Strategies to implement community guidelines on nutrition and their long-term clinical effects in nursing home residents

Evaluation of the Climate Impact and Nutritional Quality of Menus in an Italian Long-Term Care Facility

Global warming poses a significant threat to our planet, with the food sector contributing up to 37% of total greenhouse gas emissions. This study aimed to assess the climate change impact and healthiness of menus in a long-term care facility in Italy. We analyzed two 28-day cyclical menus using the carbon footprint (CF) and the Modified EAT-Lancet Diet Score (MELDS) to evaluate adherence to the Planetary Health Diet (PHD). Monte Carlo simulations were employed to explore 20,000 daily menu permutations. Results showed that the mean GHGEs of spring/summer and autumn/winter daily menus were 2.64 and 2.82 kg of CO2eq, respectively, with 99% of menus exceeding the 2.03 kg of CO2eq benchmark. Only 22% of menus were adherent to the PHD, with MELDSs ranging from 12 to 29. A strong inverse association between the CF and adherence to the PHD was observed. These findings suggest significant potential for reducing the CFs of meals served in nursing homes while promoting adherence to a planetary diet, presenting an opportunity to set new standards in caregiving and environmental sustainability.

Vitamin D deficiency in nursing home residents: a systematic review

CONTEXT

Vitamin D deficiency is a global public health issue, particularly in nursing home residents.

OBJECTIVE

This review critically summarizes the prevalence of vitamin D deficiency in nursing home residents worldwide. In addition, it outlines the effect of vitamin D intervention, alone or in combination with other nutrients or therapies, on improving vitamin D status and associated health outcomes in nursing home residents.

DATA SOURCES, EXTRACTION, AND ANALYSIS

Searches were conducted of electronic databases for articles published from 2010 to May 2021. After screening of the 366 papers initially identified, 58 articles were included.

CONCLUSIONS

A paucity of observational studies in nursing homes suggests a high prevalence of vitamin D deficiency ranging from 8% [25(OH)D <25 nmol/L], up to 94% [25(OH)D <50 nmol/L] in some cohorts where supplement use was low. Reported factors associated with deficiency and suboptimal vitamin D status include lack of sunlight exposure, poor dietary intake of vitamin D, limited vitamin D food fortification, frailty, poor renal function, and low use of vitamin D supplements. Residents who are severely deficient, deficient, or insufficient in vitamin D require remedial vitamin D supplementation prior to maintenance supplementation at doses >800 IU/day. High-dose vitamin D supplementation may reduce respiratory illness; however, supportive data are limited. Oral nutritional supplements, in combination with exercise, may benefit physical function and performance, whereas supplementation with vitamin D- and calcium-fortified foods has been associated with improved quality of life and reduced bone resorption. Globally, vitamin D deficiency is highly prevalent in nursing home residents. There is an urgent need for standardized dietary and supplementation guidelines to prevent deficiency in this vulnerable group.

Vitamin D and Bone Health of Older Adults within Care Homes: An Observational Study

Limited studies have reported vitamin D status and health outcomes in care home residents, a group at risk of vitamin D deficiency. This study investigated serum 25-hydroxyvitamin D (25-OHD) concentrations in older adults within care homes in Northern Ireland (NI) and its association with musculoskeletal health (ultrasound T-score, muscle strength, Timed Up & Go test (TUG)), bone turnover markers (BTMs), and immune function markers. A total of 87 participants were recruited with mean ± SD age 83.2 ± 7.9 years. Mean ± SD serum 25-OHD concentration (n 69) was 49.52 ± 35.58 nmol/L. Vitamin D deficiency (25-OHD <25 nmol/L) was observed in 34.8% (n 24) of participants with 17.4% (n 12) classified as insufficient (25-OHD 25−50 nmol/L) and 47.8% (n 33) as sufficient (25-OHD >50 nmol/L). 25-OHD concentration was not an independent predictor of T-score, muscle strength, TUG, or inflammatory cytokines. After adjusting for covariates, a significant negative association was observed between 25-OHD concentration and the BTMs; osteocalcin (β = −0.395; p = 0.001), procollagen type 1 N propeptide (P1NP) (β = −0.320; p = 0.012), and C-terminal telopeptide of type 1 collagen (CTX) (β = −0.377; p = 0.003). Higher 25-OHD concentration was positively associated with use of vitamin D ± calcium supplementation (β = 0.610; p < 0.001). Vitamin D deficiency and insufficiency were highly prevalent in this sample of care home residents in NI. Higher 25-OHD concentration was associated with greater supplement use and with reduced bone turnover, which in this population is linked with reduced bone loss. These findings emphasize the need for a mandatory vitamin D ± calcium supplementation policy specific for care home residents.

Nutritional status and quality-of-life of older adults in aged care: A systematic review and meta-analysis

The effect of malnutrition beyond morbidity and mortality has become a critical area of investigation in older people with an increased focus on quality-of-life (QoL), but as yet the relationship between malnutrition and QoL remains to be reviewed in older people from aged care settings. The current study conducted a systematic review and meta-analyses of studies published between the years 1995 and 2020 examining the relationship between nutritional status and QoL or the effects of a nutrition-based intervention on QoL in older people in residential aged care. Based on searches of the databases MEDLINE, PsycINFO, Emcare, and Embase, 21 studies were identified. Meta-analyses of the cross-sectional and quasi-experimental studies revealed a significant positive relationship between nutritional status and QoL and that nutritional intervention significantly improved QoL. By contrast, meta-analysis of randomised controlled trials revealed a non-significant but improved trend post-intervention in QoL. Although the effect sizes were small, the present findings indicate that nutrition-based interventions improve QoL in older people in residential aged care and align with previous reviews based on findings from other aged settings. Future research is needed to determine causality and to better identify and control for confounding factors which may influence both nutritional status and QoL.

Quality improvement studies in nursing homes: a scoping review

BACKGROUND

Quality improvement (QI) is used in nursing homes (NH) to implement and sustain improvements in patient outcomes. Little is known about how QI strategies are used in NHs. This lack of information is a barrier to replicating successful strategies. Guided by the Framework for Implementation Research, the purpose of this study was to map-out the use, evaluation, and reporting of QI strategies in NHs.

METHODS

This scoping review was completed to identify reports published between July 2003 through February 2019. Two reviewers screened articles and included those with (1) the term "quality improvement" to describe their methods, or reported use of a QI model (e.g., Six Sigma) or strategy (e.g., process mapping) (2), findings related to impact on service and/or resident outcomes, and (3) two or more NHs included. Reviewers extracted data on study design, setting, population, problem, solution to address problem, QI strategies, and outcomes (implementation, service, and resident). Vote counting and narrative synthesis were used to describe the use of QI strategies, implementation outcomes, and service and/or resident outcomes.

RESULTS

Of 2302 articles identified, the full text of 77 articles reporting on 59 studies were included. Studies focused on 23 clinical problems, most commonly pressure ulcers, falls, and pain. Studies used an average of 6 to 7 QI strategies. The rate that strategies were used varied substantially, e.g., the rate of in-person training (55%) was more than twice the rate of plan-do-study-act cycles (20%). On average, studies assessed two implementation outcomes; the rate these outcomes were used varied widely, with 37% reporting on staff perceptions (e.g., feasibility) of solutions or QI strategies vs. 8% reporting on fidelity and sustainment. Most studies (n = 49) reported service outcomes and over half (n = 34) reported resident outcomes. In studies with statistical tests of improvement, service outcomes improved more often than resident outcomes.

CONCLUSIONS

This study maps-out the scope of published, peer-reviewed studies of QI in NHs. The findings suggest preliminary guidance for future studies designed to promote the replication and synthesis of promising solutions. The findings also suggest strategies to refine procedures for more effective improvement work in NHs.

Models of provider care in long-term care: A rapid scoping review

INTRODUCTION

One of the current challenges in long-term care homes (LTCH) is to identify the optimal model of care, which may include specialty physicians, nursing staff, person support workers, among others. There is currently no consensus on the complement or scope of care delivered by these providers, nor is there a repository of studies that evaluate the various models of care. We conducted a rapid scoping review to identify and map what care provider models and interventions in LTCH have been evaluated to improve quality of life, quality of care, and health outcomes of residents.

METHODS

We conducted this review over 10-weeks of English language, peer-reviewed studies published from 2010 onward. Search strategies for databases (e.g., MEDLINE) were run on July 9, 2020. Studies that evaluated models of provider care (e.g., direct patient care), or interventions delivered to facility, staff, and residents of LTCH were included. Study selection was performed independently, in duplicate. Mapping was performed by two reviewers, and data were extracted by one reviewer, with partial verification by a second reviewer.

RESULTS

A total of 7,574 citations were screened based on the title/abstract, 836 were reviewed at full text, and 366 studies were included. Studies were classified according to two main categories: healthcare service delivery (n = 92) and implementation strategies (n = 274). The condition/ focus of the intervention was used to further classify the interventions into subcategories. The complex nature of the interventions may have led to a study being classified in more than one category/subcategory.

CONCLUSION

Many healthcare service interventions have been evaluated in the literature in the last decade. Well represented interventions (e.g., dementia care, exercise/mobility, optimal/appropriate medication) may present opportunities for future systematic reviews. Areas with less research (e.g., hearing care, vision care, foot care) have the potential to have an impact on balance, falls, subsequent acute care hospitalization.

Is it possible to influence ability, willingness and understanding among nursing home care staff to implement nutritional guidelines? A comparison of a facilitated and an educational strategy

BACKGROUND

Translating nutrition knowledge into care practice is challenging since multiple factors can affect the implementation process. This study examined the impact of two implementation strategies, that is external facilitation (EF) and educational outreach visits (EOVs), on the organisational context and individual factors when implementing nutritional guidelines in a nursing home (NH) setting.

METHODS

The EF strategy was a one-year, multifaceted (including support, guidance, a practice audit and feedback) intervention given to four NH units. The EOV strategy was a three-hour lecture about the nutritional guidelines given to four other NH units. Both strategies were directed at selected NH teams, consisting of a unit manager, a nurse and 5-10 care staff. A questionnaire was distributed, before and after the interventions, to evaluate the prerequisites for the staff to use the guidelines. Three conditions were used to examine the organisational context and the individual factors: the staff's ability and willingness to implement the nutritional guidelines and their understanding of them. Confirmatory factor analysis and structural equation models were used for the data analysis.

RESULTS

The results indicated that on average, there was a significant increase in the staff's ability to implement the nutritional guidelines in the EF group. The staff exposed to the EF strategy experienced better resources to implement the guidelines in terms of time, tools and support from leadership and a clearer assignment of responsibility regarding nutrition procedures. There was no change in staff's willingness and understanding of the guidelines in the EF group. On average, no significant changes were observed for the staff's ability, willingness or understanding in the EOV group.

CONCLUSIONS

A long-term, active and flexible implementation strategy (i.e. EF) affected the care staff's ability to implement the nutritional guidelines in an NH setting. No such impact was observed for the more passive, educational approach (i.e. EOV).

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.

Implementation strategies used to implement nursing guidelines in daily practice: A systematic review

OBJECTIVES

Research specifically addressing implementation strategies regarding nursing guidelines is limited. The objective of this review was to provide an overview of strategies used to implement nursing guidelines in all nursing fields, as well as the effects of these strategies on patient-related nursing outcomes and guideline adherence. Ideally, the findings would help guideline developers, healthcare professionals and organizations to implement nursing guidelines in practice.

DESIGN

Systematic review. PROSPERO registration number: CRD42018104615.

DATA SOURCES

We searched the Embase, Medline, PsycINFO, Web of Science, Cochrane, CINAHL and Google Scholar databases until August 2019 as well as the reference lists of relevant articles.

REVIEW METHODS

Studies were included that described quantitative data on the effect of implementation strategies and implementation outcomes of any type of a nursing guideline in any setting. No language or date of publication restriction was used. The Cochrane Effective Practice and Organisation of Care taxonomy was used to categorize the implementation strategies. Studies were classified as effective if a significant change in either patient-related nursing outcomes or guideline adherence was described. Strength of the evidence was evaluated using the 'Cochrane risk of bias tool' for controlled studies, and the 'Newcastle-Ottawa Quality Assessment form' for cohort studies.

RESULTS

A total of 54 articles regarding 53 different guideline implementation studies were included. Fifteen were (cluster) Randomized Controlled Trials or controlled before-after studies and 38 studies had a before-after design. The topics of the implemented guidelines were diverse, mostly concerning skin care (n = 9) and infection prevention (n = 7). Studies were predominantly performed in hospitals (n = 34) and nursing homes (n = 11). Thirty studies showed a positive significant effect in either patient-related nursing outcomes or guideline adherence (68%, n = 36). The median number of implementation strategies used was 6 (IQR 4-8) per study. Educational strategies were used in nearly all studies (98.1%, n = 52), followed by deployment of local opinion leaders (54.7%, n = 29) and audit and feedback (41.5%, n = 22). Twenty-three (43.4%) studies performed a barrier assessment, nineteen used tailored strategies.

CONCLUSIONS

A wide variety of implementation strategies are used to implement nursing guidelines. Not one single strategy, or combination of strategies, can be linked directly to successful implementation of nursing guidelines. Overall, thirty-six studies (68%) reported a positive significant effect of the implementation of guidelines on patient-related nursing outcomes or guideline adherence. Future studies should use a standardized reporting checklist to ensure a detailed description of the used implementation strategies to increase reproducibility and understanding of outcomes.

Dietary Factors Associated with Frailty in Old Adults: A Review of Nutritional Interventions to Prevent Frailty Development

Frailty syndrome is a medical condition that is characterised by a functional decline, usually from 65 years old on, and creates the need for assistance to perform daily living activities. As the population ages, the need for specialised geriatric care will increase immensely, and consequently, the need for specialised services for the care of these people will increase accordingly. From a nutritional point of view, to control or balance the nutritional status of residents will be essential in order to prevent sarcopenia and, consequently, frailty development. In this line, previous studies have highlighted the association among low energy intake, inadequate intake of protein and vitamin D, and an increased risk of frailty development. However, there is a lack of intervention studies on frail patients, especially in the realm of quality clinical trials. The few studies performed to date seem to indicate that there is a protective role of protein supplementation against frailty syndrome. In this regard, it is tempting to suggest daily 30 g protein supplements to prevent frailty. However, it is well established that excess protein can also be harmful; therefore, specific individual characteristics should be considered before prescribing these supplements. On the other hand, the relevance of other nutritional interventions, such as vitamin D, omega-3, and medium-chain triglycerides, is much more scarce in the literature. Therefore, we encourage the development of new clinical trials to carry out effective therapies to prevent frailty development.

Recognition of roles of various professionals by home-visiting specialists

[Purpose] To support home care patients through specialist teams, it is important that home-visiting specialists recognize the roles of other professionals. The present study aimed to determine whether home-visiting specialists recognized the roles of various other professionals. [Subjects and Methods] The study population comprised 400 nurses, 400 rehabilitation specialists, and 122 managerial dieticians providing home medical care. A questionnaire examining whether the home-visiting specialists recognize the roles of various other professionals was mailed to the participants. Returned questionnaires indicated agreement for participation in this study. Based on the responses to the questionnaire, 49 nurses (response rate: 12.3%), 74 rehabilitation specialists (18.5%), and 42 managerial dieticians (34.4%) were included in the study. [Results] Among all the professionals, the recognition of roles of their own profession was greater than that of other professions, as indicated by their response to the question “to explain possible changes in symptoms and how to deal with possible changes in symptoms.” Unlike in case of other professionals, role recognition among managerial dieticians was less than 70% for all items. [Conclusion] Home medical care teams do not always comprise the most suitable professionals. An understanding of how to compensate for gaps in professional roles is therefore important. Good physical assessment skills and an understanding of symptoms of various disorders is important, regardless of the profession.

The effects of nutritional guideline implementation on nursing home staff performance: a controlled trial

RATIONALE

Suboptimal nutritional practices in elderly care settings may be resolved by an efficient introduction of nutritional guidelines.

AIMS

To compare two different implementation strategies, external facilitation (EF) and educational outreach visits (EOVs), when introducing nutritional guidelines in nursing homes (NHs), and study the impact on staff performance.

METHODOLOGICAL DESIGN

A quasi-experimental study with baseline and follow-up measurements.

OUTCOME MEASURES

The primary outcome was staff performance as a function of mealtime ambience and food service routines.

INTERVENTIONS/RESEARCH METHODS

The EF strategy was a 1-year, multifaceted intervention that included support, guidance, practice audit and feedback in two NH units. The EOV strategy comprised one-three-hour lecture about nutritional guidelines in two other NH units. Both strategies were targeted to selected NH teams, which consisted of a unit manager, a nurse and 5-10 care staff. Mealtime ambience was evaluated by 47 observations using a structured mealtime instrument. Food service routines were evaluated by 109 food records performed by the staff.

RESULTS

Mealtime ambience was more strongly improved in the EF group than in the EOV group after the implementation. Factors improved were laying a table (p = 0.03), offering a choice of beverage (p = 0.02), the serving of the meal (p = 0.02), interactions between staff and residents (p = 0.02) and less noise from the kitchen (p = 0.01). Food service routines remained unchanged in both groups.

CONCLUSIONS

An EF strategy that included guidance, audit and feedback improved mealtime ambience when nutritional guidelines were introduced in a nursing home setting, whereas food service routines were unchanged by the EF strategy.

Evaluation of a Continuing Educational Intervention for Primary Health Care Professionals about Nutritional Care of Patients at Home

OBJECTIVE

Evaluate the effectiveness of a continuing educational intervention on primary health care professionals' familiarity with information important to nutritional care in a palliative phase, their collaboration with other caregivers, and their level of knowledge about important aspects of nutritional care.

DESIGN

Observational cohort study.

SETTING

10 primary health care centers in Stockholm County, Sweden.

PARTICIPANTS

140 district nurses/registered nurses and general practitioners/physicians working with home care.

INTERVENTION

87 professionals participated in the intervention group (IG) and 53 in the control group (CG). The intervention consisted of a web-based program offering factual knowledge; a practical exercise linking existing and new knowledge, abilities, and skills; and a case seminar facilitating reflection.

MEASUREMENTS

The intervention's effects were measured by a computer-based study-specific questionnaire before and after the intervention, which took approximately 1 month. The CG completed the questionnaire twice (1 month between response occasions). The intervention effects, odds ratios, were estimated by an ordinal logistic regression.

RESULTS

In the intra-group analyses, statistically significant changes occurred in the IG's responses to 28 of 32 items and the CG's responses to 4 of 32 items. In the inter-group analyses, statistically significant effects occurred in 20 of 32 statements: all 14 statements that assessed familiarity with important concepts and all 4 statements about collaboration with other caregivers but only 2 of the 14 statements concerning level of knowledge. The intervention effect varied between 2.5 and 12.0.

CONCLUSION

The intervention was effective in increasing familiarity with information important to nutritional care in a palliative phase and collaboration with other caregivers, both of which may create prerequisites for better nutritional care. However, the intervention needs to be revised to better increase the professionals' level of knowledge about important aspects of nutritional care.

Does Low Body Mass Index Matter? Relationship between Body Mass Index and Subjective Well-Being among Long-Lived Women over 95 Years of Age

OBJECTIVES

To examine the relationship between body mass index (BMI) and subjective well-being (SWB) among long-lived women over 95 years of age and evaluate whether this relationship is mediated by functional ability.

DESIGN

Retrospective cohort study.

SETTING

Data from the Rugao longevity cohort, a population-based study in Rugao, China.

PARTICIPANTS

A sample of 342 long-lived women (mean age 97.4 ± 2.1, range 95-107) whose SWB and other covariates were available were included in this study.

MEASUREMENTS

BMI was calculated as weight in kilograms divided by height in meters-squared (kg/m(2)). SWB was measured by life satisfaction (LS), positive affect (PA), negative affect (NA) and affect balance (AB). Functional ability was assessed by the Katz Index of Activities of Daily Living (ADL).

RESULTS

According to BMI classification standards for China, the underweight group had lower levels of LS than the normal and overweight groups (28.62 vs. 30.51 and 31.57, respectively; p<.05). Correlation analysis showed that BMI was significantly related to LS (r = 0.166, p<.01). The strength of the BMI and LS association was diminished when ADL was included in the general linear regression models. Mediation analysis revealed that ADL mediated this relationship (effect size = 22.6%). We did not observe significant associations of BMI with other SWB components (PA, NA, and AB).

CONCLUSION

For long-lived women, low BMI, rather than elevated BMI, is an indicator of poor psychological well-being. The findings call for public health awareness about low body weight in long-lived women, especially in those with physical disabilities when focusing on quality of life.

A systematic review of instruments for measuring outcomes in economic evaluation within aged care

BACKGROUND

This paper describes the methods and results of a systematic review to identify instruments used to measure quality of life outcomes in older people. The primary focus of the review was to identify instruments suitable for application with older people within economic evaluations conducted in the aged care sector.

METHODS

Online databases searched were PubMed, Medline, Scopus, and Web of Science, PsycInfo, CINAHL, Embase and Informit. Studies that met the following criteria were included: 1) study population exclusively above 65 years of age 2) measured health status, health related quality of life or quality of life outcomes more broadly through use of an instrument developed for this purpose, 3) used a generic preference based instrument or an older person specific preference based or non-preference based instrument or both, and 4) published in journals in the English language after 2000.

RESULTS

The most commonly applied generic preference based instrument in both the community and residential aged care context was the EuroQol - 5 Dimensions (EQ-5D), followed by the Adult Social Care Outcomes Toolkit (ASCOT) and the Health Utilities Index (HUI2/3). The most widely applied older person specific instrument was the ICEpop CAPability measure for Older people (ICECAP-O) in both community and residential aged care.

CONCLUSION

In the absence of an ideal instrument for incorporating into economic evaluations in the aged care sector, this review recommends the use of a generic preference based measure of health related quality of life such as the EQ-5D to obtain quality adjusted life years, in combination with an instrument that has a broader quality of life focus like the ASCOT, which was designed specifically for evaluating interventions in social care or the ICECAP-O, a capability measure for older people.