and among nations. The region has varied geographic, ethnic, cultural, and economic conditions, which create unique challenges to AD diagnosis and management. To address these issues, the Americas Health Foundation convened a panel of eight neurologists, geriatricians, and psychiatrists from Argentina, Brazil, Colombia, Ecuador, Guatemala, Mexico, and Peru who are experts in AD for a three-day virtual meeting to discuss best practices for AD diagnosis and treatment in LAC and create a manuscript offering recommendations to address identified barriers. In LAC, several barriers hamper diagnosing and treating people with dementia. These barriers include access to healthcare, fragmented healthcare systems, limited research funding, unstandardized diagnosis and treatment, genetic heterogeneity, and varying social determinants of health. Additional training for physicians and other healthcare workers at the primary care level, region-specific or adequately adapted cognitive tests, increased public healthcare insurance coverage of testing and treatment, and dedicated search strategies to detect populations with gene variants associated with AD are among the recommendations to improve the landscape of AD.

The Impact of Xerostomia on Food Choices-A Review with Clinical Recommendations

Xerostomia and hyposalivation are highly prevalent conditions in old age, particularly among multimorbid elders, and are often attributed to the use of multiple medications. These conditions negatively affect oral functions, such as chewing, swallowing, speech, and taste. Additionally, the lack of lubrication of the oral mucosa frequently leads to super-infections with candida. Denture retention and comfort may also be compromised. The risk of dental caries and erosion of natural teeth increases since saliva, which is essential for repairing initial lesions in tooth structures, is insufficient. The dry sensation in the mouth also impacts the emotional and social well-being of elderly individuals. Patients experiencing xerostomia often avoid certain foods that are uncomfortable or difficult to consume. However, some foods may alleviate the symptoms or even stimulate salivation. This review discusses the limited available evidence on nutritional advice for patients with xerostomia and aims to provide insight into the patient's perspective while offering clinical recommendations. Future studies should focus on investigating the nutritional intake of individuals suffering from xerostomia or hyposalivation in order to ensure oral health comfort, prevent malnutrition, and minimize the impact on their quality of life.

Sodium depletion and secondary hyperaldosteronism in outpatients with an ileostomy: a cross-sectional study

OBJECTIVE

Patients with an ileostomy may experience postoperative electrolyte derangement and dehydration but are presumed to stabilise thereafter. We aimed to investigate the prevalence of sodium depletion in stable outpatients with an ileostomy and applied established methods to estimate their fluid status.

METHODS

We invited 178 patients with an ileostomy through a region-wide Quality-of-Life-survey to undergo outpatient evaluation of their sodium and fluid status. The patients delivered urine and blood samples, had bioelectrical impedance analysis performed and answered a questionnaire regarding dietary habits.

RESULTS

Out of 178 invitees, 49 patients with an ileostomy were included; 22 patients (45%, 95% CI, 31-59%) had unmeasurably low urinary sodium excretion (<20 mmol/L), indicative of chronic sodium depletion, and 26% (95% CI, 16-41%) had plasma aldosterone levels above the reference value. Patients with unmeasurably low urinary sodium excretion had low estimated glomerular filtration rates (median 76, IQR 63-89, mL/min/1.73m2) and low venous blood plasma CO2 (median 24, IQR 21-26, mmol/L), indicative of chronic renal impairment and metabolic acidosis. Bioelectrical impedance analysis, plasma osmolality, creatinine and sodium values were not informative in determining sodium status in this population.

CONCLUSION

A high proportion of patients with an ileostomy may be chronically sodium depleted, indicated by absent urinary sodium excretion, secondary hyperaldosteronism and chronic renal impairment, despite normal standard biochemical tests. Sodium depletion may adversely affect longstanding renal function. Future studies should investigate methods to estimate and monitor fluid status and aim to develop treatments to improve sodium depletion and dehydration in patients with an ileostomy.IMPACT AND PRACTICE RELEVANCE STATEMENTSodium depletion in otherwise healthy persons with an ileostomy was identified in a few publications from the 1980s. The magnitude of the problem has not been demonstrated before. The present study quantifies the degree of sodium depletion and secondary hyperaldosteronism in this group, and the results may help guide clinicians to optimise treatment. Sodium depletion is easily assessed with a urine sample, and sequelae may possibly be avoided if sodium depletion is detected early and treated. This could ultimately help increase the quality of life in patients with an ileostomy.