ESPEN practical guideline: Clinical nutrition and hydration in geriatrics

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.

Association between early enteral nutrition and clinical outcomes among critically ill patients with circulatory shock: A secondary analysis of a large-scale randomized controlled trial

BACKGROUND

It remains unclear if early enteral nutrition benefits patients with circulatory shock, particularly in those with prolonged use of vasopressors. This study aimed to assess the association between early enteral nutrition and clinical outcomes in patients with circulatory shock and whether the duration of circulatory shock (transient or persistent) impacts this association.

METHODS

Using data from a multicenter, cluster-randomized controlled trial, this secondary analysis involved patients with baseline circulatory shock as defined by a cardiovascular Sequential Organ Failure Assessment score of two or more. Patients were dichotomized into transient or persistent circulatory shock depending on the duration, while transient circulatory shock was defined by the resolution of shock within the first day of enrollment. Early enteral nutrition was defined as the initiation of enteral nutrition within 48 h after intensive care unit admission. The association between early enteral nutrition and a composite outcome (presence of any organ failure on study day 10 or 28-day mortality) was investigated by multivariable and propensity-score-weighted multivariable logistic regression analyses.

RESULTS

Seven hundred and eighty-five patients were included in the analysis, and early enteral nutrition was administered to 385 patients (49.0 %) in the whole study cohort. In patients with transient circulatory shock (n = 527), 221 patients (41.9 %) received early enteral nutrition, and in those with persistent circulatory shock (n = 258), 164 patients (63.6 %) did so. For the overall cohort, there was no difference in the incidence of primary composite outcome between early enteral nutrition and 'no early enteral nutrition ' groups (adjusted odd ratio 0.84, 95 % confidence interval 0.60-1.18) after adjustment for potential confounders. In patients with transient circulatory shock, receipt of early enteral nutrition, compared to no early enteral nutrition, was significantly associated with reduced incidence of the composite outcome (adjusted odd ratio 0.63, 95 % confidence interval 0.41-0.95, p = 0.027). On the contrary, there is no association between early enteral nutrition and the incidence of the composite outcome in patients with persistent circulatory shock (adjusted odd ratio 1.28, 95 % confidence interval 0.64-2.58, p = 0.485). The results of propensity-weighted multivariable analysis conform to the primary analysis.

CONCLUSION

Early enteral nutrition was associated with improved clinical outcomes among patients with circulatory shock that resolved within the first day. RESEARCH REGISTRATION UNIQUE IDENTIFYING NUMBER (UIN) OF THE ORIGINAL NEED TRIAL: ISRCTN Registry, Registry number: ISRCTN12233792.

[Protein-energy-malnutrition]

Loss of appetite is part of the so-called "sickness behavior", which is a uniform reaction to many diseases, mainly triggered by inflammatory signals. Whereas this pattern may have been an evolutionary advantage long time ago, loss of appetite with consecutive malnutrition nowadays represents more a collateral damage of many acute and chronic diseases.Protein-energy-malnutrition should be diagnosed with the recently globally consented criteria of the "Global Leadership Initiative on Malnutrition" (GLIM). These criteria comprise 3 phenotypic and 3 etiologic criteria. If one criterium of each group is fulfilled, the diagnosis can be made.Besides the disease related loss of appetite, there are many potential causes of malnutrition. The entire spectrum may reach from malignancies to insufficient support in functionally impaired older subjects. Frequently, several factors may play a role. The very complex spectrum of potential and frequent causes of malnutrition has been summarized in the DoMAP model.Malnutrition may lead to severe consequences such as muscle atrophy and sarcopenia, leading to falls and fractures, impaired function of the immune system with an increase of infections and impaired wound healing, all of which are connected with increased morbidity and mortality.Many meta-analyses and guidelines have demonstrated the effectiveness of nutritional therapy in malnourished patients. There is good evidence for various approaches, that may be utilized alone or in combination, depending on the situation and disease of each individual patient. Particularly, the EFFORT-study, a large prospective randomized controlled trial, has demonstrated, that a structured, but individualized approach may be most effective.

Incidence of dysphagia-related safety incidents in older adults across feeding methods: A systematic review and meta-analysis

OBJECTIVE

Dysphagia-related safety incidents encompass near-miss events, no-harm occurrences, or harmful incidents associated with oral or enteral feeding methods. This systematic review and meta-analysis aimed to assess the incidence rates of dysphagia-related safety incidents in older adults across various feeding methods.

METHODS

A comprehensive literature search was conducted using PubMed, Embase, Web of Science, Cochrane Library, and CINAHL databases to identify studies reporting dysphagia-related safety incidents in older adults. The feeding methods analyzed included oral feeding, nasogastric (NG) tube feeding, and percutaneous endoscopic gastrostomy (PEG) tube feeding. Randomized controlled trials (RCTs), non-randomized studies, and cohort studies were included. The analysis adhered to the PRISMA guidelines, and meta-analytic outcomes were presented with 95% confidence intervals (CIs).

RESULTS

A total of 30 studies satisfied the inclusion criteria. The overall incidence rates of safety incidents were 13.8% for oral feeding, 23.9% for NG tube feeding, and 26.5% for PEG tube feeding. Aspiration pneumonia emerged as the most prevalent safety incident across all feeding methods, with incidence rates of 12.0% for oral feeding, 20.6% for NG tube feeding, and 12.4% for PEG tube feeding. Tube feeding methods were associated with diarrhea and wound infection. Additionally, specialized safety incidents were observed for each feeding method: suffocation in oral feeding; gastroesophageal reflux in NG tube feeding; and tube blockage, tube dislodgment, tube leakage, vomiting, nausea, site pain, gastrointestinal hemorrhage, and peritonitis in PEG tube feeding.

CONCLUSIONS

Dysphagia-related safety incidents in older adults demonstrated considerable variability in type and frequency across different feeding methods. Understanding these differences could provide healthcare professionals with valuable insights for targeted risk prediction and proactive management strategies to mitigate such incidents.

Personalized Diet With or Without Physical Exercise Improves Nutritional Status, Muscle Strength, Physical Performance, and Quality of Life in Malnourished Older Adults: A Prospective Randomized Controlled Study

Objectives: Malnutrition (MN) is prevalent in older adults and closely related to sarcopenia, frailty, morbidity, mortality, and decreased quality of life. In this study, we aimed to evaluate the effects of a personalized diet combined with planned physical exercise on nutritional status, physical performance, and quality of life (QoL) in malnourished older adult patients. Methods: In this prospective study, 20 older adults with MN risk according to the Mini Nutritional Assessment-Short Form (MNA-SF) were randomized into (i) personalized diet (PD) and (ii) personalized diet with physical exercise (PDE) groups, and followed up with for 12 weeks. The physical exercise included warm-up, strengthening, balance, and cooldown phases, with a frequency of 3-4 days per week. Anthropometric measurements, physical performance, and quality of life were assessed using standardized tools at baseline and at the 4th, 8th, and 12th weeks. QoL was measured using the EQ-5D index and EQ-5D visual analog scale (VAS) scores. Results: A total of 20 patients (55% male) participated in the study. During the study, BMIs, MNA-SF scores, and hand grip strength were increased, and the patients' average duration on the Timed Up and Go (TUG) test decreased significantly in both groups. The EQ-5D index score of the PD group and the EQ-5D VAS scores of both groups were increased. Conclusions: A personalized diet with or without physical exercise therapy was associated with improved nutritional status, physical performance, and QoL.

Perspectives on Diet and Exercise Interaction for Healthy Aging: Opportunities to Reduce Malnutrition Risk and Optimize Fitness

Nutrition and exercise play a pivotal role in counteracting the effects of aging, promoting health, and improving physical fitness in older adults. This perspective study examines their interplay, highlighting their combined potential to preserve muscle mass, cognitive function, and quality of life. The objective is to address gaps in the current understanding, such as the frequent neglect of dietary intake in exercise interventions and vice versa, which can limit their effectiveness. Through a synthesis of the existing literature, we identify key findings, emphasizing the importance of adequate nutritional intake-particularly protein, essential amino acids, and micronutrients-in supporting exercise benefits and preventing sarcopenia and malnutrition. Additionally, supplementation strategies, such as omega-3 fatty acids, creatine, and essential amino acids, are explored alongside the emerging role of the gut microbiota in mediating the benefits of nutrition and exercise. Despite these advances, challenges remain, including determining optimal dosages and timing and addressing individual variability in responses. Personalized approaches tailored to sex differences, gut microbiota diversity, and baseline health conditions are critical for maximizing intervention outcomes. Our conclusions underscore the necessity of integrated strategies that align dietary and exercise interventions to support healthy and active aging. By addressing these gaps, future research can provide actionable insights to optimize health and quality of life in older populations.

Protein Intake and Its Association With Meal Patterns and Dietary Patterns in a Swedish Population of Older Adults

BACKGROUND

Meeting protein intake recommendations is relevant for maintaining muscle mass. This study aimed to describe protein intake and its association with meal patterns and dietary patterns.

METHODS

An in-house designed, web-based 4-day record was used in the national dietary survey (in 2010/2011). Participants 60 years and older were included in the analysis (n = 533). Protein intake was described by hour of consumption, self-indicated meals and food source. Eating and drinking occasion (EDO) and food groups were defined, from which meal patterns and three a posteriori dietary patterns (using principal component analysis) were assessed.

RESULTS

We observed a mean protein intake of just over 1 g/kg body weight (bw) in both men and women. Over 50% of the protein intake was sourced from the food groups meat, fish and milk/yoghurt. A bolus intake of 30 g protein per meal was observed in a small proportion of participants at breakfast and lunch, but was most common at dinner (41% women and 56% men). No strong correlations were observed between protein intake and neither dietary patterns nor the number of EDOs. A 5 g higher protein intake at any meal, but not higher EDO frequency, was associated with higher odds of meeting a protein intake over 1.1 g/kg bw.

CONCLUSIONS

Protein intake over 1.1 g/kg bw was met by 44% of the participants. Lunch and dinner were the highest contributors to protein intake. Dietary and meal patterns were weakly associated with protein intake. Only total daily protein intake was associated with reaching > 1.1 g/kg bw.

Evaluation of an updated educational intervention on nutritional care to prevent undernutrition among older adults in primary health care

AIM

The aim of this study was to evaluate district nurses' perceived and factual knowledge about nutritional care after an updated and expanded educational intervention. Furthermore, we aimed to compare the outcomes of the revised and the original educational intervention.

BACKGROUND

In-depth knowledge of nutritional care is a prerequisite to supporting older adults' well-being and health. District nurses' actual knowledge of the nutrition care process, older adults' need for food, and palliative care in diverse phases of disease is therefore of utmost importance. An updated and expanded educational intervention meeting these needs was evaluated.

METHODS

A study-specific questionnaire about nutritional care was used before and after the educational intervention. Participants (n = 118) were district nurses working in primary health care in Region Stockholm. Additionally, a pre- and post-test quasi-experimental design was used to assess differences in learning outcomes of the revised intervention compared with the original intervention.

FINDINGS

District nurses who completed the questionnaire had worked in health care for about 18 years and as district nurses for 5 years after their specialist examination. After the revised educational intervention, significant improvements were found in all statements concerning perceived challenges and actions related to nutritional care, while questions about factual knowledge showed significant improvements in three of the four questions.Comparison between the revised and the original intervention revealed no differences in most areas of perceived challenges and actions related to nutritional care. Additionally, in half of the areas assessed, factual knowledge improved more after the revision than after the original educational intervention, including the maximum length of overnight fast and the type of oral nutritional supplements (ONS) that should be prescribed.

CONCLUSION

The intervention was successful in increasing knowledge about nutritional care, nutritional counselling, food adaptation, and prescribing ONS in an individually tailored way. In-depth knowledge supports usability in clinical practice. Nevertheless, we need to follow-up and understand how increased knowledge about undernutrition and ONS prescription are implemented in primary health care when caring for older adults' desires and needs.

Nutritional Support in the Prevention and Treatment of Pressure Ulcers in Healthy Aging: A Systematic Review of Nursing Interventions in Community Care

Introduction: Pressure ulcers (PUs) represent a significant challenge in chronic care, particularly among the elderly with reduced mobility. They result in substantial socio-healthcare costs and negatively impact patients' psychological well-being. Malnutrition is a key risk factor, hindering healing and increasing the risk of complications. As such, appropriate nutritional interventions are crucial for managing PUs. However, these interventions are often underestimated in clinical practice, underscoring the need for a more comprehensive approach to elder care and healthy aging. Objectives: The primary objective of this study was to identify the best scientific evidence on nutritional interventions implemented by nurses in community settings to prevent complications related to PUs. Additionally, qualitative and quantitative outcomes reported in the included studies were analyzed. Method: This systematic review was conducted following PRISMA international guidelines. Searches were performed in PubMed, Scopus, Embase, and CINAHL databases. A predefined search strategy using Boolean operators was employed, and two researchers independently selected papers, with a third researcher resolving any discrepancies. Additional sources and manual reviews were conducted to minimize selection bias. Results: Out of 1003 records, 6 studies were included. Findings indicate that nurses play a fundamental role in managing PUs in community settings through specific nutritional intervention assistance processes. These healthcare professionals are pivotal in the prevention, care, and rehabilitation of vulnerable individuals with PUs. Conclusions: Nurses are strategic in the management of PUs within community care for frail populations. With nutritional support that plays a key role in both preventing and accelerating the healing of PUs. Policymakers are encouraged to invest in nursing roles to enhance assistance in community contexts, supporting healthy aging and lifestyle medicine approaches.

Integrating frailty interventions into existing care models: a comprehensive approach to enhancing patient outcomes in chronic disease management

Frailty syndrome (FS) is a complex and multifaceted condition commonly observed in old adults patients with chronic diseases, often accompanied by cognitive impairments. This review explores the integration of frailty interventions into existing care models to improve patient outcomes, focusing on four key areas. First, it emphasizes the importance of comprehensive assessment tools to identify frailty and cognitive impairments early, facilitating targeted care planning. Second, it highlights the value of personalized interventions, such as dietary modifications, exercise programs, and cognitive training, tailored to individual patient needs and preferences. Third, the review underscores the critical role of multidisciplinary care teams in providing holistic and coordinated care, leveraging the expertise of diverse healthcare professionals. Finally, it examines the potential of technological innovations and caregiver support systems in enhancing frailty management and addressing the challenges posed by cognitive impairments. By integrating these approaches, this review presents a patient-centered framework aimed at mitigating the impact of frailty and improving long-term outcomes. The findings emphasize the need for a unified strategy that combines personalized care, interdisciplinary collaboration, and technological advancements to address the multifaceted challenges of frailty in chronic disease management.

Interdisciplinary Oral Nutrition Support and Supplementation After Hip Fracture Surgery in Older Adult Inpatients: A Global Cross-Sectional Survey (ONS-STUDY)

BACKGROUND

Malnutrition predicts poor outcomes following hip fracture, affecting patient recovery, healthcare performance, and costs. Evidence-based guidelines recommend multicomponent, interdisciplinary nutrition care to improve intake, reduce complications, and enhance outcomes. This study examines global variation in oral nutrition support for older (65+ years) hip fracture inpatients.

METHODS

A global survey was conducted as part of a broader program to improve interdisciplinary nutrition care. The protocol was based on evidence-based guidelines, reviewed by experts, and piloted for validity. Recruitment used snowball sampling to achieve diversity across income levels, countries, and healthcare roles.

RESULTS

The survey (July-September 2023) recruited 308 participants from 46 countries across five global regions. Respondents primarily worked in acute teaching (57.5%) and non-teaching (17.5%) hospitals, representing medical (48.4%), nursing (28.2%), and allied health (17.9%) roles. Findings revealed a global knowledge-to-practice gap in multicomponent nutrition care, across providing high-protein/energy food and fluids (median: "half the time"), post-operative provision of oral nutritional supplements (median: "half the time") and continuation for one month with assessment (median: "not very often"), and nutritional education (median: "not very often"). Only 17.9% of respondents reported routine provision ("often" and "nearly always or always") of high-protein/energy food, supplements, and education. Substantial regional variation showed Western Pacific respondents perceiving the lowest provision across multicomponent processes. Interdisciplinary, multicomponent interventions were seen as a potential opportunity requiring further exploration.

CONCLUSIONS

Major gaps persist in implementing evidence-based, interdisciplinary, multicomponent nutrition care for older adults with hip fractures. A targeted implementation approach is the next step to addressing the knowledge-to-practice gap.

Clinical Importance of Protein Intake in Hospitalized Elderly Patients With Heart Failure

Background

The relationship between protein intake and the long-term prognosis of elderly patients with heart failure remains poorly understood. We investigated the association between predischarge protein intake and long-term prognosis in hospitalized elderly patients with heart failure.

Methods and Results

A single-center, retrospective analysis of hospitalized patients aged ≥65 years with heart failure and reduced ejection fraction was conducted. Protein intake was evaluated by nutritionists based on visual measurements of the percentage of dietary intake obtained for 7 days before discharge by a nurse. A cutoff of 1.2 g/kg/day protein intake was used to compare the incidence of a composite endpoint, including all-cause mortality and heart failure rehospitalization within 1 year. Among the 100 patients (median age 79 years; 47% male), 56% had low protein intake (<1.2 g/kg/day). Patients with low protein intake had a significantly higher rate of composite endpoints than those with high protein intake (50% vs. 20%; log-rank test P=0.03). Multivariable Cox proportional hazards model revealed that low protein intake was independently associated with long-term prognosis with a hazard ratio of 2.73 and a 95% confidence interval of 1.10-6.80 (P=0.03).

Conclusions

Low protein intake in the predischarge phase was associated with long-term prognosis in hospitalized elderly patients with heart failure and reduced ejection fraction.

Health status correlates of malnutrition diagnosed based on the GLIM criteria in older Polish adults-Results of the PolSenior 2 study

INTRODUCTION

Older individuals are at risk of malnutrition resulting from chronic diseases-related body and muscle mass reduction. In turn, nutritional deficiencies may enhance catabolic processes, leading to accelerated aging and comorbidity, thus creating a vicious cycle. Our study aimed to assess the prevalence of malnutrition using the Global Leadership Initiative on Malnutrition (GLIM) criteria and to determine the health correlates of malnutrition in a representative sample of community-dwelling older adults.

METHODS

We used the GLIM criteria to diagnose malnutrition in 5,614 participants of the PolSenior2 study. The PolSenior2 study was a population-based survey designed to assess the medical, psychological, social, and economic characteristics of community-dwelling older adults.

RESULTS

Malnutrition was diagnosed in 13.4% of the participants using the GLIM criteria. Results of multiple logistic regression showed that the risk of depression [OR 4.18, p<0.001], peptic ulcer disease [OR 2.73, p<0.001], past stroke [OR 1.71, p<0.001], cognitive impairment [OR 1.34, p = 0.015], and chronic pain [OR 1.23, p = 0.046] were independent correlates of malnutrition.

CONCLUSION

Due to the high risk of malnutrition, special attention should be paid to individuals in late old age. Suspected malnutrition should also be considered in people at risk of depression, with peptic ulcer disease, past stroke, and cognitive impairment. Chronic pain should also prompt the diagnosis for malnutrition.

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.

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.

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.

Nutritional Status in a Group of Patients with Wounds Due to Diabetic Foot Disease and Chronic Venous Insufficiency

Background: Wound healing is a complex physiological process that begins immediately upon injury. Nutritional status significantly affects the course of regenerative processes. Malnutrition can prolong the inflammatory phase, limit collagen synthesis, and increase the risk of new wound formation. The issue of malnutrition is becoming increasingly prevalent and remains a significant concern, particularly among older adults dealing with chronic conditions. Methods: The study was conducted at the Wound Treatment Clinic of the Specialist Hospital at the Podkarpackie Oncology Center in Brzozów, Poland, over 12 months (31 December 2022 to 31 December 2023). A prospective assessment was carried out on 106 patients with chronic wounds. The sample selection was purposeful, based on the following criteria: individuals with hard-to-heal vascular wounds related to diabetic foot disease or venous insufficiency, who provided informed consent to participate after reviewing the study concept. The assessment included a questionnaire and biochemical blood analysis. Further evaluations covered wound characteristics and classification based on clinical scales. The morphotic and biochemical blood parameter assessment included albumin concentration, hemoglobin, C-reactive protein (CRP), and the nutritional risk index (NRI). Results: A larger wound area was associated with lower morphotic values in both groups. Exudate levels and severity in chronic venous insufficiency (CVI) patients and diabetic foot disease (DFD) were associated with lower hemoglobin, albumin, and NRI values. At the same time, the depth of tissue structure damage correlated with the measured biochemical parameters. Conclusions: NRI values and morphotic blood parameters, along with albumin, hemoglobin, and CRP levels, are closely associated with wound characteristics, including surface area, exudate level, and the severity of tissue destruction. The greater the destruction of tissue structures, the higher the risk of malnutrition and wound infection, as indicated by biochemical assessment.

Editorial for the Special Issue: Geriatric Nursing Nutrition

Malnutrition, a significant risk factor for mortality and morbidity in the elderly, poses a huge threat in the geriatric population, showing a high prevalence, especially in people affected by chronic non-communicable age-related diseases [...].

Multimodal prehabilitation combined with perioperative enhanced recovery after surgery care for older patients undergoing spinal fusion surgery in China: protocol for a multicentre randomised controlled trial (PRACTICE trial)

INTRODUCTION

Besides the comorbid risk factors shared by older and younger patients, older individuals may also experience malnutrition, as well as cognitive or functional impairments. The accumulation of frailty and various geriatric syndromes in older individuals results in decreased physiological reserves, which makes the recovery process after spine surgery particularly challenging. Theoretically, combining the presurgery optimisation provided by a multimodal prehabilitation programme with the reduction of surgical stress provided by an enhanced recovery after surgery (ERAS) programme could improve postoperative recovery of older patients.

METHODS AND ANALYSIS

This is a prospective, multicentre, assessor-blinded, randomised controlled study. Patients who are 75 years of age or older and are scheduled for spinal fusion surgery will be enrolled on three academic medical centres. Regular preadmission education and perioperative ERAS care will be given to participants who were randomised to the control group. Participants randomised to the intervention group will receive multimodal prehabilitation combined with ERAS (PREERAS) management. We will include 164 patients with spinal fusion in three hospitals in China. All included patients will be followed for 90 days after surgery or until death. The primary outcome is the Comprehensive Complication Index (CCI), which ranges from 0 to 100, where a score of 100 indicates death due to complications. Secondary outcomes include length of stay and non-home discharge, rates of postoperative complications and unplanned readmission, North American Spine Society satisfaction, and Oswestry Disability Index/Neck disability index. Ninety-day CCI will be compared between groups using linear regression. Other continuous or categorical outcomes will be compared using linear or logistic regression.

ETHICS AND DISSEMINATION

This study has received ethical approval from the Xuanwu Hospital of Capital Medical University Ethics Committees (2024-088-001). The findings will be submitted to a peer-reviewed journal for publication.

TRIAL REGISTRATION NUMBER

NCT06140797.

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.