The SNAQ(RC), an easy traffic light system as a first step in the recognition of undernutrition in residential care

Challenges in identifying malnutrition in obesity; An overview of the state of the art and directions for future research

(Protein-energy) malnutrition in individuals living with obesity presents complex diagnostic challenges due to the distinctive physiological characteristics of obesity. This narrative review critically examines the identification of malnutrition within the population with obesity, distinguishing malnutrition in obesity from related conditions such as sarcopenic obesity. While noting some shared features, the review highlights key differences between these conditions. The review also highlights the limitations of current malnutrition screening tools, which are not designed for individuals living with obesity. These tools primarily rely on anthropometric measurements, neglecting (among others) nutrient intake assessment, which hinders accurate malnutrition detection. Additionally, this review discusses limitations in existing diagnostic criteria, including the Global Leadership Initiative on Malnutrition (GLIM) criteria, when applied to individuals living with obesity. Challenges include the identification of appropriate cut-off values for phenotypic criteria (unintentional weight loss, low body mass index and muscle mass) and aetiological criteria such as reduced food intake and inflammation for the population with obesity. Overall, this review emphasises the need for modified screening tools and diagnostic criteria to recognise and assess malnutrition in obesity, leading to improved clinical outcomes and overall wellbeing.

Low micronutrient intake in nursing home residents, a cross-sectional study

Low intake of micronutrients is associated with health-related problems in nursing home residents. As their food intake is generally low, it is expected that their micronutrient intake will be low as well. The nutrient intake of 189 residents (mean age 85.0 years (SD: 7.4)) in five different Dutch nursing homes was measured based on 3-day direct observations of intake. Micronutrient intake, without supplementation, was calculated using the Dutch food composition table, and SPADE software was used to model habitual intake. Intake was compared to the estimated average requirement (EAR) or adequate intake (AI) as described in the Dutch dietary reference values. A low intake was defined as >10% not meeting the EAR or when the P50 (median) intake was below the AI. Vitamin A, thiamin, riboflavin, niacin, B6, folate, B12, C, D, E, copper, iron, zinc, calcium, iodine, magnesium, phosphorus, potassium, and selenium were investigated. Our data showed that vitamin and mineral intake was low for most assessed nutrients. An AI was only seen for vitamin B12 (men only), iodine (men only), and phosphorus. A total of 50% of the population had an intake below the EAR for riboflavin, vit B6, folate, and vitamin D. For reference values expressed in AI, P50 intake of vitamin E, calcium, iodine, magnesium, potassium, and selenium was below the AI. To conclude: micronutrient intake in nursing home residents is far too low in most of the nursing home population. A "food-first" approach could increase dietary intake, but supplements could be considered if the "food-first" approach is not successful.

Transparency in hip fracture recovery over institutional boundaries: The transmural monitoring pathway

OBJECTIVES

To develop a transmural pathway for healthcare professionals across institutions to monitor the recovery of hip fracture patients. The secondary objectives were to evaluate the pathway's feasibility and initial outcomes.

DESIGN

Prospective cohort study.

METHOD

Stakeholders of the hospital and geriatric rehabilitation institutions implemented a transmural monitoring pathway in which different geriatric health domains were monitored during three phases: The in-hospital, inpatient rehabilitation, and outpatient follow-up phase. The outcomes for the first 291 patients and the feasibility of the pathway were evaluated. If the outcomes of the clinimetrics significantly improved over time, progress in functional recovery was assumed. Feasibility was assessed according to the rate of adherence to the clinimetric tests.

RESULTS

During the in-hospital phase, patients showed a decline in functional level (the Katz index of independence in Activities of Daily Living (Katz-ADL) pre-fracture vs. discharge: 0 (0-2) vs. 4 (4-5), P < 0.001). Patients, in which 78.6% (n = 140) had cognitive impairment and 41.2% had malnutrition, showed the most progress (Katz-ADL 2 (1-3)) during the inpatient rehabilitation phase. In the outpatient follow-up phase, recovery remained ongoing, but most patients had not returned to their pre-fracture functional levels (Katz-ADL 1 (1-3)). The pathway feasibility during the first phase was excellent (>85%), whereas room for improvement existed during other phases (<85%).

CONCLUSION

The transmural monitoring pathway provides insight into the entire recovery process for all involved healthcare professionals. Patients showed the most progress during the rehabilitation phase. The pathway feasibility was excellent during the in-hospital phase, but improvements could be made during other phases.

Too low protein and energy intake in nursing homes residents

OBJECTIVES

An optimal diet contributes to reducing malnutrition prevalence in the nursing home population. For this population, recommended daily intakes are ≥1.0 g protein/kg body weight and ≥27 energy kcal/kg body weight. The aim of this study was to identify the protein and energy intake of nursing home residents and to assess groups at increased risk for low intake.

METHODS

Cross-sectional data regarding food intake was collected by three-day observations in 189 residents (aged ≥65 y, mean age 85.0 y) of five different nursing homes. Linear mixed models were used to examine associations of protein and energy intake as dependent variables with demographic and disease-related problems as determinants. Results were adjusted for age, sex, and mobility levels and stratified by a protein/energy-enriched diet (P/E+).

RESULTS

The daily protein intake of the residents was 0.80 (SD 0.22) g/kg body weight, with 84.7% having an intake below the recommended daily 1 g/kg body weight. Mean daily energy intake was 20.7 (SD 6.1) kcal/kg body weight, with 85.2% having an intake below recommendation. Protein/energy intake was higher in the P/E+ group compared with standard diet: 0.92 (SD 0.23) versus 0.74 (SD 0.19) g/kg body weight, and 23.9 (SD 6.1) versus 19.1 (SD 5.4) kcal/kg body weight, respectively. The oldest age groups (>85 y), chair-bound residents, women, and residents having difficulties with chewing, dysphagia, a reported decreased food intake, or a decreased appetite were at a higher risk for a low protein/energy intake.

CONCLUSION

Nearly all nursing home residents were at increased risk for not meeting the minimum protein/energy requirements. Intakes should, on average, be increased with ≥15 g protein and ≥520 kcal to reach the minimum intake targets. Although using a P/E+ diet was associated with higher intakes, even these residents had intakes below the requirements.

Malnutrition in older adults

Malnutrition is a highly prevalent condition in older adults, and poses a substantial burden on health, social, and aged-care systems. Older adults are vulnerable to malnutrition due to age-related physiological decline, reduced access to nutritious food, and comorbidity. Clinical guidelines recommend routine screening for malnutrition in all older adults, together with nutritional assessment and individually tailored nutritional support for older adults with a positive screening test. Nutritional support includes offering individualised nutritional advice and counselling; oral nutritional supplements; fortified foods; and enteral or parenteral nutrition as required. However, in clinical practice, the incorporation of nutritional guidelines is inadequate and low-value care is commonplace. This Review discusses the current evidence on identification and treatment of malnutrition in older adults, identifies gaps between evidence and practice in clinical care, and offers practical strategies to translate evidence-based knowledge into improved nutritional care. We also provide an overview of the prevalence, causes, and risk factors of malnutrition in older adults across health-care settings.

Communication support needs assessment in dementia (CoSNAT-D): An international content validation study

The decline of language and communication abilities is common among people living with dementia and impacts on many areas of everyday life, including active participation in social activities and decision-making. Despite a growing body of supporting evidence for approaches that address language and communication decline in dementia, the concept of communication rehabilitation is largely neglected in this population. This paper reports on the content validation of a novel tool, the Communication Support Needs Assessment Tool for Dementia (CoSNAT-D). The tool has been developed to assist in the initial identification of communication difficulties and related support needs of people living with dementia. Importantly, the CoSNAT-D is the only available tool that takes a three-way informed approach, considering the view of the person living with dementia, their carer and an administering healthcare professional. Content validity was established between September and December 2018 using a modified Delphi approach. An international expert panel rated 32 items of a face-validated item pool regarding their importance and relevance through an iterative feedback process. Consensus was pre-determined at 70% of agreement for both importance and relevance of an item. Data were analysed using descriptive statistics and qualitative content analysis of comments provided in each round. Twenty-eight experts working in dementia, language and communication participated in the Delphi survey. Qualitative analysis resulted in the addition of five items, of which three reached the required consensus in Round 3. Consensus was established for 35/37 items in three rounds. The pilot version of the CoSNAT-D demonstrates adequate content validity and face validity. The use of the CoSNAT-D may assist a range of healthcare professionals in the decision-making process about appropriate next management steps, and thereby improve the care path for people with dementia and language and communication impairment. The establishment of further psychometric properties is warranted.

GLIM in nursing homes; practical implications

BACKGROUND

Only very few papers have described malnutrition prevalence rates according to the Global Leadership Initiative on Malnutrition (GLIM) criteria in nursing homes, likely due to practical reasons such as missing data on body composition, dietary intake, or acute disease/inflammation.

METHODS

Data was collected in 5 different nursing homes. Food intake measurements took place over 3 days of observations, and intakes below 90% of energy or protein requirements were regarded as insufficient. The GLIM diagnosis was based on body weight loss and/or low BMI in combination with insufficient food intake. Additionally, we also studied the sensitivity of GLIM with the question from the Mini Nutritional Assessment Short Form (MNA-SF) on insufficient food intake (GLIM_MNA) versus GLIM with measured food intake.

RESULTS

Out of 176 participants, 21.0% were categorized as malnourished according to GLIM. Observations revealed an insufficient food intake in 81.3% (N = 143) of residents; only 39% of those (N = 56) scored positive on the MNA-SF question regarding low food intake. GLIM_MNA diagnosed 17.0% of residents as malnourished. Sensitivity of GLIM_MNA for GLIM was 62.2%, and specificity 95.0% (kappa = 0.61).

CONCLUSION

Twenty-one percent of nursing home residents were diagnosed malnourished based on a limited set of GLIM criteria. The MNA question on insufficient food intake missed ∼60% of residents with a truly low food intake. Herewith, malnutrition prevalence rates with GLIM_MNA decreased to 17%. We advise measuring food intake for studies, and to be aware of too low prevalence rates of GLIM when an estimate of reduced food intake is applied.

Pain and its associated factors in nursing home residents

This study examined the associated factors of pain in nursing home residents in Austria. A secondary data analysis was conducted with data collected in the 'Nursing Quality Measurement 2.0' study, which is conducted annually in Austrian healthcare institutions. Data from nursing homes from 2016 to 2019 were used. Of the 1,239 residents, 40.4% had experienced pain in the last 7 days and/or were experiencing pain at the time of the survey. The regression analysis showed that diseases of the musculoskeletal system, diseases of the skin and subcutaneous tissue, diseases of the circulatory system, pressure injuries, and a risk of malnutrition were statistically associated with pain (Χ2 (11) = 82,392, p < 0.000). Healthcare professionals working in nursing homes need to be aware of associated factors when treating pain in residents. This awareness is important because it enables professionals to identify high-risk groups and take appropriate steps.

Healthy Ageing and Intellectual Disability study: summary of findings and the protocol for the 10-year follow-up study

INTRODUCTION

The Healthy Ageing and Intellectual Disability (HA-ID) study is a prospective multicentre cohort study in the Netherlands that started in 2008, including 1050 older adults (aged ≥50) with intellectual disabilities (ID). The study is designed to learn more about the health and health risks of this group as they age. Compared with the amount of research in the general population, epidemiological research into the health of older adults with ID is still in its infancy. Longitudinal data about the health of this vulnerable and relatively unhealthy group are needed so that policy and care can be prioritised and for guiding clinical decision making about screening, prevention and treatment to improve healthy ageing.

METHODS AND ANALYSIS

This article presents a summary of the previous findings of the HA-ID study and describes the design of the 10-year follow-up in which a wide range of health data will be collected within five research themes: (1) cardiovascular disease; (2) physical activity, fitness and musculoskeletal disorders; (3) psychological problems and psychiatric disorders; (4) nutrition and nutritional state; and (5) frailty.

ETHICS AND DISSEMINATION

Ethical approval for the 10-year follow-up measurements of the HA-ID study has been obtained from the Medical Ethics Review Committee of the Erasmus MC, University Medical Centre Rotterdam (MEC-2019-0562).

TRIAL REGISTRATION NUMBER

This cohort study is registered in the Dutch Trial Register (NTR number NL8564) and has been conducted according to the principles of the Declaration of Helsinki.

Nutritional Assessment in Older Adults : MNA® 25 years of a Screening Tool and a Reference Standard for Care and Research; What Next?

A tool to assess nutritional status in older persons was really needed. It took 5 years to design the MNA® (Mini Nutrition Assessment) tool, complete the first validations studies both in Europe and in the U.S. and to publish it. After the full MNA®, the MNA® short form and the self-MNA® have been validated. As well as Chinese and other national MNA® forms. Now more than 2000 clinical research have used the MNA® all over the world from community care to hospital. At least 22 Expert groups included the MNA® in new clinical practice guidelines, national or international registries. The MNA® is presently included in almost all geriatric and nutrition textbook and part of the teaching program for medicine and other health care professional worldwide. The urgent need is to target the frail older adults more likely to have weight loss and poor appetite and to prevent frailty and weight loss in the robust. We present in this paper the review of 25 years of clinical research and practice using the MNA® worldwide.

Fingerfoods: a feasibility study to enhance fruit and vegetable consumption in Dutch patients with dementia in a nursing home

BACKGROUND

Eating problems are highly prevalent in older patients with dementia and as a consequence, these patients are at greater risk of becoming malnourished. Fingerfoods, snacks that can be picked with thumb and forefinger, could be used to counteract malnutrition in patients with dementia. The aim of this feasibility study was to evaluate whether providing fruit and vegetable rich fingerfoods in the form of recognizable and familiar snacks on top of the normal intake was feasible for both patients with dementia and caregivers as a means to increase patients' nutritional status.

METHODS

Institutionalised patients with dementia (N = 15, 93% female, mean age = 85 years) were included in this feasibility study in the Netherlands. The residents received their regular diet supplemented with fingerfoods, comprising quiches and cakes rich in fruit or vegetables, for 6 weeks. Daily fingerfood consumption together with compensation behaviour at dinner of residents was administered with a checklist and food diaries at the start and end of the intervention as dose delivered. Furthermore, caregivers were asked to fill out a feedback form at the end of the intervention to measure fidelity and appreciation of the intervention.

RESULTS

Patients consumed on average 1.4 pieces (70 g) of fingerfoods daily, containing 41 g of fruit and/or vegetables. Fruit and vegetable consumption increased during the provision of the fingerfoods and the residents seemed not to compensate this intake during the rest of the day. The intervention was generally positively received by the majority of caregivers, depending on the type of fingerfood and state of the resident.

CONCLUSION

This feasibility study showed that providing recognizable fruit and vegetable rich fingerfoods to patients with dementia seems feasible for both patients and caregivers and could provide a pragmatic approach to enhance fruit and vegetable consumption and total food intake in institutionalized elderly. In an up-scaled study, effects of fingerfoods on nutritional status and quality of life should be investigated.

Modifiable patient-related factors associated with pressure ulcers on the sacrum and heels: Secondary data analyses

AIM

To explore factors associated with the presence of category I-IV pressure ulcers on the sacrum and heels.

DESIGN

Cross-sectional, secondary data analysis using data collected from the Landelijke Prevalentiemeting Zorgproblemen (LPZ) project, a multicentre prevalence study including nursing home residents and community care clients (N = 4,842) in the Netherlands in 2017.

METHODS

A single binary logistic regression model was designed to identify factors associated with the presence of pressure ulcers. Additionally, a multiple binary logistic regression model including modifiable explanatory factors associated with the presence of pressure ulcers was designed.

RESULTS

Impaired mobility, friction and shear (evaluated using the Braden Scale) are significantly associated with the presence of both sacral and heel category I-IV pressure ulcers. Incontinence-associated dermatitis is significantly associated with category I-IV sacral pressure ulcers.

CONCLUSION

In pressure ulcer prevention, nursing interventions should focus on frequent repositioning and mobilization while avoiding exposure of the skin to friction and shear. The need to consider incontinence-associated dermatitis, incontinence and moisture as important factors in pressure ulcer risk assessment is confirmed.

IMPACT

Pressure ulcers occur when skin and tissues are deformed between bony prominences and the support surface in a sitting or lying position. They are the result of a complex interaction between direct causal factors and a wide range of indirect factors. Recognition of these factors influences risk assessment guidance and practice. Knowledge of skin-specific factors at the patient level, modifiable by nursing interventions, enables a better targeted and tailored preventive approach.

A review of the validity of malnutrition screening tools used in older adults in community and healthcare settings - A MaNuEL study

BACKGROUND

Older adults are at increased risk of malnutrition compared to their younger counterparts. Malnutrition screening should be conducted using a valid malnutrition screening tool. An aim of the Healthy Diet for a Healthy Life (HDHL) Joint Programming Initiative (JPI) 'Malnutrition in the Elderly Knowledge Hub' (MaNuEL) was to review the reported validity of existing malnutrition screening tools used in older adults.

METHODS

A literature search was conducted to identify validation studies of malnutrition screening tools in older populations in community, rehabilitation, residential care and hospital settings. A database of screening tools was created containing information on how each tool was validated.

RESULTS

Seventy-four articles containing 119 validation studies of 34 malnutrition screening tools used in older adults were identified across the settings. Twenty-three of these tools were designed for older adults. Sensitivity and specificity ranged from 6 to 100% and 12-100% respectively. Seventeen different reference standards were used in criterion validation studies. Acceptable reference standards were used in 68 studies; 38 compared the tool against the Mini Nutritional Assessment-Full Form (MNA-FF), 16 used clinical assessment by a nutrition-trained professional and 14 used the Subjective Global Assessment (SGA). Twenty-five studies used inappropriate reference standards. Predictive validity was measured in 14 studies and was weak across all settings.

CONCLUSIONS

Validation results differed significantly between tools, and also between studies using the same tool in different settings. Many studies have not been appropriately conducted, leaving the true validity of some tools unclear. Certain tools appear to be more valid for use in specific settings.

Colorectal cancer survivors' beliefs on nutrition and cancer; correlates with nutritional information provision

Purpose

To investigate CRC survivors’ beliefs on nutrition and cancer and the association with nutritional information provision by (kind and number) of health professionals and to inquire about foods that CRC survivors believed either had a positive or negative influence on their cancer.

Methods

A total of 326 CRC survivors of an ongoing prospective cohort study filled out questionnaires 1 month after surgery on whether they had received nutritional information from health professionals. Also, their beliefs that nutrition influences (1) feelings of well-being, (2) complaints after treatment, (3) recovery and (4) cancer recurrence were investigated. Prevalence ratios were calculated (using Cox proportional hazard regression analysis) to study associations between information provision and the four beliefs adjusted for age, gender and cancer stage.

Results

Sixty-two percent of respondents received information about nutrition from one or more health professionals. Most respondents who received information strongly believe nutrition influences feelings of well-being (59%) and recovery after cancer (62%). Compared with those who did not receive information, respondents who received information from three professionals showed the strongest beliefs on the influence of nutrition on complaints after treatment (PR 3.4; 95% CI 1.6–7.4), recovery after treatment (PR 2.0; 95% CI 1.2–3.3) and recurrence (PR 2.8; 95% CI 1.3–6.2).

Conclusion

Nutritional information provision by health professionals positively influences the beliefs of CRC survivors on the influence of nutrition on cancer outcomes: stronger beliefs occur when respondents received information from three health professionals.

The Role of Delirium and Other Risk Factors on Mortality in Elderly Patients with Critical Limb Ischemia Undergoing Major Lower Limb Amputation

BACKGROUND

Delirium in patients with critical limb ischemia (CLI) is associated with increased mortality. The main goal of this study was to investigate the association between delirium and mortality in patients undergoing major lower limb amputation for CLI. In addition, other risk factors associated with mortality were analyzed.

METHODS

An observational cohort study was conducted including all patients aged ≥70 years with CLI undergoing a major lower limb amputation between January 2014 and July 2017. Delirium was scored using the Delirium Observation Screening Score in combination with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Risk factors for mortality were analyzed by calculating hazard ratios using a Cox proportional hazards model.

RESULTS

In total, 95 patients were included; of which, 29 (31%) patients developed a delirium during admission. Delirium was not associated with an increased risk of mortality (hazard ratio [HR] = 0.84; 95 % confidence interval [CI]: 0.51-1.73; P = 0.84). Variables independently associated with an increased risk of mortality were age (HR 1.1; 95% CI 1.0-1.1), cardiac history (HR 3.3; 95% CI 1.8-6.1), current smoking (HR 2.9; 95% CI 1.6-5.5), preoperative anemia (HR 2.8; 95% CI 1.1-7.2), and living in a nursing home (HR 2.2; 95% CI 1.1-4.4).

CONCLUSION

Delirium was not associated with an increased mortality risk in elderly patients with CLI undergoing a major lower limb amputation. Factors related to an increased mortality risk were age, cardiac history, current smoking, preoperative anemia, and living in a nursing home.

Speaking the same language: Development of a Nutrition Minimum Data Set for healthcare professionals in primary healthcare

Providing the best possible nutritional care requires accurate and precise communication between healthcare professionals. Developing a Nutrition Minimum Data Set will inform professionals in primary healthcare of which core elements should be documented and facilitate a standardized approach to the documentation of nutritional care. A two-step methodological approach was utilized in this study: (1) a systematic scoping review was conducted to map evidence underpinning the development of a Minimum Data Set and (2) the datasources were categorized using the inductive content analysis approach. A total of 32 items were identified in the datasources. Five categories were inductively derived from the data: (1) physiologic measurements, (2) ability to eat, (3) intake, (4) stress factors and (5) factors which indirectly affect intake and needs. Organizing the documentation following the structure presented in this Minimum Data Set will contribute to a standardized terminology, which may lead to increased quality of documentation, increased continuity of care and improved health outcomes.

Screening for malnutrition in patients admitted to the hospital with a proximal femoral fracture

INTRODUCTION

The prevalence of malnutrition in patients admitted with a proximal femoral fracture is considered high and the negative effects on health are well-studied. The SNAQ and the MNA-SF are two screening tools routinely used during admission of acute medical patients. The aim of this study is to compare the screening capacity of the SNAQ score and the MNA-SF, and to evaluate their predictive values for malnutrition using the ESPEN criteria.

MATERIALS AND METHODS

A single-centre study with data routinely collected prospectively from the original patient records was performed in the Haaglanden Medical Centre Bronovo in the Netherlands. All patients with a proximal femoral fracture consecutively admitted between December 19th 2016 and December 21st 2017 were included. The Intraclass Correlation Coefficient was used to assess the agreement between the malnutrition screening tools and the predictive values were calculated to compare the SNAQ with the MNA-SF using the ESPEN diagnostic criteria as the reference standard.

RESULTS

Data was available from 437 patients. Of all patients admitted with a proximal femoral fracture 16.9% was diagnosed as malnourished by the ESPEN criteria. When screened, 20.1% (SNAQ score) to 47.8% (MNA-SF) of all patients were classified as either at risk for malnutrition or as malnourished. A moderate agreement was found between the MNA-SF and the SNAQ (κ = 0.68). The sensitivity, specificity, PPV and NPV of the SNAQ score were 71.6%, 90.4%, 60% and 94% respectively, compared to 100%, 62.8%, 35.4% and 100% for the MNA-SF.

DISCUSSION

The SNAQ has been proven to be a very specific screening tool and the positive predictive value tends to be higher than that of the MNA-SF. However, 28.4% of all malnourished patients with a proximal femoral fracture had a negative screening test when using the SNAQ score.

CONCLUSIONS

No benefits were observed for the SNAQ over the MNA-SF as a screening tool for malnutrition in admitted patients with a proximal femoral fracture. Missing a significant portion of malnourished patients or those at risk and consequent under treatment of fragile older patients should be avoided. The well-validated MNA-SF seems more preferable as a screening tool for this patient population.

Development and application of a scoring system to rate malnutrition screening tools used in older adults in community and healthcare settings - A MaNuEL study

RATIONALE

Many malnutrition screening tools are used to screen for risk of malnutrition in older adults. An aim of the Joint Programming Initiative (JPI) 'A Healthy Diet for a Healthy Life' (HDHL) MalNutrition in the ELderly Knowledge hub (MaNuEL) is to devise recommendations on the best tools to screen for risk of malnutrition in older adults in community and healthcare settings across Europe. The aim of this paper was to develop and apply a scoring system to rate malnutrition screening tools.

METHODS

Using a targeted literature search strategy, 48 malnutrition screening tools used to screen for risk of malnutrition in older adults were identified across community, rehabilitation, residential care and hospital settings. Criteria to rate each tool were developed; these were based on published evidence and expert opinion. These criteria were translated into a scoring system.

RESULTS

The scoring system had three equally weighted sections; validation, parameters and practicability, and was applied to all 48 tools. Overall, the highest scoring tools per setting for screening for risk of malnutrition in older adults were i) DETERMINE your health checklist for the community setting; ii) the Nutritional Form for the Elderly (NUFFE) for the rehabilitation setting; iii) the Short Nutritional Assessment Questionnaire-Residential Care (SNAQ^RC) for residential care and iv) both the Malnutrition Screening Tool (MST) and the Mini Nutritional Assessment Short Form Version 1 (MNA-SF-V1) for the hospital setting.

CONCLUSION

Setting-specific tools are more appropriate for use with older adults. These findings will inform recommendations for the optimal screening of geriatric malnutrition across Europe.

Dementia and delirium, the outcomes in elderly hip fracture patients

BACKGROUND

Delirium in hip fractured patients is a frequent complication. Dementia is an important risk factor for delirium and is common in frail elderly. This study aimed to extend the previous knowledge on risk factors for delirium and the consequences. Special attention was given to patients with dementia and delirium.

METHODS

This is a retrospective cohort study performed in the Amphia Hospital, Breda, the Netherlands. A full electronic patient file system (Hyperspace Version IU4: Epic, Inc., Verona, WI, USA) was used to assess data between January 2014 and September 2015. All patients presented were aged ≥70 years with a hip fracture, who underwent surgery with osteosynthesis or arthroplasty. Patients were excluded in case of a pathological or a periprosthetic hip fracture, multiple traumatic injuries, and high-energy trauma. Patient and surgical characteristics were documented. Postoperative outcomes were noted. Delirium was screened using Delirium Observation Screening Scale and dementia was assessed from medical notes.

RESULTS

Of a total of 566 included patients, 75% were females. The median age was 84 years (interquartile range: 9). Delirium was observed in 35%. Significant risk factors for delirium were a high American Society of Anesthesiology score, delirium in medical history, functional dependency, preoperative institutionalization, low hemoglobin level, and high amount of blood transfusion. Delirium was correlated with a longer hospital stay (P=0.001), increased association with complications (P<0.001), institutionalization (P<0.001), and 6-month mortality (P<0.001). Patients with dementia (N=168) had a higher delirium rate (57.7%, P<0.001) but a shorter hospital stay (P<0.001). There was no significant difference in the 6-month mortality between delirious patients with (34.0%) and without dementia (26.3%).

CONCLUSION

Elderly patients with a hip fracture are vulnerable for delirium, especially when the patient has dementia. Patients who underwent an episode of delirium were at increased risk for adverse outcomes.

Use of routinely available clinical, nutritional, and functional criteria to classify cachexia in advanced cancer patients

BACKGROUND

Cachexia is a highly prevalent syndrome in cancer and chronic diseases. However, due to the heterogeneous features of cancer cachexia, its identification and classification challenge clinical practitioners.

OBJECTIVE

To determine the clinical relevance of a cancer cachexia classification system in advanced cancer patients.

DESIGN

Beginning with the four-stage classification system proposed for cachexia [non-cachexia (NCa), pre-cachexia (PCa), cachexia (Ca) and refractory cachexia (RCa)], we assigned patients to these cachexia stages according to five classification criteria available in clinical practice: 1) biochemistry (high C-reactive protein or leukocytes, or hypoalbuminemia, or anemia), 2) food intake (normal/decreased), weight loss: 3) moderate (≤5%) or 4) significant (>5%/past six months) and 5) performance status (Eastern Cooperative Oncology Group Performance Status ≥ 3). We then determined if symptom severity, body composition changes, functional levels, hospitalizations and survival rates varied significantly across cachexia stages.

RESULTS

Two-hundred and ninety-seven advanced cancer patients with primary gastrointestinal and lung tumors were included. Patients were classified into Ca (36%), PCa and RCa (21%, respectively) and NCa (15%). Significant (p < 0.05) differences were observed among cachexia stages for most of the outcome measures (symptoms, body composition, handgrip strength, emergency room visits and length of hospital stays) according to cachexia severity. Survival also differed between cachexia stages (except between PCa and Ca).

CONCLUSION

Five clinical criteria can be used to stage cancer cachexia patients and predict important clinical, nutritional and functional outcomes. The lack of statistical difference between PCa and Ca in almost all clinical outcomes examined suggests either that the PCa group includes patients already affected by early cachexia or that more precise criteria are needed to differentiate PCa from Ca patients. More studies are required to validate these findings.

New aspects of delirium in elderly patients with critical limb ischemia

Objective

The primary objective was to identify possible risk factors for delirium in patients with critical limb ischemia undergoing surgery. The secondary objective was to study the effect of delirium on complications, the length of hospital stay, health care costs, and mortality.

Methods

All patients 65 years or older with critical limb ischemia undergoing surgery from February 2013 to July 2014 at Amphia Hospital, were included and followed up until December 31, 2014. Delirium was scored using the Delirium Observation Screening Scale (DOSS). Perioperative risk factors (age, comorbidity, factors of frailty, operation type, hemoglobulin, and transfusion) were collected and analyzed using logistic regression. Secondary outcomes were the number of complications, total hospital stay, extra health care costs per delirium, and mortality within 3 months and 6 months of surgery.

Results

We included 92 patients with critical limb ischemia undergoing surgery. Twenty-nine (32%) patients developed a delirium during admission, of whom 17 (59%) developed delirium preoperatively. After multivariable analysis, only diabetes mellitus (odds ratio [OR] =6.23; 95% confidence interval [CI]: 1.11–52.2; P=0.035) and Short Nutritional Assessment Questionnaire for Residential Care (SNAQ-RC) ≥3 (OR =5.55; 95% CI: 1.07–42.0; P=0.039) was significantly associated with the onset of delirium. Delirium was associated with longer hospital stay (P=0.001), increased health care costs, and higher mortality after 6 months (P<0.001).

Conclusion

Delirium is a common adverse event in patients with critical limb ischemia undergoing surgery with devastating outcome in the long term. Most patients developed delirium preoperatively, which indicates the need for early recognition and preventive strategies in the preoperative period. This study identified undernourishment and diabetes mellitus as independent risk factors for delirium.

A systematic review of malnutrition screening tools for the nursing home setting

RATIONALE

Malnutrition screening among nursing home residents is often performed with tools developed for use among older subjects, and sometimes with tools designed for an adult population. Only a few tools have been designed specifically for the nursing home setting. This systematic review assesses the criterion and predictive validity of malnutrition screening tools used in nursing homes.

METHODS

The databases MEDLINE, CINAHL, and EMBASE were searched on January 30, 2013, for manuscripts including search terms for malnutrition, screening or assessment tools, and setting. Articles were eligible for inclusion if they expressed criterion validity (how well can a tool assess nutritional status) or predictive validity (how well can a tool predict clinical outcome) of malnutrition screening tools in a nursing home population. Included were articles that had been published in the English, German, French, Dutch, Spanish, or Portuguese language.

RESULTS

The search yielded 8313 references. Of these, 24 met the inclusion criteria and were available; 2 extra manuscripts were retrieved by reference checking. Twenty tools were identified. Seventeen studies reported on criterion validity, and 9 on predictive validity. Four of the tools had been designed specifically for use in long term care. None of the tools, not even the ones specifically designed for the nursing home setting, performed (on average) better than "fair" in either assessing the residents' nutritional status or in predicting malnutrition-related outcomes.

CONCLUSION

The use of existing screening tools for the nursing home population carries limitations, as none performs better than "fair" in assessing nutritional status or in predicting outcome. Also, no superior tool can be pointed out. This systematic review implies that further considerations regarding malnutrition screening among nursing home residents are required.

Validity of nutritional screening with MUST and SNAQ in hospital outpatients

BACKGROUND/OBJECTIVES

The majority of hospital outpatients with undernutrition is unrecognized, and therefore untreated. There is a need for an easy and valid screening tool to detect undernutrition in this setting. The aim of this study was to determine the diagnostic accuracy of the MUST (Malnutrition Universal Screening Tool) and SNAQ (Short Nutritional Assessment Questionnaire) tools for undernutrition screening in hospital outpatients.

METHODS

In a large multicenter-hospital-outpatient population, patients were classified as: severely undernourished (body mass index (BMI) <18.5 (<65 years) or <20 ( ≥ 65 years) and/or unintentional weight loss >5% in the last month or >10% in the last 6 months), moderately undernourished (BMI 18.5-20 (<65 years) or 20-22 ( ≥ 65 years) and/or 5-10% unintentional weight loss in the last 6 months) or not undernourished. Diagnostic accuracy of the screening tools versus the reference method was expressed as sensitivity (Se), specificity (Sp), positive predictive value (PPV) and negative predictive value (NPV).

RESULTS

Out of the 2236 outpatients, 6% were severely and 7% were moderately undernourished according to the reference method. MUST and SNAQ identified 9% and 3% as severely undernourished, respectively. MUST had a low PPV (Se=75, Sp=95, PPV=43, NPV=98), whereas SNAQ had a low Se (Se=43, Sp=99, PPV=78, NPV=96).

CONCLUSIONS

The validity of MUST and SNAQ is insufficient for hospital outpatients. While SNAQ identifies too few patients as undernourished, MUST identifies too many patients as undernourished. We advise to measure body weight, height and weight loss, in order to define undernutrition in hospital outpatients.

Evaluation of dominance-based ordinal multiple regression for variables with few categories

Dominance-based ordinal multiple regression (DOR) is designed to answer ordinal questions about relationships among ordinal variables. Only one parameter per predictor is estimated, and the number of parameters is constant for any number of outcome levels. The majority of existing simulation evaluations of DOR use predictors that are continuous or ordinal with many categories, so the performance of the method is not well understood for ordinal variables with few categories. This research evaluates DOR in simulations using three-category ordinal variables for the outcome and predictors, with a comparison to the cumulative logits proportional odds model (POC). Although ordinary least squares (OLS) regression is inapplicable for theoretical reasons, it was also included in the simulations because of its popularity in the social sciences. Most simulation outcomes indicated that DOR performs well for variables with few categories, and is preferable to the POC for smaller samples and when the proportional odds assumption is violated. Nevertheless, confidence interval coverage for DOR was not flawless and possibilities for improvement are suggested.

Questionário nutricional simplificado de apetite (QNSA) para uso em programas de reabilitação cardiopulmonar e metabólica

O presente estudo teve por objetivo traduzir e validar para a língua portuguesa o Questionário Nutricional Simplificado de Apetite (QNSA), verificando sua clareza e validade para participantes de programa de Reabilitação Cardiopulmonar e Metabólica (RCPM). Cento e quarenta e seis indivíduos foram entrevistados, sendo 79 homens, com média de idade de 63 anos (± 10) e 67 mulheres, com média de 66 anos (± 11). A análise descritiva foi apresentada em média, desvio padrão e frequência. A consistência interna da escala foi avaliada por meio do coeficiente alfa de Cronbach e a análise fatorial pelo método de extração de análise dos componentes principais utilizando os critérios de Kaiser (autovalores > 1). Todas as questões do instrumento apresentaram resultados positivos em relação à clareza. Os itens do questionário apresentaram carga fatorial superior a 0,40, com variação de 0,40 a 0,81. Com exceção da questão relacionada com a quantidade de refeições diárias, todas as demais apresentaram alta correlação com o escore total da versão brasileira do instrumento. No que se refere à análise de consistência interna, obteve-se resultado de 0,61. A versão brasileira do QNSA demonstrou ser válida para aplicação em participantes de programa de RCPM, constituindo-se em uma importante ferramenta na avaliação do apetite nessa população.

Primary care and public health a natural alliance? The introduction of the guidelines for obesity and undernutrition of the Dutch College of General Practitioners

The prevalence of obesity and overweight is increasing globally and forms a huge public health problem. On the other hand, the prevalence of malnutrition or undernutrition is substantial, especially in nursing homes or in the elderly at home. Primary care and public health are separate disciplines. But in the field of nutrition and other lifestyle-related interventions, there are many direct and indirect interfaces for over- as well as undernutrition. The Dutch College of General Practitioners (NHG) published the Practice Guideline Obesity in adults and children to lead GPs in this process and to bridge the gap with public health. The same applies for the recently published National Primary Care Cooperation Agreement Undernutrition on the collaboration of primary care workers to enhance awareness and early intervention in case of nutritional impairment. This article goes into the background as well as the content of these two NHG products and the implications for daily practice. An attempt is made to connect primary care and public health in this matter. Particularly in the case of obesity, a close relationship with public health is of vital importance.

Development and validation of criteria for determining undernutrition in community-dwelling older men and women: The Short Nutritional Assessment Questionnaire 65+

BACKGROUND & AIMS

There is no valid, fast and easy-to-apply set of criteria to determine (risk of) undernutrition in community-dwelling older persons. The aim of this study was to develop and validate such criteria.

METHODS

Selection of potential anthropometric and undernutrition-related items was based on consensus literature. The criteria were developed using 15-year mortality in community-dwelling older persons ≥ 65 years (Longitudinal Aging Study Amsterdam, n = 1687) and validated in an independent sample (InCHIANTI, n = 1142).

RESULTS

Groups distinguished were: (1) undernutrition (mid-upper arm circumference <25 cm or involuntary weight loss ≥4 kg/6 months); (2) risk of undernutrition (poor appetite and difficulties climbing staircase); and (3) no undernutrition (others). Respective hazard ratio's for 15-year mortality were: (1) 2.22 (95% CI 1.83-2.69); and (2) 1.57 (1.22-2.01) ((3) = reference). The area under the curve (AUC) was 0.55. Comparable results were found stratified by sex, excluding cancer/obstructive lung disease/(past) smoking, using 6-year mortality, and applying results to the InCHIANTI study (hazard ratio's 2.12 and 2.46, AUC 0.59).

CONCLUSIONS

The developed set of criteria (SNAQ⁶⁵⁺) for determining (risk of) undernutrition in community-dwelling older persons shows good face validity and moderate predictive validity based on the consistent association with mortality in a second independent study sample.

Hospital malnutrition: prevalence, identification and impact on patients and the healthcare system

Malnutrition is a debilitating and highly prevalent condition in the acute hospital setting, with Australian and international studies reporting rates of approximately 40%. Malnutrition is associated with many adverse outcomes including depression of the immune system, impaired wound healing, muscle wasting, longer lengths of hospital stay, higher treatment costs and increased mortality. Referral rates for dietetic assessment and treatment of malnourished patients have proven to be suboptimal, thereby increasing the likelihood of developing such aforementioned complications. Nutrition risk screening using a validated tool is a simple technique to rapidly identify patients at risk of malnutrition, and provides a basis for prompt dietetic referrals. In Australia, nutrition screening upon hospital admission is not mandatory, which is of concern knowing that malnutrition remains under-reported and often poorly documented. Unidentified malnutrition not only heightens the risk of adverse complications for patients, but can potentially result in foregone reimbursements to the hospital through casemix-based funding schemes. It is strongly recommended that mandatory nutrition screening be widely adopted in line with published best-practice guidelines to effectively target and reduce the incidence of hospital malnutrition.