ESPEN practical guideline: Clinical nutrition and hydration in geriatrics

Progress in dysphagia management in older patients

PURPOSE OF REVIEW

The review summarizes current knowledge, recent findings and knowledge gaps about the pathophysiology and therapy of oropharyngeal dysphagia in older persons.

RECENT FINDINGS

Oropharyngeal dysphagia is a major yet underrecognized health problem in older persons. Due to its high prevalence, its multifactorial etiology and multimodal treatment it has been classified as a geriatric syndrome. Although the knowledge of its pathophysiology and the effective diagnostic approach increased substantially during the last years, there is still minor evidence on how to effectively manage and treat dysphagia. However, treatment should be a multicomponent approach, combining swallowing training, nutritional therapy and oral hygiene. Emerging new fields are neurostimulation and chemical sensory stimulation which may be added in selected patients and indications. The individual components to be chosen should be based on the individual dysphagia pattern and severity as well as the capabilities of the patient. Frequently, the competing risks of inadequate nutrition and unsafe swallowing represent a challenge in determining the individual relevance of each component.

SUMMARY

The understanding of the pathophysiology of oropharyngeal dysphagia increased substantially during recent years. However, due the multifaceted appearance of dysphagia, which requires an individualized treatment, the evidence for therapeutic approaches increases rather slowly.

Assessment and management of frailty in individuals living with dementia: expert recommendations for clinical practice

Frailty complicates the care of individuals with dementia, increasing their vulnerability to adverse outcomes. This Personal View presents expert recommendations for managing frailty in individuals with dementia, aimed at health-care providers, particularly those in primary care. We conducted a rapid literature review followed by a consensus process involving 18 international experts on dementia and frailty. The experts identified key areas, including diagnosis of frailty, assessment of nutritional status and nutritional management, physical activity, prevention of falls, and polypharmacy management. The recommendations emphasise early identification of frailty and a comprehensive, interdisciplinary approach to care that aims to maintain the individual's daily functioning, quality of life, and independence. The recommendations highlight the importance of tailored interventions, regular monitoring, and the integration of psychosocial support into the therapeutic approach. These recommendations address a crucial gap in existing clinical guidelines, offering practical guidance for clinicians managing frailty in individuals with dementia.

The association between nutrition risk status assessment and hospital mortality in Chinese older inpatients: a retrospective study

PURPOSE

The association between nutritional risk status assessment and hospital mortality in older patients remains controversial. The aim of this study was to assess the relationship between nutritional risk on admission and in-hospital mortality, and explore the best Nutritional Risk Status Screening 2002 (NRS2002) threshold for predicting in-hospital mortality of older inpatients in China.

METHOD

The elderly inpatients were recruited from a hospital in Hunan Province, China. Nutritional risk was screened and assessed using the NRS2002. Logistic regression was used to analyze whether NRS2002 scores were independently associated with hospital mortality, and the results were expressed as odds ratios (OR) and 95% confidence intervals (CIs). Receiver operating characteristic curve (ROC) was used to determine the best NRS2002 threshold for predicting in-hospital mortality in elderly inpatients. And 500 bootstrap re-samplings were performed for ROC analysis.

RESULT

In total, 464 elderly inpatients completed the survey (15 of whom died, 205 males and 259 females, mean age = 72.284 ± 5.626 years). Multifactorial analysis revealed that age, the NRS2002 score, and length of hospital stay significantly influenced in-hospital mortality among older inpatients (P < 0.05). The results also showed that higher NRS2002 scores were associated with an increased risk of in-hospital mortality in both the unadjusted (OR = 1.731,95%CI = 1.362-2.20, P < 0.0001), adjusted model I (OR = 1.736, 95% CI = 1.354-2.206, P < 0.0001) and model II (OR = 1.602, 95% CI = 1.734-2.488, P = 0.0005). The optimal NRS2002 threshold for predicting in-hospital mortality in older inpatients was 3.5, with the largest ROC area of 0.84.

CONCLUSION

Our findings indicated that nutritional risk was an independent predictor of in-hospital mortality, with a cut-off value of 3.50 for the NRS2002 nutritional risk assessment being more appropriate than a cut-off value of 3.0.

Food, nutrition and dining information on residential aged care facility websites: A website analysis

OBJECTIVE

High-quality food, nutrition and dining are essential tenets of residential aged care facilities (RACF). Residential aged care facilities provide website information on their services for prospective residents, which may offer insight into food, nutrition and dining practices. This study aimed to describe the food, nutrition and dining information on RACF websites.

METHODS

A cross-sectional website analysis was conducted on Southeast Queensland (SEQ) RACF websites. Food, nutrition and dining data were extracted verbatim under domains of nutrition care processes, food and menu planning, eating assistance and mealtime experiences, with further subdomains under each. Quantitative content analysis was conducted to describe the information reported on websites, descriptive statistics were used to describe RACF characteristics, and Pearsons χ2 analyses were performed to detect associations between different food, nutrition and dining practices and RACF characteristics.

RESULTS

A total of 268 websites were reviewed. Food, nutrition and dining information were limited, with no subdomains mentioned by all websites. The most frequently mentioned subdomains were the foodservice model (64%, n = 171), allied health services (72%, n = 173) and communal dining (73%, n = 193). Assistive/adaptive equipment to support independence (0%, n = 0), personalised nutrition care plan (0%, n = 1) and reference to food, nutrition or food safety standards (2%, n = 5) were the least mentioned subdomains. Facility characteristics had minimal associations with subdomains.

CONCLUSIONS

There are opportunities for RACF to improve the information on food, nutrition and dining information on websites to increase transparency to future residents. The subdomains developed in this study could provide guidance to RACF to enhance online information.

Immunonutrition in Acute Geriatric Care: Clinical Outcomes, Inflammatory Profiles, and Immune Responses

BACKGROUND AND AIMS

Malnutrition is common in acutely ill geriatric patients, worsening immune function and clinical outcomes. Immunonutrition, containing nutrients like omega-3 fatty acids, arginin and glutamine, may improve recovery in this population. This study aimed to evaluate the impact of immunonutrition on clinical outcomes, inflammatory markers, and immune responses in frail, hospitalized older adults.

METHODS

This is a retrospective observational study. In total, 36 subjects, during hospitalization, received either an immunonutrition formula or isoproteic and isocaloric enteral nutrition. The primary outcome was the length of hospital stay (LOS), with secondary outcomes focused on inflammatory cytokines and immune parameters within a week of hospitalization.

RESULTS

Patients were primarily oldest-old, with a mean age of 88.6 years ± 4.9 (range 79-96). The immunonutrition group had a significantly shorter LOS (11.37 ± 4.87 vs. 16.82 ± 10.83 days, p = 0.05) and showed increases in key cytokines (G-CSF, INF-α2, IL-12p70, IL-15, IL-2, and IL-3, p < 0.05) enhanced immune function. A decrease in T cells and an increased B/T cell ratio was also observed. No significant differences in infection rates or 90-day survival were found.

CONCLUSIONS

Enteral immunonutrition improved clinical outcomes by reducing LOS and modulating immune responses in frail patients, suggesting potential benefits in recovery. Further studies are needed to confirm these findings.

Healthcare professionals' experience with nutritional care beyond formal quality systems - A qualitative study

BACKGROUND

Numerous formal strategies, screening tools, and interventions have been used to prevent malnutrition in long-term care patients. Despite these efforts, the proportion of screened patients is low, and a large proportion are malnourished. Previous research has revealed that healthcare professionals use a broad approach in their nutritional care but has also emphasised the need for further investigation into these approaches.

OBJECTIVE

To explore how healthcare professionals working in long-term care experience and apply nutritional care.

DESIGN

A descriptive, exploratory, qualitative design containing 240 h of participant observation, 12 focus groups and 2 individual interviews.

SETTING(S)

Twelve nursing homes and home care units in three Norwegian municipalities.

PARTICIPANTS

Participant observation of interactions between healthcare professionals and patients. Forty-three registered nurses participated in focus group or individual interviews.

METHODS

The data were analysed using inductive thematic analysis.

RESULTS

The analysis identified three themes: The first theme, limited significance of nutritional screening, showed that healthcare professionals experienced the limited value of nutritional screening, as it often did not capture patients' nutritional challenges. They also perceived nutritional screening as unsuitable for patients at the end of their lives, those with overweight-related complications, or undergoing rehabilitation. In addition, nutritional screening was perceived as something healthcare professionals did for their managers or administrators, not because it was crucial to providing good nutritional care. The second theme, provision of individualised food, captures the healthcare professionals' efforts in adapting and preparing food according to the patient's preferences. Facilitation to enable patients to make individual food choices and the use of food cards or lists were two approaches to individualising nutrition care. The third theme, making meals more than about food, elucidated how healthcare professionals used meals to help patients cope with their situations and experience social belonging. Conversations about or around meals were used to provide patients with a sense of belonging to their past or present situation. The meals were also used as a diversion strategy for patients with unrest, as arenas for daily activity training, and for meaningful social interactions between patients around the tables.

CONCLUSIONS

Nutritional screening and prevention of malnutrition are only one part of healthcare professionals' nutritional care. Individualised food and meals that create coping, a sense of belonging, and social experiences are equally important parts of their care. Emphasising healthcare professional's person-centred approach to nutritional care would be beneficial, as it could strengthen and further develop long-term nutritional care services.

Enhanced Nutritional and Functional Recovery in Femur Fracture Patients Post-Surgery: Preliminary Evidence of Muscle-Targeted Nutritional Support in Real-World Practice

Background/Objectives: To describe the effects of muscle-targeted oral nutritional supplementation (MT-ONS) on nutrition, functional capacity, and other health outcomes in patients after femur fracture surgery. Methods: A prospective, open-label, single-centre study was conducted. Patients aged 80+ post-femur fracture were recruited. They were assessed at baseline and after 90 days with MT-ONS, 100% whey protein enriched with leucine and vitamin D. Demographics, clinical and nutritional status (MNA®-SF), functional capacity [Barthel Index (BI), Lawton and Brody (LB) scale], muscle strength (dynamometry), cognition [Global Deterioration Scale (GDS)], tolerability, and satisfaction data were collected. Descriptive statistics were performed. Ethical approval was obtained. Results: Thirty-one patients (74% women, mean age 87 ± 3.99 years) were enrolled. At baseline, 32% were malnourished and 65% were at risk. After ≥90 days of MT-ONS, malnutrition decreased to 13% and well-nourishment increased to 32%. Ninety percent gained weight, with significant muscle strength improvements (+2 kg, p < 0.001). Eighty-one percent achieved a BI score ≥ 60 points [mean 84.8 (±17.82)]. BI score improvements correlated with higher baseline muscle strength (rho = 0.413, p = 0.021) and better nutritional status (rho = 0.464, p = 0.009). The mean LB score was 4.84 (±2.26). Improvements correlated with the pre-fracture BI score (rho = 0.475, p = 0.007). Positive correlations were noted between nutritional status, muscle strength, and functional outcomes. Cognition remained stable (GDS = 1 in 67.7% patients). Tolerability and satisfaction with MT-ONS were high at 90%. Conclusions: MT-ONS, 100% whey protein enriched with leucine and vitamin D, for ≥90 days enhances nutritional status and functional recovery in patients after femur fracture surgery.

Associations between malnutrition and dehydration among older adults: A cross-sectional observational study

BACKGROUND

There is debate as to the association between dehydration and malnutrition. Thus, this study aimed to investigate the correlation between dehydration and malnutrition and their impact on geriatric syndromes.

METHODS

This cross-sectional study included older adults (≥60 years) who attended one outpatient geriatric clinic. Malnutrition was defined according to the Mini Nutritional Assessment (MNA) score (<17), and dehydration was based on a single calculation method (plasma osmolarity [Posm] > 295 mmol/L).

RESULTS

Among the 1409 patients studied, the prevalence of malnutrition and dehydration was 19% and 33%, respectively. The rate of malnutrition in the setting of dehydration was 18%, and the rate of dehydration in patients with malnutrition was 30% (P > 0.05). Polypharmacy, hypertension, diabetes mellitus, and higher body mass index (BMI) were associated solely with dehydration, whereas older age, a lower level of education, depression, and lower BMI were associated solely with malnutrition. Among patients with dehydration, there was a significant negative correlation between the MNA and Posm (P < 0.001, r = -0.20). Inversely, among patients without dehydration, the correlation was positive and significant (P < 0.001, r = 0.14).

CONCLUSION

A negative correlation was found between the MNA score and Posm in patients with dehydration, whereas the correlation is positive among patients without dehydration. This inverse relationship between the MNA score and Posm in patients with different levels of hydration is one potential reason for the lack of a significant correlation between malnutrition and dehydration in previously reported studies. Different risk factors of malnutrition may predominate in settings of dehydration vs no dehydration.

The ability of GLIM and MNA-FF to diagnose malnutrition and predict sarcopenia and frailty in hospitalized adults over 60 years of age

Introduction

Malnutrition remains common in adults over 60 years old. Although there are screening and diagnostic tools for malnutrition, there is no globally used approach to diagnosing malnutrition in older adults admitted to the hospital. In this study, we verified the agreement between the Global Leadership Initiative on Malnutrition (GLIM) and the Mini Nutritional Assessment (MNA) and the ability of the instruments to identify frailty and sarcopenia associated with malnutrition.

Methods

For adults over 60 years old, malnutrition diagnosis was performed using the Mini Nutritional Assessment Full Form (MNA-FF) tool and the GLIM criteria, which included calf circumference and fat-free mass index to assess muscle mass, with and without the Mini Nutritional Assessment Short Form (MNA-SF) screening. Health conditions were assessed in older adults, and the association of these conditions with malnutrition was analyzed using both tools.

Results

A total of 432 adults over 60 years old were investigated with a mean age of 71.14 ± 8 years. The GLIM criteria with the nutritional screening tool identified 61-63% of older adults as malnourished. Of these, 63-64% were severely malnourished. The MNA-FF tool classified 20% of those assessed as malnourished. The agreement between the MNA-FF and GLIM was better with the use of screening, with a kappa (K) value of -0.10 and - 0.11. Sarcopenia was associated with malnutrition as identified by the MNA-FF (OR: 3.08, 95% CI: 1.84-5.14) and only by the GLIM ANTHRO (OR: 1.66, 95% CI: 1.05-2.63). Frailty was associated with the MNA-FF (OR: 15.99, 95% CI: 2.16-118.36), GLIM ANTHRO (OR: 2.21, 95% CI: 1.31-3.71), and GLIM BIA (OR: 2.45, 95% CI: 1.45-4.12).

Conclusion

It is possible to verify that divergent conceptual frameworks are used to understand malnutrition by the MNA-FF and GLIM and that the GLIM obtained a greater number of malnutrition diagnoses. Both the GLIM ANTHRO and the MNA-FF associated malnutrition with frailty and sarcopenia, with higher hazard ratios for the MNA-FF.

Describing Community-Based Nurses' Knowledge, Attitudes, and Practices in the Nutritional Care of Older Adults: Results of a UK Survey

PURPOSE

To ascertain current nutritional knowledge and training needs of community-based nurses caring for older adults in the United Kingdom.

METHOD

A descriptive cross-sectional, anonymized, online survey of nurses' knowledge, attitudes, and practices related to older adults' nutrition was developed. Community-based nurses working with older adults in the United Kingdom were recruited via social media and convenience sampling.

RESULTS

Responses were received from 194 community-based nurses. Nutritional care was seen as a multidisciplinary responsibility by 62% of participants. Most undertook nutrition screening (93%), were confident in providing nutritional advice (83%), and ease of identifying those in need (88%) was high. However, some aspects of nutritional knowledge were less complete, including recommended daily intakes of protein (60% unsure) and fiber (52% unsure).

CONCLUSION

High confidence in delivering nutritional advice contrasted with uncertainty around some aspects of nutritional knowledge, suggesting opportunities to improve training on the nutritional needs of older adults. [Journal of Gerontological Nursing, 50(11), 13-19.].

Pharmacological Treatment of Obesity in Older Adults

Obesity is a complex health issue with growing prevalence worldwide. It is also becoming more prevalent in the population of older adults (i.e., 65 years of age and older), affecting frequency and severity as well as other comorbidities, quality of life and consequently, life expectancy. In this article we review currently available data on pharmacotherapy of obesity in the population of older adults and its role in obesity management. Even though there is growing evidence, in particular in the general population, of favourable efficacy and safety profiles of glucagon-like peptide-1 (GLP-1) receptor agonists liraglutide and semaglutide, and recently dual GLP-1 and glucose-dependent insulinotropic polypeptide (GIP) agonist tirzepatide, concise guidelines for older adults are not available to this day. We further discuss specific approaches to frequently represented phenotype of obesity in older adults, in particular sarcopenic obesity and rationale when to treat and how. In older adults with obesity there is a need for more drug trials focusing not only on weight loss, but also on geriatric endpoints including muscle mass preservation, bone quality and favourable fat distribution changes to get enough data for evidence-based recommendation on obesity treatment in this growing sub-population.

[PAPPS update on older people 2024]

Population aging is a global phenomenon that is increasing the proportion of older people, particularly those over 80 years old. This increase in longevity does not always translate into years of good quality of life. This document reviews the latest evidence on the main preventive activities for older adults, starting with major geriatric syndromes such as frailty, cognitive impairment, and social isolation. It evaluates direct interventions in nutrition, deprescription, and physical exercise. Additionally, for the first time, it includes an analysis of preventive activities related to suicide in older adults, coordinated with mental health promotion programs. Frailty, defined as the progressive deterioration of physiological systems, is a significant predictor of adverse health events and is considered potentially reversible, especially in its early stages. The diagnosis and management of frailty through comprehensive geriatric assessment (CGA) and the implementation of specific interventions such as multicomponent exercise, adequate nutrition, and medication review are key to improving the functionality and quality of life of older adults.

Twelve hot questions in the management of hypertension in patients aged 80+ years and their answers with the help of the 2023 European Society of Hypertension Guidelines

Arterial hypertension is a major risk factor for cardiovascular morbidity and mortality, and highly prevalent in older age, underscoring the importance of its appropriate management. The population is ageing at an increasing rate, with those aged 80+ years being the fastest growing population characterized by high heterogeneity in terms of functionality and autonomy. The prevalence of hypertension rises with increasing age, due to a significant increase in SBP largely as a result of age-related stiffening of the aorta and other large arteries, affecting almost 80% of those aged 80+ years. Appropriate management of blood pressure in this population is a priority for clinicians. Frailty is a condition characterized by marked vulnerability to adverse health outcomes and is common among older adults including those with hypertension. Hypertension increases frailty level and at the same time, individuals with increasing frailty present with more drug-related adverse effects meaning they are less tolerant to blood pressure lowering by medication. Thus, frailty is a factor that should be integrated when treating hypertension in this population. The European Society of Hypertension 2023 Guidelines on the management of Hypertension are the first international guidelines to integrate the concept of adapting blood pressure management in older adults according to their frailty/functionality level, and to propose practical tools for the application of this concept in the daily practice of physicians and other healthcare professionals. The present article prepared by the European Society of Hypertension Working Group on Hypertension in Older Adults aims to further address some important aspects mentioned concisely in the 2023 European Society of Hypertension guidelines, in order to help physicians and other healthcare professionals including those practicing in primary care. To this end, this study discusses 12 'hot questions' which are answered with the help of the 2023 European Society of Hypertension Guidelines. We hope the present article and Working Group's actions will contribute to understanding and applying the ideal management of hypertension in this most vulnerable population.

Malnutrition and Fall Risk in Older Adults: A Comprehensive Assessment Across Different Living Situations

BACKGROUND

Malnutrition among older adults is associated with numerous adverse effects, including increased morbidity, mortality, prolonged hospital stays, and a heightened risk of falls. This study aims to investigate the prevalence of malnutrition in different groups of older adults using the F-MNA, anthropometry, and s-albumin and the association between nutritional status and fall risk.

METHODS

A total of 228 participants aged 60 years and older were divided into three groups: (1) patients in an internal medicine ward, (2) individuals living in family homes, and (3) residents of care homes. Disease profiles, nutritional status (assessed using the F-MNA and SNAQ), body composition, fall risk, and biochemical markers were evaluated.

RESULTS

The results indicated the highest prevalence of malnutrition among hospitalized individuals. Fall risk was associated with age, calf circumference, the F-MNA, the SNAQ, serum albumin levels, residence in a care home, comorbidities, and the number of medications taken daily. Regression analysis revealed that age, calf circumference, and residence in a care home were independent predictors of fall risk in older adults.

CONCLUSION

Older adults are at significant risk of malnutrition, with the risk notably increasing during hospitalization and long-term stays in care homes. Hospitalized individuals had the poorest nutritional status and were at significant risk of further weight loss, underscoring the importance of post-discharge care and rehabilitation.

Oral Nutritional Supplementation in Older Adults with a Hip Fracture-Findings from a Bi-National Clinical Audit

BACKGROUND/OBJECTIVES

Evidence-based guidelines and care standards recommend offering oral nutrition supplements to all older adults with hip fracture, not just those already malnourished. This study aimed to identify the proportion of inpatients in a sample of hospitals in two countries that were provided with oral nutritional supplementation (ONS) following a hip fracture and to identify factors associated with ONS provision.

METHODS

An analysis of prospectively collected data from a bi-national Hip Fracture Registry nutrition sprint and registry audit data limited to older adults (≥65 years) undergoing surgical intervention for a fractured hip from 1 to 31 August 2021. Multivariable logistic regression was used to identify factors associated with providing ONS.

RESULTS

Patient-level data was available for 385 older adults (median 85 years; 60.5% female) admitted to twenty-nine hospitals. Less than half (n = 47.3%) of the audited inpatients were provided ONS. After adjusting for covariates, ONS was more likely to be provided to older adults who were identified as malnourished on formal testing (OR 11.92; 95%CI 6.57, 21.69). Other factors associated with prescription of ONS included those who did not have a preoperative medical assessment (OR 2.26; 95%CI 1.19, 4.27) or were cognitively impaired (OR 1.83; 95%CI 1.01, 3.32), severely frail, or terminally ill (OR 3.17; 95%CI 1.10, 9.17).

CONCLUSIONS

ONS was provided in line with evidence-based recommendations for less than half of the older adults with a hip fracture in 29 hospitals in two countries. A structured approach to implementation may be required to reduce complications and improve outcomes for all older adults after a hip fracture, not just those assessed as cognitively impaired, frail, and/or malnourished.

The relationship between oropharyngeal dysphagia and dehydration in older adults

BACKGROUND

Relationship between dysphagia and dehydration has not been studied widely. The aim of this study is to determine the frequency of dysphagia and dehydration in geriatric outpatient clinic, to evaluate the relationship between these two conditions.

METHODS

The cross-sectional study included 1345 patients. Plasma osmolarity (Posm) was calculated using the following formula: [1.86 x (Na + K) + 1.15 x glucose + urea + 14]. Overt dehydration was defined as a calculated Posm of > 300 mmol/L. Eating Assessment Tool (EAT-10) score of ≥ 3 was accepted as dysphagia. Associations between dehydration and dysphagia was evaluated.

RESULTS

Mean age was 78 ± 8 years, and 71% were females. Dysphagia was observed in 27% of patients. Dysphagia was associated with a higher number of drug exposure, dependency on basic activities of daily living and geriatric depression (p < 0.05). Overt dehydration was found in 29% of patients with dysphagia, and 21% of patients with no dysphagia (p = 0.002); and dysphagia was significantly associated with overt dehydration mmol/L (OR 1.49, 95% CI 1.13-1.96, p = 0.005) after adjustments for age and sex. In another model, EAT-10 score was found as one of the independent predictors of overt dehydration (OR1.03, 95% CI 1.00-1.06, p = 0.38), along with diabetes mellitus (OR 2.32, 95% CI 1.72-3.15, p < 0.001), chronic kidney disease (OR 3.05, 95% CI 2.24-4.15, p < 0.001), and MNA score (OR 0.97, 95% CI 0.94-1.00, p = 0.031).

CONCLUSION

EAT-10 scale was independently associated with overt dehydration among older adults, as MNA score was. Correction of both dysphagia and malnutrition might improve overt dehydration to a better extent than correction either of these factors alone. Future studies are needed to test cause and effect relationships.

A Review on In Vivo Research Dehydration Models and Application of Rehydration Strategies

Background: Dehydration, a common condition where the amount water lost from the body exceeds intake, disrupts metabolic processes and negatively impacts health and performance. Rehydration, the process of restoring body fluids and electrolytes to normal levels, is crucial for maintaining physiological health. In vivo dehydration models are experimental systems used to study the effects of dehydration on living organisms. However, a comprehensive summary of in vivo models and the application of human rehydration strategies is lacking. Methods: This review provides a comprehensive overview of various in vivo models and rehydration strategies. Results: In vivo models, stimulated by fluid restriction, exercise, thermal exposure, and chemicals, have been used to study dehydration. Importantly, the principles, characteristics, and limitations of the in vivo models are also discussed, along with rehydration administration methods, including oral, intestinal, intravenous, subcutaneous, and intraperitoneal routes. Additionally, rehydration strategies and the application for managing different dehydration conditions both in daily life and clinical settings have been summarized. Conclusions: Overall, this review aims to enhance the understanding of the conditions in which in vivo dehydration models and rehydration strategies are applicable, thereby advancing research into the physiological and pathological mechanisms of dehydration and supporting the development of effective rehydration therapies.

Analysis of Hydration Habits Before and During a Specific Training Session in Male Padel Athletes Aged over 65: Physiological and Psychological Implications

(1) Background: Since older adults are more susceptible to dehydration and there is a lack of information on older athletes, this study observed a group of 12 male padel players in this age group (70.42 ± 3.50 years) to characterize their hydration habits, physiological demands, and psychological responses before and during a 90 min padel training (PT). (2) Methods: After approval from the Ethics Committee (CE/FCDEF-UC/00022023) and the provision of signed informed consent, participants' body mass, height, waist and hip circumferences, body mass index, waist-to-hip ratio, and waist-to-height ratio were measured. Habitual fluid intake was monitored by diary from the evening until before the PT; the subjects completed a Profile of Mood States questionnaire (POMS) and a satiety scale (SLIM). To assess hydration levels at different moments, we used a portable osmometer and an eight-point urine color chart and weighed the participants immediately before and after the PT. During the PT, heart rate (HR) and hydration were monitored. After the PT, subjects completed another POMS and SLIM. (3) Results: Subjects trained at 73.2 ± 12.3% of their maximum HR, with brief peaks at the anaerobic threshold or higher (130.00 ± 18.78 bpm). The mean urine osmolality indicated normal hydration or minimal dehydration. However, the urine color values indicated dehydration after the training. Subjects drank 438 mL of liquids at night, 333 mL before PT, and 900 mL during the PT, with a good repartition of the liquids. POMS and SLIM were not affected by the training. (4) Conclusions: Older male padel athletes achieved challenging yet safe training, staying within healthy intensity zones; their hydration patterns nearly met the recommendations for exercise and should be slightly increased.

The Role of Nutrition in the Nursing Management of Pressure Ulcers in Adult Community Settings: A Systematic Review Protocol

BACKGROUND

The aging population drives a growing demand for care, particularly in Europe. It is estimated that approximately 1.5-2 million individuals have a chronic wound. Among these, pressure ulcers (PUs) are one of the most prevalent complications in vulnerable individuals. Malnutrition is a primary risk factor, yet it can be mitigated through proper nutrition and adequate community support. The community nurse plays a crucial role in managing chronic conditions and nutrition through constant and professional monitoring.

AIM

This article presents a comprehensive systematic review (SR) protocol to examine the role of community nursing of nutritional intervention of frail population with wound care.

METHODS

A SR will be conducted according to international standards and reported following the PRISMA Guidelines for SRs. The search will be conducted in PubMed/Medline, Scopus, Embase, and CINAHL, supplemented by grey literature sources. The methodological quality and risk of bias will be assessed using the Critical Appraisal Skills Programme (CASP) framework. The protocol has been registered in the Open Science Framework (OSF).

CONCLUSIONS

It is anticipated that the findings of this SR will provide new evidence on the relationships between nutritional nursing interventions and wound care management primarily in the community setting.

Nutritional Support and Physical Activity Intervention Programs with a Person-Centred Approach in People with Chronic Obstructive Pulmonary Disease: a Scoping Review

Background

The knowledge is sparse in the literature on intervention programs using nutritional support and physical activity for patients with chronic obstructive pulmonary disease within a person-centred approach. We aimed to explore and map the existing evidence on intervention programs with a person-centred approach, focusing on nutritional support and physical activity for people with COPD.

Methods

A scoping review was conducted using Arksey & O'Malley's methodological framework. A search in the databases CINAHL and PubMed, and a grey literature search, was conducted in June 2022 and updated in June 2023. We identified studies published between 2012 and 2023. The PRISMA checklist for scoping reviews, supported by The PAGER framework was used for reporting the method.

Results

A total of 15 studies were included. The primary interventions comprised behavior of change or self-management, addressing needs assessment, motivation, personal goals, education, and physical activity. Health-related quality of life and hospital stay displayed no clinically significant variances. However, eight studies demonstrated differences in physical function and activity levels. Nutritional outcomes were addressed in one study, and three studies involved relatives.

Conclusion

This scoping review addresses a knowledge gap in nutritional support interventions with a person-centred approach. It indicates that there is a need to increase nutritional support and consider the patient's physical and social environmental resources within Behavior of change or Self-management intervention programs for patients with COPD. The review found no clinical effect on health-related quality of life, although there were some effects on physical activity. The results highlight how the interdisciplinary team can include the patients' resources when structuring the management of COPD by applying a person-centred approach.

Feeding Assistance Skill Score: development and verification of reliability and validity

PURPOSE

Feeding assistance should be safe and improve the assisted individual's ability to feed, yet objective tools for evaluating these skills are lacking. This study focuses on developing a tool for assessing feeding assistance skills.

METHODS

A group consisting of 25 experts employed the Delphi method to achieve a consensus on the essential items necessary for assessing feeding assistance skills. Subsequently, a draft score using a three-point scale was developed. To test the reliability of the draft scores, a group of 20 patients and 20 nurses was matched to record a meal assistance scene, which were independently evaluated by three raters. We computed the AC1 statistic to assess both intra- and inter-rater reliability, and further examined correlations between the Feeding Assistance Skill Score (FASS) scores and outcome items to verify validity.

RESULTS

Initially, an 18-item draft score was generated using the Delphi method. Subsequently, seven items were omitted from the intra- or inter-rater reliability analysis. Furthermore, after discussion, researchers removed one item that assessed food cognition, because the agreement score between the two items was 91%. Finally, the 10-item FASS was developed, showing a correlation with dietary intake upon validation.

CONCLUSIONS

We successfully developed a scoring system for peer evaluation of feeding assistance skills. Future studies should aim to validate the FASS. The implementation of the FASS aims to assess the effectiveness of feeding assistance training and care quality, potentially improving safety and satisfaction for those receiving feeding assistance.

Associations between in-hospital daily protein intake and adverse clinical outcomes in older patients with heart failure

AIMS

The adverse effects of low daily protein intake (DPI) on clinical outcomes in patients with heart failure (HF) are known; however, an optimal DPI to predict event adverse outcomes remains undetermined. Moreover, whether protein restriction therapy for chronic kidney disease is applicable in patients with HF and renal dysfunction remains unclear.

METHODS AND RESULTS

In this single-centre, ambispective cohort study, we included 405 patients with HF aged ≥65 years (mean age, 78.6 ± 7.5 years; 50% women). DPI was estimated from consumption over three consecutive days before discharge and normalized relative to the ideal body weight [IBW, 22 kg/m2 × height (m)2]. The primary outcome was a composite of all-cause mortality and HF-related readmission within the 2 year post-discharge period.

RESULTS

During an average follow-up period of 1.49 ± 0.74 years, 100 patients experienced composite events. Kaplan-Meier survival curves revealed a significantly lower composite event-free rate in patients within the lowest quartile of DPI than in the upper quartiles (log-rank test, P = 0.02). A multivariate Cox proportional hazards analysis after adjusting for established prognostic markers and non-proteogenic energy intake revealed that patients in the lowest DPI quartile faced a two-fold higher risk of composite events than those in the highest quartile [hazard ratio (HR), 2.03; 95% confidence interval (CI), 1.08-3.82; P = 0.03]. The composite event risk linearly increased as DPI decreased (P for nonlinearity = 0.90), with each standard deviation (0.26 g/kg IBW/day) decrease in DPI associated with a 32% increase in composite event risk (HR, 1.32; 95% CI, 1.10-1.71; P = 0.04). There was significant heterogeneity in the effect of DPI, with the possible disadvantage of lower DPI in patients with HF with cystatin C-based estimated glomerular filtration rate <30 mL/min/1.73 m2. The cutoff value of DPI for predicting the occurrence of composite events calculated from the Youden index was 1.12 g/kg IBW/day. Incorporating a DPI < 1.12 g/kg IBW/day into the baseline model significantly improved the prediction of post-discharge composite events (continuous net reclassification improvement, 0.294; 95% CI, 0.072-0.516; P = 0.01).

CONCLUSIONS

Lower DPI during hospitalization is associated with an increased risk of mortality and HF readmission independent of non-proteogenic energy intake, and the possible optimal DPI for predicting adverse clinical outcomes is >1.12 g/kg IBW/day in older patients with HF. Caution is warranted when protein restriction therapy is administered to older patients with HF and renal dysfunction.

Emerging Targets and Treatments for Sarcopenia: A Narrative Review

BACKGROUND

Sarcopenia is characterized by the progressive loss of skeletal muscle mass, strength, and function, significantly impacting overall health and quality of life in older adults. This narrative review explores emerging targets and potential treatments for sarcopenia, aiming to provide a comprehensive overview of current and prospective interventions.

METHODS

The review synthesizes current literature on sarcopenia treatment, focusing on recent advancements in muscle regeneration, mitochondrial function, nutritional strategies, and the muscle-microbiome axis. Additionally, pharmacological and lifestyle interventions targeting anabolic resistance and neuromuscular junction integrity are discussed.

RESULTS

Resistance training and adequate protein intake remain the cornerstone of sarcopenia management. Emerging strategies include targeting muscle regeneration through myosatellite cell activation, signaling pathways, and chronic inflammation control. Gene editing, stem cell therapy, and microRNA modulation show promise in enhancing muscle repair. Addressing mitochondrial dysfunction through interventions aimed at improving biogenesis, ATP production, and reducing oxidative stress is also highlighted. Nutritional strategies such as leucine supplementation and anti-inflammatory nutrients, along with dietary modifications and probiotics targeting the muscle-microbiome interplay, are discussed as potential treatment options. Hydration and muscle-water balance are emphasized as critical in maintaining muscle health in older adults.

CONCLUSIONS

A combination of resistance training, nutrition, and emerging therapeutic interventions holds potential to significantly improve muscle function and overall health in the aging population. This review provides a detailed exploration of both established and novel approaches for the prevention and management of sarcopenia, highlighting the need for further research to optimize these strategies.

Novel Insights into Diabetic Kidney Disease

Diabetic kidney disease (DKD) is a major complication of diabetes mellitus (DM), affecting over one-third of type 1 and nearly half of type 2 diabetes patients. As the leading cause of end-stage renal disease (ESRD) globally, DKD develops through a complex interplay of chronic hyperglycemia, oxidative stress, and inflammation. Early detection is crucial, with diagnosis based on persistent albuminuria and reduced estimated glomerular filtration rate (eGFR). Treatment strategies emphasize comprehensive management, including glycemic control, blood pressure regulation, and the use of nephroprotective agents such as angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), sodium-glucose cotransporter-2 (SGLT2) inhibitors, and glucagon-like peptide-1 (GLP-1) receptor agonists. Ongoing research explores novel therapies targeting molecular pathways and non-coding RNAs. Preventive measures focus on rigorous control of hyperglycemia and hypertension, aiming to mitigate disease progression. Despite therapeutic advances, DKD remains a leading cause of ESRD, highlighting the need for continued research to identify new biomarkers and innovative treatments.

Time for a Re-Think? The Rationale for Multi-Component Intervention to Prevent Malnutrition in At-Risk Community-Dwelling Older Adults

Dietary strategies for early intervention in older adults are highly desirable, as they encourage individuals to retain a good functional status despite morbidity [...].

Oral Protein Supplements Might Improve Nutritional Status and Quality of Life in Elderly Patients after Standard Pancreatic Resection

Elderly patients who undergo pancreaticoduodenectomy (PPPD) or distal pancreatectomy (DP) experience not only a reduction in protein intake but also a decrease in protease secretion, leading to impaired protein digestion and absorption. This increases the risk of malnutrition and creates a dual burden of sarcopenia. This randomized, double-blind, placebo-controlled trial examined the impact of protein supplements on the nutritional status and quality of life (QoL) of elderly patients after PPPD and DP surgeries. For six weeks, the case group (CG; n = 23) consumed protein supplements containing 18 g of protein daily, while the placebo group (PG; n = 18) consumed a placebo with the same amount of carbohydrate. In elderly patients where protein digestion and intake were compromised, the CG showed significantly higher protein intake (77.3 ± 5.3 g vs. 56.7 ± 6.0 g, p = 0.049), improved QoL, better nutritional status, and faster walking speed compared to the PG. Protein intake was positively correlated with muscle mass and phase angle. Protein supplementation may not only increase protein intake but also improve clinical outcomes such as walking speed, nutritional status, and QoL in elderly post-surgical patients at high risk of sarcopenia. Further studies are needed to determine the optimal dosage and long-term effects.

Nutritional care in older adults: are we doing everything? An expert opinion review

Malnutrition is a prevalent, yet often underdiagnosed and undertreated, condition in older adults. It is characterized by weight loss and/or reduced muscle mass due to diminished caloric intake, inflammation, and/or disease burden. In return, malnutrition can lead to diminished skeletal muscle functionality and disability, among others. Malnutrition plays a crucial role in the pathogenesis of two prevalent geriatric syndromes, namely sarcopenia and frailty. The complex interplay between malnutrition, sarcopenia, and frailty significantly impacts the older population, leading to increased morbidity, mortality, hospitalization rates, quality-of-life, and healthcare costs. Given the prognostic significance of malnutrition in geriatric care, recent guidelines emphasized the role of nutritional support in vulnerable populations. A group of vulnerable populations to malnutrition, sarcopenia, and frailty are older patients with hip fractures, cancer patients, and those with sarcopenic dysphagia. This article highlights the importance of individualized nutritional assessment and treatment in the management of vulnerable populations such as older patients with hip fractures, cancer, and those suffering from sarcopenic dysphagia. It presents practical protocols and guidelines that can be instrumental in enhancing the nutritional care of these groups, thereby improving their overall health outcomes.

Safety and Effectiveness of Percutaneous Endoscopic Gastrostomy May Be Improved by Proper Pre- and Post-Positioning Management of Elderly Patients with Multimorbidity

INTRODUCTION

The main risk factors for major complications and early mortality after the positioning of percutaneous endoscopic gastrostomy (PEG) reported in the literature are old age, multimorbidity, and the use of inappropriate methods for PEG positioning. A proper PEG positioning technique and adequate post-positioning patient management and surveillance are the main protective factors, but the information on protective factors in the literature is much poorer. The aim of this study was to provide more information on PEG-related complications and mortality in geriatric patients treated with long-term enteral nutrition administered by PEG according to a specific home enteral nutrition (HEN) protocol.

METHODS

This was a retrospective study based on data from 136 elderly patients in whom PEG was positioned from 2017 to 2023 at the geriatric hospital IRCCS INRCA, Ancona (Italy), 88 of whom were treated with HEN. Data on PEG-related complications, duration of HEN, hospitalizations, and mortality were analyzed.

RESULTS

No complications were registered during or immediately after the PEG positioning. The prevalence of a major complication-buried bumper-was in the lower limit of the range reported in the literature (4.32%). The prevalence of minor complications such as peristomal leakage, inadvertent tube removal, and granulation tissue was higher than that reported in the literature (14.71%, 23.53%, 29.41%), while tube blockage and peristomal site infection were less frequent (8.82%, 38.23%). Three hospitalizations for PEG-related complications occurred. Both the all-cause 30-day mortality and within-two-months mortality were lower than those in the literature (1.92% and 3.84%).

CONCLUSIONS

The impact of the risk factors recognized by the literature on complications and mortality could be probably mitigated by improving the PEG placement techniques and pre- and post-PEG placement patient management practices. Data on the prevalence of complications and mortality must be interpreted in correlation to this information.

Geriatric syndrome awareness and its determinants in China: a cross-sectional study

BACKGROUND

This study aims to investigate the awareness rate of six common geriatric syndromes and related influencing factors among the older adults aged 65 and above in China.

METHODS

This is a multicenter cross-sectional study involving 6,653 participants aged 65 and older from four regions who completed a questionnaire on geriatric syndrome awareness. The questionnaire covered demographic data, health information, medication usage, and an assessment scale for knowledge of six geriatric syndromes (GS Awareness Scale).

RESULTS

A total of 6,653 respondents were surveyed, with 5,318 valid questionnaires collected (79.93%), including 1,311 from Zhejiang (24.7%), 1,356 from Beijing (25.5%), 1,373 from Sichuan (25.8%), and 1,278 from Fujian (24.0%). The highest awareness was for falls, with 3,295 individuals (62.0%), followed by dementia with 2,929 individuals (55.1%), malnutrition with 2,907 individuals (54.7%), frailty with 2,156 individuals (40.5%), urinary incontinence with 2,006 individuals (37.7%), and sarcopenia with 1,914 individuals (36.0%). Univariate analysis showed that factors such as region, age, marital status, living situation, educational level, source of respondents, income status, and smoking had statistically significant differences in awareness rates (P < 0.05). Multivariate logistic regression results indicated that the source of respondents significantly affected the awareness rates (P < 0.05), with the older adults from rural areas having an increased risk of lower awareness compared to urban areas; age also significantly influenced the awareness rates (P < 0.05), with older age groups (76-85, 86-95 years) having a higher risk of reduced awareness compared to those aged 65-75 years.

CONCLUSIONS

The awareness of common geriatric syndromes among the older adults population aged 65 years and older in China is notably low. Consequently, there exists a critical need to enhance the formulation of policies regarding geriatric syndromes across various regions, aiming to elevate health literacy among this demographic.

GLIM criteria-based identification of severe malnutrition and its relationship with the risk of mortality among older Chinese adults with arthritis or rheumatism

BACKGROUND

Malnutrition is a well-known risk factor for mortality among older adults. Arthritis and rheumatism are characterized by chronic inflammation and are also related to malnutrition as diagnosed using the Global Leadership Initiative on Malnutrition (GLIM) criteria. This study was thus developed to examine the associations linking malnutrition and all-cause death among older adults in China, employing the GLIM criteria to assess malnutrition.

METHODS

Two waves of the China Health and Retirement Longitudinal Study from 2013 and 2018 were used to conduct this study. Moderate malnutrition was defined as low BMI (< 18.5 and < 20 for individuals < 70 and 70 + years of age, respectively), an unintended 10-20% decrease in weight, or low muscle mass based on the sex-specific lowest 20% of the height-adjusted muscle mass as < 5.039 kg/m2 in women and < 6.866 kg/m2 in men. Severe malnutrition was defined as a > 20% unintended decrease in weight only or the combination of both low muscle mass and an unintended reduction of over 10% in weight. Associations between malnutrition and the risk of all-cause death were assessed through Cox regression analyses.

RESULTS

Overall, this study enrolled 1766 subjects 60 + years of age, of whom 57.36% (1033/1766) were female. Malnutrition was estimated to affect 418 (23.67%) of these individuals at baseline, with 21.06% and 2.60% affected by moderate and severe malnutrition, respectively. Over the 5-year follow-up, 189 of these individuals died. Covariate-adjusted Cox regression analyses confirmed a significant association between severe malnutrition and the risk of death in this cohort (HR = 2.196, 95%CI 1.125-4.286, P = 0.021).

CONCLUSIONS

Severe malnutrition, identified through screening based on the GLIM criteria, was associated with an increased risk of all-cause death among older Chinese adults with arthritis or rheumatism.

Nutritional support in hospitalised patients with diabetes and risk for malnutrition: a secondary analysis of an investigator-initiated, Swiss, randomised controlled multicentre trial

OBJECTIVES

The main objective of this study was to investigate the effects of nutritional support on mortality in hospitalised patients with diabetes and nutritional risk participating in the Effect of early nutritional support on Frailty, Functional Outcomes, and Recovery of malnourished medical inpatients Trial (EFFORT) trial.

DESIGN

Secondary analysis of a Swiss-wide multicentre, randomised controlled trial.

PARTICIPANTS

Patients with diabetes and risk for malnutrition.

INTERVENTIONS

Individualised nutritional support versus usual care.

PRIMARY OUTCOME MEASURE

30-day all-cause mortality.

RESULTS

Of the 2028 patients included in the original trial, 445 patients were diagnosed with diabetes and included in this analysis. In terms of efficacy of nutritional therapy, there was a 25% lower risk for mortality in patients with diabetes receiving nutritional support compared with controls (7% vs 10%, adjusted HR 0.75 (95% CI 0.39 to 1.43)), a finding that was not statistically significant but similar to the overall trial effects with no evidence of interaction (p=0.92). Regarding safety of nutritional therapy, there was no increase in diabetes-specific complications associated with nutritional support, particularly there was no increase in risk for hyperglycaemia (adjusted OR 0.97, 95% CI 0.56 to 1.67 p=0.90).

CONCLUSION

Patients with diabetes and malnutrition in the hospital setting have a particularly high risk for adverse outcomes and mortality. Individualised nutritional support reduced mortality in this secondary analysis of a randomized trial, but this effect was not significant calling for further large-scale trials in this vhighly ulnerable patient population.

TRIAL REGISTRATION NUMBER

NCT02517476.

Effects of a Specialized Oral Nutritional Supplement with Dietary Counseling on Nutritional Outcomes in Community-Dwelling Older Adults at Risk of Malnutrition: A Randomized Controlled Trial

This study investigated the effects of oral nutritional supplements (ONSs) along with dietary counseling (DC) in community-dwelling older adults at risk of malnutrition. In this randomized controlled trial, 196 older adults who were at risk of malnutrition, as identified by the Malnutrition Universal Screening Tool (MUST) were randomly assigned to receive ONSs twice daily with DC (intervention) or DC-only (control) for 60 days. Primary outcome was change in body weight from baseline to day 60. Nutritional status, energy, and macronutrient intakes were measured. A significant larger weight gain was observed in the intervention compared to the control from baseline to day 60 (1.50 ± 0.22 kg, p < 0.0001). The intervention group also showed a significantly greater increase in weight at day 30 (p < 0.0001). Intakes of energy and macronutrients were significantly higher in the intervention group compared to the control group at both days 30 and 60 (all p < 0.0001). The odds of achieving better nutritional status were significantly higher in the intervention group than in the control group (OR:3.9, 95% CI: 1.9, 8.2, p = 0.0001). ONS supplementation combined with DC significantly improved body weight and nutritional outcomes in community-dwelling older adults at risk of malnutrition.

Measuring calf circumference in frail hospitalized older adults and prediction of in-hospital complications and post-discharge mortality

Background

Sarcopenia, characterized by muscle mass, strength, and performance decline, significantly impacts outcomes in older adults. This study aims to assess the predictive value of calf circumference (CC), in conjunction with SARC-F and hand grip, concerning in-hospital complications and post-discharge mortality among hospitalized frail older adults.

Methods

A cohort of 158 hospitalized patients aged over 65 years underwent Comprehensive Geriatric Assessment and sarcopenia screening, including CC measurement. Multivariable regression analyses, adjusted for confounders, were conducted to assess predictive associations.

Results

The study cohort, comprising 53% males with a median age of 86 years, exhibited significant sarcopenia prevalence based on SARC-F (85% indicating sarcopenia), hand grip strength (probable sarcopenia in 77% of males and 72% of females), and CC (sarcopenia in 83%). Multivariate analysis, adjusting for age, sex, Clinical Frailty Scale (CFS), and Mini Nutritional Assessment-Short Form (MNA-SF), demonstrated associations of CC and SARC-F with in-hospital complications, while CC also showed a significant association with reduced risks of in-hospital mortality (OR 0.441, 95% CI 0.257 to 0.754, p = 0.003) and 90-day mortality (OR 0.714, 95% CI 0.516 to 0.988, p = 0.043).

Conclusion

This study provides insights into the predictive accuracy of sarcopenia screening tools on mortality in real-world hospitalized older adults with frailty. Notably, CC emerges as a robust predictor of mortality outcomes. Further research is warranted to validate and elucidate the respective contributions of CC and frailty to mortality in vulnerable populations.

The relationship between dehydration and etiologic subtypes of major neurocognitive disorder in older patients

PURPOSE

Studies investigating associations between etiologic subtypes of major neurocognitive disorder (MND) and dehydration frequency are lacking. The aim of this study was to investigate the prevalence and risk factors of dehydration among older adults with and without MND (dementia), and across different etiologic subtypes of MND.

METHODS

This cross-sectional study included adults aged ≥ 65 years old from one geriatric outpatient clinic. 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. MND was diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition criteria. The underlying etiologic subtypes were determined by specific diagnostic criteria.

RESULTS

Of the 1377 patients 72% were female, the mean age was 80 ± 8 years, and 575 had dementia. Dehydration was more common in patients with dementia than those without dementia (58% vs. 53%, p = 0.044). The prevelance of dehydration was 57%, 62%, 54%, 57% and 68% in Alzheimer's disease, Parkinson's disease dementia, fronto-temporal dementia, dementia with Lewy bodies, and vascular dementia, respectively (p ≥ 0.05). MND was associated with dehydration (OR 1.26, 95% CI 1.01-1.57; p = 0.037) after adjustment for age and sex. In multivariable analysis, among patients with dementia, hypertension, DM, CKD, and dysphagia were more common while mean Mini-Mental State Examination score was lower in those who had dehydration versus no dehydration in older patients with dementia (p < 0.05).

CONCLUSION

Dehydration is slightly associated with the presence of MND independent of age and sex. However, dehydration is also quite common in older patients without cognitive disorders. Therefore, hydration status should be monitored in older adults irrespective of neurocognitive status. Hypertension, DM, CKD, dysphagia and severity of cognitive dysfunction were associated with dehydration in patients with dementia. The prevalence of dehydration is highest in patients with vascular dementia.

Perioperative management of sarcopenia in patients undergoing major surgeries in Singapore: a modified Delphi consensus

BACKGROUND

Ageing population is a worldwide phenomenon with correspondingly higher proportion of older patients being treated in the hospital setting. Sarcopenia, which increases with age, has serious negative implications on health, hospitalisation, and overall postoperative recovery. There is no mutual consensus on perioperative management of sarcopenia in surgical patients in Singapore. The purpose of this study is to create greater clarity pertaining to the recognition of sarcopenia, the application of assessment criteria of sarcopenia and perioperative management of surgical patients in Singapore.

METHODS

A modified Delphi consensus consisting of a panel of experts from Singapore forming a multidisciplinary team, including surgeons, geriatricians, anesthesiologists, physiotherapists, and dieticians. Eight recommendations were proposed by the steering committee. Literature search from MEDLINE, Embase, and Scopus for articles up till June 2023 were performed to support recommendation statements. The expert panel voted on agreement to recommendation statements and graded the level of evidence supporting each statement through surveys to achieve consensus, set at 85% a priori.

RESULTS

The panellists underwent two rounds of anonymized, independent voting before reaching consensus for all eight statements. After the first round, seven statements reached consensus, including the corresponding grading for level of evidence. The statement which did not achieve consensus was revised with supporting literature and after the second round of survey, all eight statements and level of evidence reached consensus, completing the Delphi process. These eight statements covered themes to (1) encourage the identification of sarcopenia, (2) guide preoperative, and (3) postoperative management of sarcopenia.

CONCLUSION

With the varying approaches in perioperative management, poor understanding of and identification of sarcopenia can result in suboptimal management of sarcopenia in surgical patients. Given the abundance of evidence linking beneficial impact on recovery and postoperative complications with prudent management of sarcopenia, it is imperative and urgent to achieve awareness and consensus.

Effects of Oral Nutritional Supplement with β-Hydroxy-β-methylbutyrate (HMB) on Biochemical and Hematological Indices in Community-Dwelling Older Adults at Risk of Malnutrition: Findings from the SHIELD Study

Malnutrition may result in abnormal biochemical and hematological indices. This planned prespecified analysis investigated the effects of a specialized oral nutritional supplement (ONS) on biochemical and hematological indices in community-dwelling older adults at risk of malnutrition. In the Strengthening Health in ELDerly through nutrition (SHIELD) study, 811 older adults aged 65 years and above took part in this randomized, double-blind, placebo-controlled, multi-center study. Participants were randomly allocated to either a complete and balanced specialized ONS (each serving provides 262 kcal, 10.5 g protein, 7.75 µg vitamin D3, and 0.74 g calcium β-hydroxy-β-methylbutyrate) and dietary counselling (intervention group) or a placebo and dietary counselling (placebo group). Both groups consumed study products twice a day for 180 days. Data were collected at baseline, day 90, and day 180. Blood analysis results at follow-up visits were analyzed using repeated measures analysis of covariance with adjustments for confounders. Overall, when compared with the placebo group, the intervention group showed significantly greater urea (6.0 mmol/L vs. 5.4 mmol/L, p < 0.001), urea to creatinine ratio (4.39 vs. 4.26, p < 0.001), prealbumin (24.9 mg/dL vs. 24.0 mg/dL, p < 0.001), vitamin B12 (480.0 pmol/L vs. 420.1 pmol/L, p < 0.001), and globulin levels (26.8 g/L vs. 26.5 g/L, p = 0.032). The intervention group also had a significantly higher absolute reticulocyte count (62.0 × 103/µL vs. 58.2 × 103/µL, overall p < 0.001) and mean platelet volume (10.0 fL vs. 9.9 fL, overall p = 0.003). Furthermore, significant improvements were seen in total protein at day 90 (71.7 g/L vs. 71.1 g/L, p = 0.017) and in absolute monocyte count at day 90 (0.50 × 103/µL vs. 0.47 × 103/µL, p = 0.009) in the intervention group. In conclusion, daily consumption of a specialized ONS for six months led to significant improvements in biochemical and hematological indices in community-dwelling older adults at risk of malnutrition.

Dietary protein, amino acids and type 2 diabetes mellitus: a short review

Diabetes is a widespread metabolic disorder and results from insulin resistance and impaired insulin secretion. Modifiable factors like diet, physical activity, and body weight play crucial roles in diabetes prevention, with targeted interventions reducing diabetes risk by about 60%. High-protein consumption, above the recommended intake of 0.8 g/kg body weight per day, have often explored in relation to diabetes risk. However, the relationship between dietary protein and diabetes is multifaceted. Observational studies have linked high total and animal protein intake to an increased risk of type 2 diabetes, particularly in obese women. Elevated levels of branched-chain amino acids (BCAA), which can result from dietary intake, protein breakdown, as well as an impaired catabolism, are strong predictors of cardiometabolic risk and insulin resistance. With several mechanism linking BCAA to insulin resistance. On the other hand, intervention studies suggest that high-protein diets can support weight loss and improve cardiometabolic risk factors. However, the impact on insulin sensitivity and glucose homeostasis is not straightforward. Proteins and amino acids stimulate both insulin and glucagon secretion, influencing glucose levels, but chronic effects remain uncertain. This short narrative review aims to provide an update on the relationship between increased dietary protein intake, amino acids, insulin resistance and type 2 diabetes, and to describe protein recommendations for type 2 diabetes.

Characteristics of older adults receiving enteral feeding at a geriatric medical center

BACKGROUND

Malnutrition is a prevalent and hard-to-treat condition in older adults. enteral feeding is common in acute and long-term care. Data regarding the prognosis of patients receiving enteral feeding in geriatric medical settings is lacking. Such data is important for decision-making and preliminary instructions for patients, caregivers, and physicians. This study aimed to evaluate the prognosis and risk factors for mortality among older adults admitted to a geriatric medical center receiving or starting enteral nutrition (EN).

METHODS

A cohort retrospective study, conducted from 2019 to 2021. Patients admitted to our geriatric medical center who received EN were included. Data was collected from electronic medical records including demographic, clinical, and blood tests, duration of enteral feeding, Norton scale, and Short Nutritional Assessment Questionnaire score. Mortality was assessed during and after hospitalization. Data were compared between survivors and non-survivors. Multivariate logistic regressions were performed to identify the variables most significantly associated with in-hospital mortality.

RESULTS

Of 9169 patients admitted, 124 (1.35%) received enteral feeding tubes. More than half of the patients (50.8%) had polypharmacy (over 8 medications), 62% suffered from more than 10 chronic illnesses and the majority of patients (122/124) had a Norton scale under 14. Most of the patients had a nasogastric tube (NGT) (95/124) and 29 had percutaneous endoscopic gastrostomies (PEGs). Ninety patients (72%) died during the trial period with a median follow-up of 12.7 months (0.1-62.9 months) and one-year mortality was 16% (20/124). Associations to mortality were found for marital status, oxygen use, and Red Cell Distribution Width (RDW). Age and poly-morbidity were not associated with mortality.

CONCLUSION

In patients receiving EN at a geriatric medical center mortality was lower than in a general hospital. The prognosis remained grim with high mortality rates and low quality of life. This data should aid decision-making and promote preliminary instructions.

Skeletal muscle dysfunction with advancing age

As a result of advances in medical treatments and associated policy over the last century, life expectancy has risen substantially and continues to increase globally. However, the disconnect between lifespan and 'health span' (the length of time spent in a healthy, disease-free state) has also increased, with skeletal muscle being a substantial contributor to this. Biological ageing is accompanied by declines in both skeletal muscle mass and function, termed sarcopenia. The mechanisms underpinning sarcopenia are multifactorial and are known to include marked alterations in muscle protein turnover and adaptations to the neural input to muscle. However, to date, the relative contribution of each factor remains largely unexplored. Specifically, muscle protein synthetic responses to key anabolic stimuli are blunted with advancing age, whilst alterations to neural components, spanning from the motor cortex and motoneuron excitability to the neuromuscular junction, may explain the greater magnitude of function losses when compared with mass. The consequences of these losses can be devastating for individuals, their support networks, and healthcare services; with clear detrimental impacts on both clinical (e.g., mortality, frailty, and post-treatment complications) and societal (e.g., independence maintenance) outcomes. Whether declines in muscle quantity and quality are an inevitable component of ageing remains to be completely understood. Nevertheless, strategies to mitigate these declines are of vital importance to improve the health span of older adults. This review aims to provide an overview of the declines in skeletal muscle mass and function with advancing age, describes the wide-ranging implications of these declines, and finally suggests strategies to mitigate them, including the merits of emerging pharmaceutical agents.

Hydration status in adults with metabolic disorders in relation to socioeconomic, lifestyle and health factors

INTRODUCTION

Adequate hydration is essential for maintaining the health and functionality of the human body. This study aimed to examine the association between selected socioeconomic, lifestyle, and health factors and the hydration status of adults with metabolic disorders by analyzing their urine osmolality.

METHODS

The study involved 290 adults aged 18-70 years with metabolic disorders. Separate multivariate logistic regression models were conducted to evaluate the factors associated with urine osmolality in tertiles for women and men. Odds Ratios (OR) and 95% Confidence Intervals (95% CI) were calculated.

RESULTS

In women, the following factors of urine osmolality were identified in 1st tertile: age (OR:1.04), physical activity (moderate/high vs. no/low; OR:0.38), and headaches (no vs. yes; OR:1.55), in 2nd tertile: physical activity (moderate/high vs. no/low; OR:2.46) and fatigue during the day (sometimes vs. never/very rarely; OR:0.45), and in 3rd tertile: age (OR:0.94), professional status ('I work part-time/I study and I work' vs. 'I do not work/I study'; OR:0.27), fatigue during the day (very often vs. never/very rarely; OR:2.55), and headaches (no vs. yes; OR:0.44). In men, the following factors of urine osmolality were identified in 1st tertile: place of residence (city vs. village; OR:2.72) and health assessment (average vs. poor; OR:0.32).

CONCLUSION

Different factors affecting urine osmolality have been identified in women and men. These results highlight the need to implement studies to clarify the relationship between socioeconomic, lifestyle and health factors, and hydration status in adults with metabolic disorders.

Prevention of Chronic Kidney Disease and Its Complications in Older Adults

In an era marked by a global demographic shift towards an aging society, there is a heightened prevalence of chronic kidney disease (CKD) among older adults. The burden of CKD spans from kidney-related complications to impacting psychological well-being, giving rise to depressive symptoms and caregiver burnout. This article delves into CKD prevention strategies within the context of aging, contributing to the discourse by exploring its multifaceted aspects. The prevention of CKD in the older adults necessitates a comprehensive approach. Primary prevention is centered on the modification of risk factors, acknowledging the intricate interplay of various comorbidities. Secondary prevention focuses on early CKD identification. Tertiary prevention aims to address factors contributing to CKD progression and complications, emphasizing the importance of timely interventions. This comprehensive strategy aims to enhance the quality of life for individuals affected by CKD, decelerating the deterioration of functional status. By addressing CKD at multiple levels, this approach seeks to effectively and compassionately care for the aging population.

Nutrition of aging people with diabetes mellitus: Focus on sarcopenia

As populations age, chronic diseases accumulate, and new health conditions emerge. One noteworthy pair that warrants further evaluation is diabetes mellitus and sarcopenia, given that the latter occurs in 28 % of the population aged over 50 who have diabetes mellitus. The management of both entails nutritional interventions, making the development of unified dietary recommendations an alluring strategy. This review aims to elucidate the current recommendations for the combined management of sarcopenia and diabetes, while featuring elements that require further research. The goal of nutritional management is to improve muscle mass and strength while regulating metabolic risk and glucose levels. To ensure muscle synthesis in the elderly, recommendations align at daily calorie intake that exceeds 30 kcal/kg, with adjustments based on comorbidities. Additionally, a protein intake of at least 1-1.2 g/kg/d is essential, emphasizing both daily and per-meal intake, and can be achieved through diet or branched-amino-acids supplements. Specific considerations for diabetes include restricted protein intake in diabetic nephropathy and exploring the potential link between branched amino acids and insulin resistance. Further recommendations that both promote metabolic health and have demonstrated at least a potential to increase muscle strength include prioritizing polyunsaturated fatty acids as a fat source and maintaining adequate levels of vitamin D. Clinicians should consult their patients on dietary optimization, but evidence is insufficient to recommend additional supplementation. Lastly, an emerging challenge of diabetes and sarcopenia is sarcopenic obesity, which requires the combination of a hypocaloric diet with increased protein intake.

Plant proteins: are they a good alternative to animal proteins in older people?

PURPOSE OF REVIEW

This review provides the latest insight into the impact of consuming plant-based protein for older people.

RECENT FINDINGS

According to the latest data, a healthy diet rich in plant-based-protein-rich-food could promote healthy aging. This health effect is partly because of the amino acid composition of proteins, as well as to the important constituents such as fiber and bioactive compounds found in the matrix. Furthermore, even though animal protein is more effective at stimulating muscle protein synthesis, a high consumption of plant protein (beyond 31 g/day) appears to enhance physical performance and reduce the risk of frailty in older individuals.

SUMMARY

Recent literature highlights numerous health benefits for older people associated with a substantial intake of plant-based vs. animal-based protein, both in preventing and mitigating chronic age-related diseases and reducing the risk of all-cause mortality. However, a high intake of plant-based protein-rich products could pose risks of malnutrition and fiber-related intestinal intolerances. Further research is needed to assess the risk-benefit ratio of a high consumption of plant proteins in older individuals before we can make robust recommendations on how far animal proteins can be healthfully replaced with plant proteins.

Hypoxemic Cardiac Arrest from Aspiration of a Cracker in the Postanesthesia Care Unit: A Case Report

A 71-year-old woman with coronary artery disease presented for carotid artery revascularization. After general anesthesia, the patient arrived in stable condition to the postanesthesia care unit. While awaiting transfer to her inpatient room, telemetry alarms alerted her nurse, who found the patient unresponsive, cyanotic, and pulseless. Advanced cardiovascular life support was initiated, with return of spontaneous circulation obtained after 1 round of chest compressions. On oropharyngeal examination, food particles were observed and suctioned. The patient then coughed up additional cracker pieces. This case highlights the risk of aspiration from dry, solid foods in the elderly during the postanesthesia recovery period.

Challenges in Managing Malnutrition in the Elderly

Malnutrition in aging is currently considered a public health problem characterized by a multifactorial physiological state. Diverse and complex factors can contribute to the risk of developing malnutrition or even worsening. This chapter aims to provide a conceptual overview of malnutrition in elderly individuals, covering aspects related to nutritional assessment, monitoring, and recommendations, as well as possible challenges in managing this condition in clinical nutrition. The management is complicated and challenging. Nutritionists should perform interventions based on recommendations to prevent or minimize malnutrition in elderly individuals. Depending on the environment and the condition of the elderly patient, different therapeutic approaches will be needed to manage malnutrition. All family and health professionals involved with elderly care must stay engaged in preventing or identifying malnutrition in these patients.

Need for a consensus definition of chronic dehydration: A scoping review

Dehydration is common in older adults and impacts their clinical outcomes. Chronic dehydration is especially important as it has been under-recognized. This scoping review aimed to summarize the available definitions of chronic dehydration to identify gaps between each definition and discuss future research needs. Four databases (Pubmed, CINAHL, Cochrane Library, Science Direct) were systematically searched for peer-reviewed articles that clearly described the definition of chronic dehydration published from inception to June 8th, 2023. Two researchers reviewed the articles independently, and any disagreement was solved upon discussion. We identified five articles with a wide range of subjects from children to older adults. Chronic dehydration was defined as a state of persistently elevated blood urea levels; weight loss ≥ 1% as a result of fluid loss; a ratio of blood urea nitrogen to creatinine > 20; serum osmolarity ≥ 295 mOsm/kg; and a dehydrated state lasting 72 hours or longer. The definition varied among studies, indicating the need to establish an international consensus on the definition of chronic dehydration.

"I see it very much as an end-of-life food" - Barriers to oral nutritional supplement adherence, views from healthy older adults

Malnutrition affects approximately one quarter of UK adults aged 65 years and over. As the global demographic shift continues, malnutrition is expected to increase. Oral nutritional supplements (ONS) are used both to prevent and to treat malnutrition. However, their effectiveness is compromised by poor adherence, and it is not well understood what contributes to this. Therefore, the current research was designed to explore ONS adherence from the parallel perspectives of ONS as a prescribed "medication" and as a food supplement/substitute. Eighteen older adults (13F, 5M; mean age = 73.4 yr; range: 70-80 yr) participated in focus groups (three in-person and one online), to investigate experiences of taking prescribed medications, including dietary supplements, and what should be factors to consider in supporting regular intake of ONS for trial development, as well as any potential improvements to products. Focus group sessions were recorded and then transcribed. Thematic Analysis was applied to the transcripts by the first author, and themes were discussed in depth, using exemplar quotes from participants. Five dominant themes were identified from the data: Disgust, Palatability and Acceptance; End-of-Life Care; Resistance to Medicines; Rituals and Reminders; and Real Food Displacement. Nutritional supplements were characterised as "disgusting", "manufactured", and associated with serious, chronic illness, as well as end-of-life care, in contrast to probiotics which were linked with health and wellness. The sweet taste of ONS was identified as a barrier to intake, given that it is generally associated with a signal to stop eating, and low hunger. As a group, participants tried to "avoid taking medicines", and viewed the need to have them negatively, yet most regularly took prescribed medication and/or vitamin supplements. Participants identified several, rituals and reminders to take medicines, including meal-based, or time-of-day-based prompts (e.g., before, with or after meals). To improve adherence, savoury products were suggested, as well as a more person-centred approach to individual nutritional needs and preferences. Overall, the group discussion mainly identified barriers to intake, but that improving taste, adding to "real food" (not replacing meals), and offering variety of flavour and form (e.g., savoury soups as well as sweet drinks) could be included in future trials to improve appeal and therefore intake. Future work should continue to explore how best to formulate, market and/or prescribe ONS, and how this might vary for malnutrition prevention vs treatment strategies.

The effect of a low-calorie diet on depressive symptoms in individuals with overweight or obesity: a systematic review and meta-analysis of interventional studies

BACKGROUND

Individuals with overweight or obesity are at a high risk for so-called 'atypical' or immunometabolic depression, with associated neurovegetative symptoms including overeating, fatigue, weight gain, and a poor metabolic profile evidenced e.g. by dyslipidemia or hyperglycemia. Research has generated preliminary evidence for a low-calorie diet (LCD) in reducing depressive symptoms. The aim of the current systematic review and meta-analysis is to examine this evidence to determine whether a LCD reduces depressive symptoms in people with overweight or obesity.

METHODS

Eligible studies were identified through PubMed, ISI Web of Science, and PsycINFO until August 2023. Standardized mean differences (SMDs) were derived using random-effects meta-analyses for (1) pre-post LCD comparisons of depression outcomes, and (2) LCD v. no-diet-control group comparisons of depression outcomes.

RESULTS

A total of 25 studies were included in the pre-post meta-analysis, finding that depression scores were significantly lower following a LCD (SMD = -0.47), which was not significantly moderated by the addition of exercise or behavioral therapy as a non-diet adjunct. Meta-regressions indicated that a higher baseline BMI and greater weight reduction were associated with a greater reduction in depression scores. The intervention-control meta-analysis (n = 4) found that overweight or obese participants adhering to a LCD showed a nominally lower depression score compared with those given no intervention (SMD = -0.29).

CONCLUSIONS

There is evidence that LCDs may reduce depressive symptoms in people with overweight or obesity in the short term. Future well-controlled intervention studies, including a non-active control group, and longer-term follow-ups, are warranted in order to make more definitive conclusions.