Malnutrition in Geriatric Rehabilitation: Prevalence, Patient Outcomes, and Criterion Validity of the Scored Patient-Generated Subjective Global Assessment and the Mini Nutritional Assessment

Malnutrition and sarcopenia in inpatient rehabilitation: prevalence and associations with changes in bodyweight, muscle strength, and functional independence

OBJECTIVE

To investigate the prevalence of malnutrition and sarcopenia in different disciplines of inpatient rehabilitation and the course of nutritional status parameters.

DESIGN

Multi-centre cross-sectional prevalence study and longitudinal observational study.

SUBJECTS/PATIENTS

Inpatients (> 18 years) in geriatric, pulmonary, cardiovascular, internal medicine/oncological, musculoskeletal, or neurological rehabilitation in 5 rehabilitation centres were included.

METHODS

Malnutrition was assessed according to the Global Leadership Initiative on Malnutrition criteria. Sarcopenia was assessed according to the European Working Group on Sarcopenia in Older People criteria. Bodyweight, hand grip strength (HGS), and functional independence measure (FIM) were assessed within 3 days of admission and after 21 days of rehabilitation and analysed using linear mixed models with time*diagnosis interaction.

RESULTS

The study included 558 patients (51.8% male, median age 73.0 years). The overall prevalence of malnutrition and sarcopenia was 35.5% (95% CI 31.5, 39.6%) and 32.7% (95% CI 28.8, 36.8%), respectively. Patients with risk of malnutrition lost on average 1.14 kg (95% CI -1.64, -0.63) during rehabilitation. Patients slightly increased their HGS and FIM, irrespective of risk or diagnosis of malnutrition or sarcopenia. However, at the end of the rehabilitation, malnourished or sarcopenic patients had still a significantly lower bodyweight, HGS, and FIM than patients without (p < 0.01). Some 37.3% of patients at risk of and 35.4% with diagnosed -malnutrition did not receive group or individual nutritional -counselling.

CONCLUSION

Malnutrition and sarcopenia are highly prevalent during inpatient rehabilitation. Nevertheless, dietitians are often not involved in the therapy. While nutritional parameters and functional independence improve, patients with malnutrition and sarcopenia remain on a lower level after 3 weeks of rehabilitation. Long-term follow-up after rehabilitation is recommended to prevent nutritional and muscular decline and related negative health outcomes.

Correlation Analysis Between the Geriatric Nutritional Risk Index Hip Fracture in Male: Based on the National Health and Nutrition Examination Survey Database

Hip fractures (HFs) are common in elderly patients and are associated with high mortality rates and functional impairment. Malnutrition has been shown to negatively impact postoperative survival rates in HF patients. However, the relationship between the Geriatric Nutrition Risk Index (GNRI) and the risk of HF remains unclear. This study aims to evaluate the association between GNRI and HF risk, with a particular focus on the elderly male population.We conducted a cross-sectional study using data from the National Health and Nutrition Examination Survey (NHANES) for the periods 2007-2010, 2013-2014, and 2017-2018. Through multivariate regression analysis, we assessed the association between GNRI and HF and performed stratified and subgroup analyses to further explore this relationship. Additionally, we utilized restricted cubic splines (RCSs) to investigate the potential nonlinear relationship between GNRI and HF risk.The study found that gender significantly influenced the relationship between GNRI and HF (p for interaction = 0.002). In males, GNRI was significantly negatively associated with the risk of HF (OR < 1, p < 0.05). RCS analysis showed that the relationship between GNRI and HF risk in elderly males might be linearly negative. The critical threshold for GNRI was identified as 104.14, beyond which the risk of HF significantly decreased.This study demonstrates a linear negative correlation between GNRI and the risk of HF in elderly males, with a GNRI of 104.14 identified as the critical threshold for predicting the risk of hip fractures.

Can invasive interventions be avoided with a holistic swallowing therapy program in older patients in intensive care units: percutaneous endoscopic gastrostomy tubes or oral intake?

Introduction

The use of percutaneous endoscopic gastrostomy (PEG) tubes in older patients did not show any benefits in terms of survival, improvement in quality of life, or reduction in aspiration pneumonia. Significant gaps exist regarding the evidence for the evaluation and management of dysphagia in older patients. This study aimed to diagnose swallowing disorders and highlight the importance of swallowing therapy in older patients in intensive care units (ICUs).

Materials and methods

Twenty-five older patients (12 men, 13 women, mean age 67.22 ± 24.03 years) hospitalized in the ICUs with complaints of dysphagia were analyzed prospectively. The 12 weeks (14-16 sessions) of swallowing therapy were administered to patients with dysphagia who signed the (voluntary) consent form. The bedside water swallowing test (BWSS), Functional Oral Intake Scale (FOIS) Score, Clinical Swallowing Evaluation, Mini Nutritional Assessment Test (MNAT), Eating Assessment Tool (EAT-10), the Turkish version of the World Health Organisation Quality of Life Scale Elderly Module, and the Swallowing Therapy Programme Protocol were applied. Pretherapy stage (T1) and post-therapy stage (T2) results were compared with videofluoroscopy swallowing study (VFSS) recordings with thin liquids, moderately thick liquids, extremely thick liquids, and crackers (International Dysphagia Diet Standardization Initiative [IDDSI] Levels 0, 3, 4, and 7, respectively).

Results

The World Health Organisation Quality of Life Scale Elderly Module (WHOQOL-OLD) raw scores significantly improved from T1 (38.63 ± 7.05) to T2 (73.07 ± 4.82). The bedside water swallowing test results demonstrated statistically significant differences in therapy timings among older patients (p < 0.001). There were significant improvements in swallowing physiology, as represented by the improved oral and pharyngeal composite scores of the Modified Barium Swallow Impairment Profile (MBSImP) and Penetration-Aspiration Scala (PAS) levels. Before therapy, all patients exhibited high rates of oropharyngeal residue with thin liquids and spoon-thick pudding viscosities (MNA ≤ 17). The results reported in the present study show that malnutrition risk is linked to a poorer QoL in older patients on admission to ICUs. Statistical analyses revealed the dominant effects of functional status and eating-related factors on QoL in this group.

Discussion

Early dysphagia diagnosis of older patients and subsequent application of exercise-based swallowing therapy increase the quality of life of patients. In this study, exercise-based swallowing therapy was developed in Turkey and can be used in older patients as part of a holistic cognitive-communication-swallowing intervention program. Results prove the effectiveness of the developed exercise-based swallowing therapy on the cognitive-communication-swallowing skills of older patients. The present findings reinforce the role of nutrition as a priority for improving patients' perceptions of QoL. Further studies are required to investigate and identify the interventions that improve QoL in older patients. More studies with better research designs are required to establish whether nutritional intervention is effective in enhancing QoL in this vulnerable group.

Association of bio-impedance phase angle and a nutritional indicator in community-dwelling patients with type 2 diabetes mellitus

Purpose

Although the bio-impedance phase angle is a relevant factor in nutritional assessment, studies with community-dwelling patients with type 2 diabetes mellitus have not been identified. The purpose of this study was to determine the association between phase angle and nutritional status in community-dwelling patients with type 2 diabetes mellitus according to gender and accounting for related factors other than nutritional status.

Methods

This study included 122 patients (mean age 52.1 ± 13.5 years, 63 males and 59 females) with type 2 diabetes mellitus living in the community who used our Endocrinology and Metabolism medical clinic. The phase angle was measured using bioelectrical impedance analysis. Albumin was an independent variable and the covariates were age, hemoglobin A1c, skeletal muscle index (SMI), and body mass index. Statistical analysis was performed using linear regression with a significance level of 5%.

Results

The linear regression model results showed a significant association between phase angle and albumin in both males and females (males: β = 0.26, females: β = 0.16). Age was also a relevant factor (male: β = -0.25, female: β = -0.51), and a significant association was found between phase angle and SMI in males (β = 0.54).

Conclusion

Phase angle was positively associated with albumin, a nutritional assessment index. These results suggest that phase angle can be a simple and noninvasive measure of nutritional status.

Harnessing delegation and technology to identify and manage malnutrition in a digital hospital: An implementation study

AIMS

Delegation of nutrition care activities to Dietetic Assistants in hospitals has been identified as one innovative malnutrition model of care, but there has been limited evaluation of their roles. This study aimed to develop, implement and evaluate a new Malnutrition Model of Care embracing automated delegation and digital systems.

METHODS

The Malnutrition Model of Care was created to detect patients at risk of malnutrition (using the Malnutrition Screening Tool) and nutritional decline (via routine intake tracking at all meals and snacks). Digital systems generated automated referrals to dietetics, with protocols to support Dietetic Assistants to action these to direct care escalation to the ward dietitian. Dietetic Assistant training included simulations and clinical task instructions. Implementation evaluation was guided by the Donabedian model of quality and included a review of inpatient dietetics occasions of service, survey of Dietetic Assistant role satisfaction and task confidence, and hospital-wide cross-sectional malnutrition audit. Data was descriptively analysed.

RESULTS

During the first year of implementation, 60% of Dietetics inpatient occasions of service were completed by Dietetic Assistants, with 26% of Dietetic Assistant inpatient tasks initiated from nursing malnutrition risk screening. Most Dietetic Assistants reported adequate training and confidence in completing delegated tasks. Malnutrition prevalence was 14% with no hospital-acquired malnutrition identified. No clinical incidents were reported.

CONCLUSIONS

The Dietetic Assistant workforce and technology were harnessed to implement an innovative delegated Malnutrition Model of Care that appears to be safe and effective at managing malnutrition from preliminary evaluation. Work continues to formally assess service efficiencies, cost and patient experience.

Efficacy of a WeChat-Based, Multidisciplinary, Full-Course Nutritional Management Program on the Nutritional Status of Patients With Ovarian Cancer Undergoing Chemotherapy: Randomized Controlled Trial

Background

As the most malignant type of cancer in the female reproductive system, ovarian cancer (OC) has become the second leading cause of death among Chinese women. Chemotherapy is the main treatment for patients with OC, and its numerous adverse effects can easily lead to malnutrition. It is difficult to centrally manage patients with OC in the intervals between chemotherapy. The use of WeChat, an effective mobile tool, in chronic disease management has been highlighted.

Objective

This study aimed to implement a continuous follow-up strategy and health monitoring based on the WeChat platform for patients with OC undergoing chemotherapy to ensure that each phase of chemotherapy was delivered on schedule and to improve the survival rate of patients with OC.

Methods

Participants were recruited and randomly assigned to either the WeChat-based nutrition intervention group or the usual care group. A self-administered general information questionnaire was used at enrollment to obtain basic information about the patients. The Patient-Generated Subjective Global Assessment (PG-SGA) Scale was used to investigate the nutritional status of the patients at 3 time points (T0=before the first admission to the hospital for chemotherapy, T1=2 weeks after the first chemotherapy, and T6=2 weeks after the sixth chemotherapy). The blood indices of patients were investigated through the inhospital health care system at 3 times（T0=before the first admission to the hospital for chemotherapy, T1=2 weeks after the first chemotherapy, and T6=2 weeks after the sixth chemotherapy). Patients in the intervention group were introduced to the nutrition applet, invited to join the nutrition management group chat, and allowed to consult on nutritional issues in private chats with nutrition management team members. Linear mixed models were used to analyze changes in each nutritional indicator in the 2 groups, with their baseline measurements as covariates; with group, time, and group-time interactions considered as fixed effects; and with patients considered as random effects.

Results

A total of 96 patients with OC undergoing chemotherapy were recruited into the study. Distribution was based on a 1:1 ratio, with 48 patients each in the nutrition intervention group and the usual care group. The attrition rate after the first chemotherapy session was 18.75%. The mixed linear model revealed that the group-based effect and the group-time interaction effect on PG-SGA scores were significant (F38,38=4.763, P=.03; F37,37=6.368, P=.01), whereas the time-based effect on PG-SGA scores was not (F38,38=0.377; P=.54). The findings indicated that the group-based effect, the time-based effect, and the group-time interaction effect on nutrition-inflammation composite indices were significant (F38,38=7.653, P=.006; F38,38=13.309, P<.001; F37,37=92.304, P<.001; F37,38=110.675, P<.001; F38,38=10.379, P=.002; and F37,37=5.289, P=.02).

Conclusions

This study provided evidence that a WeChat-based, multidisciplinary, full-course nutritional management program can significantly improve the nutritional status of patients with OC during chemotherapy.

Impact of energy intake on the activities of daily living in patients with cervical spinal cord injury undergoing post-acute rehabilitation

Objective: To investigate the association between sufficient energy intake and improvement in activities of daily living (ADL) after hospitalization in patients with cervical spinal cord injury (CSCI) undergoing post-acute rehabilitation.Design: Retrospective cohort study.Setting: Post-acute care hospital from September 2013 to December 2020.Participants: Patients with CSCI admitted to a post-acute care hospital for rehabilitation.Intervention: Not applicable.Outcome measure(s): Multiple regression analysis was performed to investigate the relationship of sufficient energy intake to Motor Functional Independence Measure (mFIM) gain, mFIM score at discharge, and body weight change during hospitalization.Results: In total, 116 patients (104 men and 12 women), median age: 55 (interquartile range [IQR] 41-65) years were included in the analysis. Then, 68 (58.6%) were in the energy-sufficient group, and 48 (41.4%) patients were classified under the energy-deficient group. The two groups did not significantly differ in terms of mFIM gain and mFIM score at discharge. The energy-sufficient group maintained body weight change during hospitalization than the energy-deficient group (0.6 [-2.0-2.0] vs. -1.9 [-4.0--0.3], P < 0.001). Multiple regression analysis showed no association between sufficient energy intake and outcomes.Conclusion: Sufficient energy intake within the first 3 days of admission did not affect ADL improvement during hospitalization in patients with a post-cute CSCI undergoing rehabilitation.

Actual situation of nutritional management and factors related to activities of daily living ability at discharge in convalescent rehabilitation ward

Saito T, Kamachi M. Actual situation of nutritional management and factors related to activities of daily living ability at discharge in convalescent rehabilitation ward. Jpn J Compr Rehabil Sci 2024; 15: 71-78.

Objective

In this study, we aimed to investigate changes in the Geriatric Nutritional Risk Index (GNRI), a nutrition-related prognostic indicator, in our convalescent rehabilitation ward and determine how this index relates to activities of daily living (ADL) ability at discharge.

Methods

We retrospectively analyzed data of 107 patients admitted to our convalescent rehabilitation ward between April and September 2023. We used the GNRI as the nutritional risk index and Functional Independence Measure (FIM) as the ADL index.

Results

The patients' mean age was 80.0 ± 10.3 years; 38 were males and 69 females. The patients' mean body weight at admission was 51.2 ± 10.2 kg, which significantly decreased to 50.2 ± 9.4 kg at discharge (p = 0.0006). Their mean body mass index (BMI) also significantly decreased from 21.4 ± 3.4 at admission to 20.0 ± 8.2 at discharge (p = 0.002). The mean GNRI significantly decreased from 93.1 ± 8.6 at admission to 91.7 ± 8.4 at discharge (p = 0.023). The mean body weight decreased until the fourth month after admission; however, no decreasing trend after the fifth month was observed. The mean monthly energy intake gradually increased after admission and reached the calculated energy requirement of 1,415 ± 22 kcal at the fifth month. Multivariate analysis demonstrated that at discharge, the GNRI score was positively associated with the FIM score (β = 0.21, p = 0.0008).

Conclusion

Body weight and GNRI scores decreased after admission but stopped decreasing after the fifth month due to a gradual increase in energy intake. At discharge, the FIM score was positively associated with the GNRI score. We expected that active nutritional therapy from the beginning of hospitalization would increase the GNRI by the time of discharge and eventually improve ADL ability at discharge.

Body Weight and Composition Changes in Geriatric Rehabilitation Are Dependent on Sarcopenia and Malnutrition: RESORT

OBJECTIVES

Body weight and muscle mass loss following an acute hospitalization in older patients may be influenced by malnutrition and sarcopenia among other factors. This study aimed to assess the changes in body weight and composition from admission to discharge and the geriatric variables associated with the changes in geriatric rehabilitation inpatients.

DESIGN

RESORT is an observational, longitudinal cohort.

SETTING AND PARTICIPANTS

Geriatric rehabilitation inpatients admitted to geriatric rehabilitation wards at the Royal Melbourne Hospital, Melbourne, Australia (N = 1006).

METHODS

Changes in body weight and body composition [fat mass (FM), appendicular lean mass (ALM)] from admission to discharge were analyzed using linear mixed models. Body mass index (BMI) categories, (risk of) malnutrition (Global Leadership Initiative on Malnutrition), sarcopenia (European Working Group on Sarcopenia in Older People), dependence in activities of daily living (ADL), multimorbidity, and cognitive impairment were tested as geriatric variables by which the changes in body weight and composition may differ.

RESULTS

A total of 1006 patients [median age: 83.2 (77.7-88.8) years, 58.5% female] were included. Body weight, FM (kg), and FM% decreased (0.30 kg, 0.43 kg, and 0.46%, respectively) and ALM (kg) and ALM% increased (0.17 kg and 0.33%, respectively) during geriatric rehabilitation. Body weight increased in patients with underweight; decreased in patients with normal/overweight, obesity, ADL dependence and in those without malnutrition and sarcopenia. ALM% and FM% decreased in patients with normal/overweight. ALM increased in patients without multimorbidity and in those with malnutrition and sarcopenia; ALM% increased in patients without multimorbidity and with sarcopenia.

CONCLUSIONS AND IMPLICATIONS

In geriatric rehabilitation, body weight increased in patients with underweight but decreased in patients with normal/overweight and obesity. ALM increased in patients with malnutrition and sarcopenia but not in patients without. This suggests the need for improved standard of care independent of patients' nutritional risk.

Measures for Identifying Malnutrition in Geriatric Rehabilitation: A Scoping Review

Malnutrition is a common condition in geriatric rehabilitation settings; however, the accuracy and predictive validity of the measures to identify malnutrition have not been established. The current scoping review followed the Joanna Briggs Institute's evidence synthesis manual and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews checklist. Literature published through September 2023 was searched using MEDLINE and CINAHL. The inclusion criteria selected studies reporting malnutrition measures, which include static body weight and weight loss. Identified tools were classified as nutritional screening tools, nutritional assessment tools, or diagnostic criteria. The domains of each tool/criterion and their accuracy and predictive validity were extracted. Fifty-six articles fulfilled the inclusion criteria, and six nutritional screening tools, three nutritional assessment tools, and three diagnostic criteria for malnutrition were identified. These measures consisted of various phenotypes, e.g., weight loss, causes such as inflammation/disease, and risk factors of malnutrition, e.g., functional impairment. The predictive validity of nutritional screening tools (n = 6) and malnutrition diagnostic criteria (n = 5) were inconsistently reported, whereas those for nutritional assessment tools were scarce (n = 1). These findings highlight the need to distinguish the functional impairment of nutritional origin from that of non-nutritional origin in nutritional assessment procedures, and the need to study the accuracy and the predictive validity of these measures in geriatric rehabilitation patients.

The Impact of Food-Shaping Techniques on Nutrition, Mealtime Experiences, and Quality of Life for Older Adults in Aged Care Settings: A Systematic Review

OBJECTIVE

Food-shaping methods, particularly for texture-modified foods, present numerous opportunities to improve the visual appeal of food and potentially the nutrition of older people with dysphagia (swallowing difficulty). This review appraises and synthesizes the evidence on the use of food-shaping methods to enhance nutrition in older adults with swallowing difficulties.

METHODS

In August 2022, five electronic databases (PubMed, CINAHL, Scopus, Cochrane Library, and Web of Science) were searched for original research related to the intersection of nutrition, food shaping, and older adults with swallowing difficulties. Characteristics of included studies were described and data from results and findings extracted for analysis across studies.

RESULTS

Eighteen studies met the inclusion criteria and encompassed a variety of settings, including aged care settings (n = 15) and food science laboratories (n = 3). Qualitative and quantitative findings demonstrated a variety of impacts of food shaping for the older adult with swallowing difficulty, including enhanced nutrition and wellbeing. The content themes identified across studies were: links between food shaping and nutrition, shaping food for individual choice, food shaping for enjoyment, a combination of supporting factors, collaborative inter-disciplinary teams and roles, and implementation aligns with local contexts.

CONCLUSION

With recent growth in research on food shaping, the body of studies reviewed identified an influence of food-shaping methods on the nutritional status of older adults with swallowing difficulties. Given the identified potential benefit of food shaping and attention to the visual appeal of food for older people, further research examining links between food shaping and nutrition are warranted.

Post-discharge consequences of protein-energy malnutrition, sarcopenia, and frailty in older adults admitted to rehabilitation: A systematic review

BACKGROUND & AIMS

Malnutrition, sarcopenia, and frailty are three prevalent wasting conditions among older rehabilitation patients that lead to multiple health-related negative outcomes. This systematic review and meta-analysis aimed to determine the post-discharge consequences of malnutrition, sarcopenia, and frailty in older adults admitted to inpatient rehabilitation.

METHODS

MEDLINE, Embase, Web of Science, and CINAHL databases were searched on 20 April, 2021 for longitudinal studies in older adults (≥65 years) admitted for inpatient rehabilitation. This systematic review included and synthesised studies that 1) measured malnutrition, sarcopenia, and/or frailty using a validated assessment tool or guideline; and 2) reported the association with post-discharge mortality, physical function, quality of life, or discharge location. The Academy of Nutrition & Dietetics Quality Criteria Checklist and GRADE criteria were used to assess risk of bias and evidence certainty. Where possible, data were pooled using Revman.

RESULTS

Twenty-six observational studies (n = 9709 participants in total) with similarly aged populations were included. Eight, seven, and eleven studies assessed malnutrition, sarcopenia, and frailty, respectively. Follow-up periods ranged from immediate to 7 years post-rehabilitation. Malnutrition was associated with discharge to a higher level of care (GRADE: very low), and worse quality of life (GRADE: very low) and physical function (GRADE: very low). Sarcopenia was associated with worse physical function (GRADE: very low) and lower rate of home discharge (OR: 0.14; 95%CI: 0.09-0.20; I²:30%; GRADE: low). Frailty was associated with increased mortality (GRADE: very low), hospital readmission (GRADE: very low), and decreased home discharge (GRADE: very low).

CONCLUSION

Wasting conditions in older adults during rehabilitation admission may be associated with poorer quality of life, lower rates of home discharge, and higher rates of health service use, physical dysfunction, and mortality following discharge. Further research is needed to investigate the comparative and combined impacts, as well as the overlap of malnutrition, sarcopenia, and frailty during and after rehabilitation to guide priority screening and intervention.

Two Distinct Nutritional Assessment Tools Have Dissimilar Outcomes in a Sample of Older Adult Patients With Cancer

Introduction

Malnutrition is strongly associated with negative outcomes in aged populations with cancer. Several studies have compared the outcomes of nutritional-screening tools, but knowledge specifically covering older adult patients with cancer remains limited. The aim of this study was to compare the outcomes of two tools, the Patient-Generated Subjective Global Assessment (PG-SGA) versus the Mini Nutritional Assessment (MNA) for this population.

Method

Cross-sectional study with 432 participants who consented to participate and were enrolled at admission to medical and surgical wards of a tertiary referral hospital. The participants’ nutritional statuses were simultaneously assessed using the PG-SGA and the MNA, and the outcomes compared using the kappa statistical test. The Receiver Operating Characteristic Curve (ROC) was employed to calculate the MNA sensitivity, specificity, positive and negative predictive values, and was compared with PG-SGA.

Results

Prevalence of good nourishment was observed in 62.5% and 61.1% of the participants, as detected by PG-SGA and MNA, respectively. Both tools concurred moderately (kappa = 0.453). Importantly, there were significant differences in the diagnosis of malnutrition (7.6% vs. 4.6%, p = 0.000). The MNA showed sensitivity of 72.2% and specificity of 75.9% in detecting good nourishment for the population investigated.

Conclusion

The MNA may not present greater sensitivity, possibly due to a lack of coverage of gastrointestinal symptoms. It is a quick and efficient tool for nutritional assessment of older adult patients with cancer, but as it is more specific than sensitive, caution is recommended when identifying borderline or early malnourished individuals of this population.

Comparing the validity of anthropometric measurements in identifying malnutrition status of older age people in Borena district, North Central Ethiopia: a cross_sectional study

Background

Malnutrition among older age people is becoming significantly higher in spite of improvements in the health care system. Life expectancy of Ethiopian elders is increasing; but reliable and valid tools for screening and diagnosis of malnutrition in this subgroup are limited. This study aimed to assess the validity of anthropometric measurements: Mid Upper Arm Circumference (MUAC), Body Mass Index (BMI), and Calf Circumference (CC) in detecting malnutrition status of older age people in Ethiopia.

Methods

A community based cross-sectional study was conducted in Borena District from January to March, 2020. A total of 421 participants aged were systematically included in the study. To test reliability and validity of the measurements,Cronbach’s α coefficient and Pearson’s correlations were used, respectively. The full Mini-Nutritional Assessment (MNA) tool was used to diagnosis malnutrition. Overall accuracy, sensitivity and specificity of BMI, MUAC and CC were estimated using Receiver Operating Characteristic curves. The Youden Index was used to determine the best cut-off point.

Results

The reliability of BMI, MUAC and CC by Cronbach’s alpha was found 0.847. Significant positive correlations between MNA, BMI(r = 0.56, p < 0.01); MNA, MUAC(r = 0.43, p < 0.01; and MNA, CC(r = 0.52, p < 0.01) revealed. The area under the curve (AUC) of BMI, MUAC and CC were found: 0.98(95% CI, 0.96–0.99, p < 0.001), 0.94(95% CI, 0.89–0.98, p < 0.001) and 0.96(95% CI, 0.94–0.98, p < 0.001) indicating the overall accuracy respectively. The sensitivity and specificity of BMI, MUAC and CC using established cut off points were found: 90%, 96%; 78%, 94% and 84%, 95% respectively. However, using the Youden index the best cut-off point, the sensitivity and specificity of MUAC and CC were 88%, 86%; 92% and 89% respectively and adjusted for age and sex.

Conclusions

The current study demonstrated that BMI was a reliable and valid method to identify the malnutrition status of older age people. A MUAC value of 19 cm and CC of 30 cm were simple and efficient cut-off points for the determination of malnutrition in the older age people. A future study is needed to validate the validity of BMI, MUAC and CC against biochemical tests as gold standard.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03467-9.

In patients admitted to a home rehabilitation service, is remote completion of the PG-SGA physical examination using still images captured by Allied Health Assistants a valid alternative to an in-person physical examination?

BACKGROUND

There is increasing provision of telehealth services, including nutrition services. However remote nutrition assessments are challenging due to difficulties in conducting physical assessments remotely, a crucial component of assessing nutritional status.

OBJECTIVE

The aim of this study was to evaluate whether remote completion of the PG-SGA physical examination using still images captured by Allied Health Assistants is a valid alternative to an in-person physical examination in patients admitted to a home rehabilitation service.

DESIGN

This study was Cross-sectional in design.

PARTICIPANTS/SETTING

This study involved 104 adults admitted to the home-rehabilitation service at Southern Adelaide Local Health Network, Adelaide Australia over two sampling periods in 2019 and 2020 who were receiving home visits by an AHA and were engaged in rehabilitation activities.

MAIN OUTCOME MEASURES

Validity of the still-image based physical assessment was determined using still-images collected by an AHA and an in-person physical assessment completed by a dietitian from each participant. A dietitian blinded to the in-person results later assessed the de-identified still-images to determine the presence and extent of deficit at each anatomical site and overall physical examination component of the Patient-generated subjective global assessment (PG-SGA).

STATISTICAL ANALYSES PERFORMED

Percentage agreement, weighted kappa, sensitivity and specificity between the still-image based and in-person physical examinations were determined to assess agreement between the two methods of assessment.

RESULTS

The still-image based physical examination achieved a percentage agreement of 75% against the in-person examination, with a weighted kappa of 0.662 (0.516, 0.808) and a sensitivity-specificity pair of 76.6% and 89.1%.

CONCLUSIONS

Physical examination using still-images collected by AHAs achieved percentage agreement, kappa and sensitivity and specificity compared to an in-person physical examination that is consistent with or superior to commonly adopted nutrition screening and assessment tools. There is potential for implementation of this method to facilitate remote nutritional assessments by dietitians however further work is needed to ensure dietitians are able to assess still-images reliably.

The Importance of Nutrition in Neurological Disorders and Nutrition Assessment Methods

Neurological disorders can change patients' nutritional status by directly or indirectly affecting dietary intake through mechanisms such as dysphagia, movement disorders, cognitive impairment, and depression. Malnutrition contributes to complications, resulting in delayed rehabilitation and increased morbidity and mortality. It is important to prevent malnutrition in patients with neurological disorders and to improve their nutritional status by identifying nutritional deterioration at an early stage and implementing appropriate nutritional interventions. This review examines the nutritional screening and assessment process in patients with neurological disorders, with a particular focus on stroke patients undergoing rehabilitation. Nutritional assessment, the first step of clinical nutrition management, identifies nutritional problems and their causes, signs, and symptoms through an overall evaluation including anthropometric measurements, dietary assessments, biochemical assessment, nutrition-related physical examinations, and functional assessment data. Based on the assessment, a nutritional intervention plan is established. By synthesizing the assessment results of selected subjective and objective indicators, nutritional screening tools to screen patients at risk of malnutrition and nutritional assessment tools to diagnose malnutrition were developed. It is important to use those tools with a clear understanding of their characteristics and scope.

Serum Leptin Levels, Nutritional Status, and the Risk of Healthcare-Associated Infections in Hospitalized Older Adults

We aimed to determine whether serum leptin levels are predictive of the occurrence of healthcare-associated infections (HAIs) in hospitalized older patients. In a prospective cohort, 232 patients had available data for leptin and were monitored for HAIs for 3 months. Admission data included comorbidities, invasive procedures, the Mini Nutritional Assessment (MNA), BMI, leptin, albumin and C-reactive protein levels, and CD4 and CD8 T-cell counts. Multivariate logistic regression modelling was used to identify predictors of HAIs. Of the 232 patients (median age: 84.8; females: 72.4%), 89 (38.4%) experienced HAIs. The leptin level was associated with the BMI (p < 0.0001) and MNA (p < 0.0001) categories. Women who experienced HAIs had significantly lower leptin levels than those who did not (5.9 μg/L (2.6–17.7) and 11.8 (4.6–26.3), respectively; p = 0.01; odds ratio (OR) (95% confidence interval): 0.67 (0.49–0.90)); no such association was observed for men. In a multivariate analysis of the women, a lower leptin level was significantly associated with HAIs (OR = 0.70 (0.49–0.97)), independently of comorbidities, invasive medical procedures, and immune status. However, leptin was not significantly associated with HAIs after adjustments for malnutrition (p = 0.26) or albuminemia (p = 0.15)—suggesting that in older women, the association between serum leptin levels and subsequent HAIs is mediated by nutritional status.

Compromised intestinal integrity in older adults during daily activities: a pilot study

BACKGROUND

Malnutrition is a common and significant problem in older adults. Insight into factors underlying malnutrition is needed to develop strategies that can improve the nutritional status. Compromised intestinal integrity caused by gut wall hypoperfusion due to atherosclerosis of the mesenteric arteries in the aging gastrointestinal tract may adversely affect nutrient uptake. The presence of compromised intestinal integrity in older adults is not known. The aim of this study is to provide a proof-of-concept that intestinal integrity is compromised in older adults during daily activities.

METHODS

Adults aged ≥75 years living independently without previous gastrointestinal disease or abdominal surgery were asked to complete a standardized walking test and to consume a standardized meal directly afterwards to challenge the mesenteric blood flow. Intestinal fatty acid-binding protein (I-FABP) was measured as a plasma marker of intestinal integrity, in blood samples collected before (baseline) and after the walking test, directly after the meal, and every 15 min thereafter to 75 min postprandially.

RESULTS

Thirty-four participants (median age 81 years; 56% female) were included. Of the participants, 18% were malnourished (PG-SGA score ≥ 4), and 32% were at risk of malnutrition (PG-SGA score, 2 or 3). An I-FABP increase of ≥50% from baseline was considered a meaningful loss of intestinal integrity and was observed in 12 participants (35%; 8 females; median age 80 years). No significant differences were observed in either baseline characteristics, walking test scores, or calorie/macronutrient intake between the groups with and without a ≥ 50% I-FABP peak.

CONCLUSION

This study is first to indicate that intestinal integrity is compromised during daily activities in a considerable part of older adults living independently.

Nutrition assessment and geriatric associated conditions among free living elderly people in Birjand, East of Iran: a cross-sectional study

BACKGROUND

Few data are available on the nutritional status of Iranian geriatric population. The present study aimed to determine the nutritional status of older adults' population in Birjand, East of Iran.

METHODS

The community-based cohort study was performed on older adults population (60 years and older) living in urban and rural areas of Birjand. The mini nutritional assessment (MNA) questionnaire was used to assess nutritional status. Anthropometric and biochemical evaluation were also performed for all of the participants.

RESULTS

A total of 1417 geriatric person were enrolled in this study, which, most of them were female (51.9 %). According to MNA tool, most of the participants (73.3 %) had normal nutrition (MNA score ≥ 24). Malnourished (MNA score < 17) and at high risk of malnutrition (MNA score: 17- 23.5) were constituted 0.9 % and 25.8 % of the participants, respectively. Marital status, occupation, period of education and family member were associated with nutritional status. Multiple logistic regression showed that with increase of body mass index (BMI) (OR = 0.96), education years (OR = 0.95), hemoglobin (OR = 0.86) and lymphocyte (OR = 0.98), the odds of malnutrition decreased, but with increase of age the odds (1.03) of malnutrition is also elevated.

CONCLUSIONS

MNA could successfully forecast the risk of malnutrition and malnourished people. Sociodemographic factors are associated with the nutritional status.

Association between Improvement of Oral Health, Swallowing Function, and Nutritional Intake Method in Acute Stroke Patients

Stroke and poor oral health are common in older people, and the brain injuries associated with stroke are often accompanied by a decline in oral function. In this study, we investigated the characteristics of stroke patients who could not recover oral ingestion until discharge and the association between improved oral health, swallowing function, and nutritional intake methods in acute care. The subjects were 216 consecutive stroke patients who were admitted to Tokyo Medical and Dental University hospital and received oral health management. Nutritional intake, dysphagia, and oral health were evaluated using the Functional Oral Intake Scale (FOIS), Dysphagia Severity Scale (DSS), and Oral Health Assessment Tool (OHAT), respectively. Patients in the tube feeding group (FOIS level 1-2, N = 68) tended to have a worse general condition, fewer functional teeth, and a worse DSS level than those in the oral nutrition group (FOIS level 3-7, N = 148). Multiple analysis with improvement in FOIS score as the dependent variable showed that number of functional teeth (odds ratio [OR]: 1.08, p = 0.04) and improved DSS (OR: 7.44, p < 0.001) and OHAT values (OR: 1.23, p = 0.048) were associated with improvement in nutritional intake methods in acute care. Therefore, recovery of swallowing function and oral health might be important for stroke patients to recover oral ingestion in acute care.

Patient-Generated Subjective Global Assessment (PG-SGA) predicts length of hospital stay in lung adenocarcinoma patients

The prevalence of malnutrition is high among oncology patients in Northern China. Malnutrition is related to the longer hospital stay, and it can be used to predict the prognostic outcome of patients. This work focused on investigating the relationship of nutritional condition with the length of hospital stay (LOS) in Northern Chinese patients with lung adenocarcinoma (LUAD). The Patient-Generated Subjective Global Assessment (PG-SGA), Nutritional Risk Screening 2002 (NRS 2002) score, recent weight loss and BMI were assessed in a probabilistic sample of 389 LUAD patients without epidermal growth factor receptor (EGFR) mutations. This study collected the demographic and clinical features of patients in a prospective manner. Then, we examined the association of nutritional status with LOS among the population developing LUAD. According to the PG-SGA, 63 (16·3 %), 174 (44·7 %) and 78 (20·1 %) patients were at risk for undernutrition, moderate undernutrition and severe undernutrition, respectively. Nutritional risk was found in 141 (36·2 %) patients based on the NRS 2002. The average LOS for tumour patients in Northern China was 12·5 d. At admission, a risk of undernutrition or undernutrition according to the PG-SGA (P < 0·001), NRS 2002 (P < 0·001) and latest weight loss (P < 0·001) predicted the longer LOS. LOS was related to nutritional status and hospitalisation expenses (P < 0·001). LUAD patients who stayed in the ICU had a poorer nutritional status and a longer LOS (P < 0·001). In Northern Chinese patients with LUAD, a risk for undernutrition evaluated by the PG-SGA, the NRS 2002 and recent weight loss, but not BMI, could predict a longer LOS.

Geriatric malnutrition and depression: Evidence from elderly home care population in Bangladesh

Malnutrition is the root of numerous complications ranging from physical disability to mental health problems like depression. Depending on the intensity, depression can lead to emotional fluctuations, even suicidal attempts. Geriatric health in a country like Bangladesh is often ignored, although they are a growing segment of society. This community-based cross-sectional study aimed to determine the prevalence and severity of depression and malnutrition in the elderly to evaluate the relationship between depression and malnutrition. Mini Nutritional Assessment (MNA) was used to determine nutritional status, and Geriatric Depression Scale (GDS) was used to assess depression. About 84% of the participants showed a different array of depression symptoms. The rate of malnutrition and depression is higher among the male participants. Being malnourished (OR: 4.05, 95% CI: 2.79-5.87) and people are at risk of malnutrition (OR:1.67, 95% CI:1.24-2.24) had a significantly higher risk of suffering from depression. Maintaining a good physical state, a healthy lifestyle, and a supportive family environment are among the factors that can reduce depression in the elderly population. Therefore, to fight depression, specific programs and targeted interventions focusing on physical and mental stability for the elderly at the community level can enhance awareness at the individual and family levels.

Evaluation of the Validity and Feasibility of the GLIM Criteria Compared with PG-SGA to Diagnose Malnutrition in Relation to One-Year Mortality in Hospitalized Patients

BACKGROUND

The Global Leadership Initiative on Malnutrition (GLIM) approach to diagnose malnutrition was published in 2018. An important next step is to use the GLIM criteria in clinical investigations to assess their validity and feasibility.

OBJECTIVE

To compare the validity and feasibility of the GLIM criteria with Patient-Generated Subjective Global Assessment (PG-SGA) in hospitalized patients and to assess the association between malnutrition and 1-year mortality.

DESIGN

Post hoc analysis of a prospective cohort study.

PARTICIPANTS/SETTING

Hospitalized patients (n = 574) from the Departments of Gastroenterology, Gynecology, Urology, and Orthopedics at the Radboudumc academic facility in Nijmegen, The Netherlands, were enrolled from July 2015 through December 2016.

MAIN OUTCOME MEASURES

The GLIM criteria and PG-SGA were applied to identify malnourished patients. Mortality rates were collected from electronic patient records. Feasibility was assessed by evaluating the amount of and reasons for missing data.

STATISTICAL ANALYSES PERFORMED

Concurrent validity was evaluated by assessing the sensitivity, specificity, and Cohen's kappa coefficient for the GLIM criteria compared with PG-SGA. Cox regression analysis was used for the association between the GLIM criteria and PG-SGA and mortality.

RESULTS

Of 574 patients, 160 (28%) were classified as malnourished according to the GLIM criteria and 172 (30.0%) according to PG-SGA (κ = 0.22, low agreement). When compared with PG-SGA, the GLIM criteria had a sensitivity of 43% and a specificity of 79%. Mortality of malnourished patients was more than two times higher than for non-malnourished patients according to the GLIM criteria (hazard ratio [HR], 2.68; confidence interval [CI], 1.33-5.41). Data on muscle mass was missing in 454 of 574 (79%) patients because of practical problems with the assessment using bioimpedance analysis (BIA).

CONCLUSIONS

Agreement between GLIM criteria and PG-SGA was low when diagnosing malnutrition, indicating that the two methods do not identify the same patients. This is supported by the GLIM criteria showing predictive power for 1-year mortality in hospitalized patients in contrast to PG-SGA. The assessment of muscle mass using BIA was difficult to perform in this clinical population.

Risk of Weight Loss in Adult Patients and the Effect of Staffing Registered Dietitians in Kaifukuki (Convalescent) Rehabilitation Wards: A Retrospective Analysis of a Nationwide Survey

There is scarce evidence regarding the risk of weight loss and the effect of having registered dietitians (RDs) on staff in rehabilitation wards on weight loss. We aimed to examine the effects of RDs in Kaifukuki (convalescent) rehabilitation wards (KRWs) on the prevention of weight loss in adult patients. Data from 2-year nationwide annual surveys on KRWs in Japan were retrospectively analysed. Weight loss was defined as loss of ≥5% weight during the KRW stay. Risk of weight loss in class 1 KRWs (obligated to provide nutrition care) was compared with that in class 2–6 KRWs (not obligated). Risk of weight loss in class 2–6 KRWs with RDs was compared to those without. Overall, 17.7% of 39,417 patients lost weight. Class 1 KRWs showed a lower risk of weight loss than class 2–6 KRWs (17.3% vs. 18.5%, p = 0.003). KRWs with RDs showed a significantly lower incidence of weight loss than those without RDs (16.1% vs. 18.8%, p = 0.015). Class 1 KRWs and exclusively staffed RDs were independently associated with lower odds of weight loss (odds ratio = 0.915 and 0.810, respectively). Approximately 18% of KRW patients lost weight, and having RDs on staff can lower the risk of weight loss.

Malnutrition is associated with poor trajectories of activities of daily living in geriatric rehabilitation inpatients: RESORT

Malnutrition is associated with poor functional performance in geriatric rehabilitation inpatients. However, it is unclear if malnourished patients have poor functional trajectories over time. This study aimed to determine the association between (the risk of) malnutrition at admission and trajectories of Activities of Daily Living (ADL) and Instrumental ADL (IADL) from pre-admission to post-discharge in geriatric rehabilitation inpatients. An observational, longitudinal study was conducted in the REStORing health of acutely unwell adulTs (RESORT) cohort of geriatric rehabilitation inpatients. A total of 618 patients (mean age 82.1 ± 7.8 years, 57.4 % females) were included. The prevalence of the risk of malnutrition, by Malnutrition Screening Tool (MST) was 41.3 % (n = 255) and malnutrition by the Global Leadership Initiative on Malnutrition (GLIM) and European Society for Clinical Nutrition and Metabolism (ESPEN) criteria were 53.5 % (n = 331) and 13.1 % (n = 81) respectively. Malnutrition by the GLIM criteria but not the ESPEN criteria nor the risk of malnutrition, was associated with ADL trajectories of 'remained poor' (OR: 3.33, 95 %CI: 1.21-9.19) and 'deteriorated' (OR: 1.68, 95 %CI: 1.13-2.52) compared to the 'recovered' trajectory. The risk of malnutrition and malnutrition were not associated with IADL trajectories. Malnutrition at admission was associated with poor ADL trajectories but not IADL trajectories in geriatric rehabilitation inpatients.

Predictive validity of the Mini Nutritional Assessment Short-Form for rehabilitation patients: A retrospective analysis of the Japan Rehabilitation Nutrition Database

BACKGROUND

Malnutrition is associated with worse outcome in rehabilitation patients; however, appropriate malnutrition screening tools for this population have not been investigated. We examined the predictive validity of specific cut-off values of the Mini Nutritional Assessment Short-Form version 2 (MNA-SFv2) for Japanese rehabilitation patients.

METHODS

This retrospective cohort study analyzed adult patients (≥ 20 years) in the Japan Rehabilitation Nutrition Database who were in convalescent rehabilitation wards after stroke or hip fracture. Patients were classified into three categories based on MNA-SFv2 original (0-7, 8-11 and 12-14 points, respectively) or modified (0-5, 6-7 and 8-14 points, respectively) cut-off values: malnutrition, at risk of malnutrition or well-nourished. Functional independence measure (FIM) and home discharge were compared between the categories.

RESULTS

Overall, 489 patients were analyzed. Based on the MNA-SFv2 original and modified cut-off values, 64.4% and 36.0% were malnourished, 32.3% and 28.4% were at risk of malnutrition, and 3.3% and 35.6% were well-nourished, respectively. Malnutrition defined by both cut-off values was significantly associated with the FIM at admission, whereas only those defined by modified cut-off values predicted the FIM at discharge (B, -7.1; 95% confidence interval = -12.3 to -1.9). Neither original, nor modified cut-off values predicted discharge to home and long-term care facilities.

CONCLUSIONS

An MNA-SFv2 score of 0-5 points may be useful to identify Japanese patients with poor outcomes in a rehabilitation setting.

Effects of nursing nutrition interventions on outcomes in malnourished hospital inpatients and nursing home residents: A systematic review

CONTEXT

Malnutrition in institutionalized patients is associated with adverse outcomes and increased costs. Nurses have a crucial role in the recognition and treatment of malnutrition and empowering patients in nutritional care.

OBJECTIVE

This systematic review provides an overview of the effectiveness of nursing nutritional interventions to counteract malnutrition.

DATA SOURCES

Data were obtained through a systematic search in MEDLINE/PubMed, Cochrane, CINAHL, EMBASE and ISI Web of Science databases from inception to February 15^th 2018.

DATA EXTRACTION

Studies were eligible for inclusion when published in English, Spanish or German. Primary outcome parameters were nutritional status and dietary intake.

DATA ANALYSIS

The Evidence analysis checklist from the American Dietetic Association and GRADE were used to evaluate the methodological quality of the studies.

RESULTS

Out of 8162 studies, fifteen studies were included in the study, representing nine hospitals and six long-term care facilities. Two main categories of nursing nutrition interventions were identified; the implementation of 1) a nursing nutrition plan focusing on nursing actions in nutritional care or 2) nursing assistance in feeding support, mostly during mealtimes. Studies were heterogeneous and of most of them of low quality. This hampered drawing conclusions on effectiveness of nursing nutrition interventions on malnutrition related outcomes in clinical care. Nevertheless, six out of 15 studies reported a slightly improved nutritional status and/or clinical outcomes as a result of the interventions.

CONCLUSION

This review identified two categories of nursing nutrition interventions to counteract malnutrition. Their effectiveness needs to be further evaluated in future studies. Tweetable abstract: Systematic review of effective Nursing Nutrition Interventions in the management of malnutrition in hospital and nursing home care.

Capitalising on opportunities: Malnutrition coding in hospital before and after the introduction of electronic health records with an embedded malnutrition screening tool

BACKGROUND AND AIMS

During conversion from paper to electronic documentation at a tertiary hospital, the Malnutrition Screening Tool was embedded into the electronic health record (e-HR) with nursing staff's completion continued as part of admission procedures with dietetic referrals automated. Currently, the impact of e-HR implementation on malnutrition identification is unknown. Consequently, this retrospective pre-test post-test study compared one year of malnutrition coding in a tertiary teaching hospital two years before and after e-HR implementation automating malnutrition screening referrals to dietitians with subsequent malnutrition assessment completion.

METHODS

Eligibility included adults (≥18yrs) admitted overnight or longer during the 2013/2014 and 2017/2018 financial years. Requested hospital data included demographics, admission data and coding for malnutrition and dietitian intervention. Eligible admissions prior to e-HR implementation were classified as pre-e-HR group, with admissions after classified as post-e-HR. Descriptive, Fisher's exact, Mann-Whitney U and independent samples t-tests were used to compare groups.

RESULTS

Patient admissions pre-e-HR (n = 37,143) and post-e-HR (n = 36,625) implementation were clinically similar in age, gender and length of stay (57 ± 19 years, 60% male, 3 (1-918) days). However, the numbers of admissions coded annually with malnutrition increased by 47% from 1436 to 2116 following e-HR implementation (p < 0.001). The proportion of eligible patients who were malnourished on admission and not seen by a dietitian during admission decreased one third from 6.5% to 4.8% (p = 0.042).

CONCLUSIONS

Malnutrition coding increased by 47% after an e-HR implementation with an embedded malnutrition screening tool that automated referrals to dietitians impacting the identification of care to optimize nutritional status.

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

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

Clinical measurement properties of malnutrition assessment tools for use with patients in hospitals: a systematic review

Background

The use of malnutrition outcome measures (OM) by registered dietitians (RD) with inpatients in hospitals has increased promoting the achievement of nutritional care goals and supporting decision-making for the allocation of nutritional care resources in hospitals. There are 3 commonly used OMs: Subjective Global Assessment (SGA), Patient Generated-Subjective Global Assessment (PG-SGA) and Mini Nutritional Assessment (MNA). The purpose of this current study was to systematically review the evidence of the clinical measurement properties of malnutrition assessment tools for use with patients admitted in hospitals.

Methods

MEDLINE, Cinahl, EMBASE, and PubMed were searched for articles published between 2000 and 2019. Research articles were selected if they established reliability, validity, and responsiveness to change properties of the SGA, PG-SGA and MNA tools, were written in English, and used any of these OMs as an outcome measure. Abstracts were not considered. The risk of bias within studies was assessed using the Quality Appraisal for Clinical Measurement Study (QA-CMS).

Results

Five hundred five studies were identified, of which 34 articles were included in the final review: SGA (n = 8), PG-SGA (n = 13), and MNA (n = 13). Of the 34 studies, 8 had a quality score greater than 75%; 23 had a quality score of 40–75% and 3 studies had a quality score of less than 40%. PG-SGA was found to have excellentdiagnostic accuracy (ROC: 0.92–0.975; Sensitivity: 88.6–98%; Specificity: 82–100%), sufficient internal consistency (Cronbach’s alpha: 0.722–0.73), and strong test-retest reliability (r = 0.866). There was insufficient evidence to suggest adequate diagnostic accuracy and good inter-rater reliability for SGA. Only one study examined the minimum detectable change of MNA (MDC = 2.1).

Conclusions

The evidence of validity for the existing malnutrition assessment tools supports the use of these tools, but more studies with sound methodological quality are needed to assess the responsiveness of these OMs to detect the change in nutritional status.

Building Global Nutrition Policies in Health Care: Insights for Tackling Malnutrition from the Academy of Nutrition and Dietetics 2019 Global Nutrition Research and Policy Forum

Around the world, the burden of malnutrition remains high despite significant efforts to thwart both undernutrition and overnutrition. The links between food security, dietary choices, and health outcomes pose a dilemma: What can nutrition policymakers and health care professionals do to harness the benefits of nutrition to improve health outcomes for young and old? The Academy of Nutrition and Dietetics gathered a group of health care policymakers, physicians, and credentialed nutrition and dietetics practitioners from around the world for a Policy and Nutrition Forum that took place on August 31, 2019 in Krakow, Poland. Participants from countries in Asia, Europe, North America, and Latin America presented on nutrition and policy from their perspective and took part in discussions about the effects of nutrition policies on health and health care. To extend the conversation about food and nutrition and to build a healthier future for people worldwide, this report highlights information from the Forum.

High prevalence of malnutrition in Internal Medicine wards - a multicentre ANUMEDI study

BACKGROUND

Disease-related malnutrition is a significant problem in hospitalized patients, with high prevalence rates depending on the studied population. Internal Medicine wards are the backbone of the hospital setting. However, prevalence and determinants of malnutrition in these patients remain unclear. We aimed to determine the prevalence of malnutrition in Internal Medicine wards and to identify and characterize malnourished patients.

METHODS

A cross-sectional observational multicentre study was performed in Internal Medicine wards of 24 Portuguese hospitals during 2017. Demographics, hospital admissions during the previous year, type of admission, primary diagnosis, Charlson comorbidity index, and education level were registered. Malnutrition at admission was assessed using Patient-Generated Subjective Global Assessment (PG-SGA). Demographic characteristics were compared between well-nourished and malnourished patients. Logistic regression analysis was used to identify determinants of malnutrition.

RESULTS

729 participants were included (mean age 74 years, 51% male). Main reason for admission was respiratory disease (32%). Mean Charlson comorbidity index was 5.8 ± 2.8. Prevalence of malnutrition was 73% (56% moderate/suspected malnutrition and 17% severe malnutrition), and 54% had a critical need for multidisciplinary intervention (PG-SGA score ≥9). No education (odds ratio [OR] 1.88, 95% confidence interval [CI]: 1.16-3.04), hospital admissions during previous year (OR 1.53, 95%CI: 1.05-2.26), and multiple comorbidities (OR 1.22, 95%CI: 1.14-1.32) significantly increased the odds of being malnourished.

CONCLUSIONS

Prevalence of malnutrition in the Internal Medicine population is very high, with the majority of patients having critical need for multidisciplinary intervention. Low education level, admissions during previous year, and multiple comorbidities increase the odds of being malnourished.

High prevalence of malnutrition both on hospital admission and predischarge

OBJECTIVES

In Dutch hospitals malnutrition screening is routinely performed at admission, but not during follow-up or before discharge. Therefore we evaluated nutritional status during hospitalization and predischarge in a routine care setting.

METHODS

The Patient-Generated Subjective Global Assessment (PG-SGA) was used to assess nutritional status (PG-SGA Categories: A = well nourished, B = moderate/suspected malnutrition, C = severely malnourished) in adult patients on four wards of a university hospital at admission, day 5, day 10, and day ≥15. Because data were obtained in the context of clinical routine, not all data points are available for all patients. Last assessment before discharge (within ≤4 d) was taken as predischarge measurement.

RESULTS

PG-SGA data at admission were obtained in 584 patients (age 57.2 ± 17.3 y, 51.4% women, body mass index 27.0 ± 5.5 kg/m²). Prevalence of PG-SGA stage B/C was 31% at admission, 56% on day 5 (n = 292), 66% on day 10 (n = 101), and 79% on day ≥15 (n = 14). PG-SGA predischarge data were available in 537 patients, 36% of whom were PG-SGA stage B/C. Of the 91 patients assessed both at admission and predischarge, 30% of well-nourished patients became malnourished and 82% of malnourished patients remained so.

CONCLUSIONS

Prevalence of malnutrition in hospitalized patients is high at admission (31%) and, importantly, also high predischarge (36%). Malnutrition is more prevalent in patients with a longer length of stay. These findings underscore the importance of follow-up of nutritional status in hospitalized patients and adequate transmural nutrition care after discharge to prevent malnutrition from remaining undetected and untreated.

Anticholinergic Load and Nutritional Status in Older Individuals

OBJECTIVES

The association between anticholinergic load-based Anticholinergic Risk Scale scores and nutritional status is unclear in Japanese patients. The aim of this study was to establish whether anticholinergic load affects the nutritional status of geriatric patients in convalescent stages.

DESIGN

Retrospective longitudinal cohort study.

SETTING

Convalescent rehabilitation wards.

PARTICIPANTS

Of the 1490 patients aged ≥65 years who were discharged from convalescent rehabilitation wards between July 2010 and October 2018, 908 patients met the eligibility criteria. They were categorized according to the presence or absence of increased anticholinergic load from admission to discharge.

MEASUREMENTS

Demographic data, laboratory data, the Functional Independence Measure were analyzed between the groups. The primary outcome was Geriatric Nutritional Risk Index (GNRI) at discharge. Multiple linear regression analysis was performed to analyze the relationship between anticholinergic load and GNRI at discharge.

RESULTS

Multiple linear regression analysis after adjusting for confounding factors revealed that anticholinergic load was independently and negatively correlated with GNRI at discharge. Particularly, the use of chlorpromazine, hydroxyzine, haloperidol, metoclopramide, risperidone, etc. increased significantly from admission to discharge.

CONCLUSION

Increased anticholinergic load during hospitalization may be a predictor of nutritional status in geriatric patients.

Nutritional status and clinical evolution of the elderly in home enteral nutritional therapy: a retrospective cohort study

OBJECTIVE

to evaluate the clinical and nutritional evolution of elderly patients receiving home enteral nutritional therapy.

METHOD

retrospective cohort observational study. Data collection was performed through the analysis of clinical and nutritional records. The demographic, nutritional and clinical variables were analyzed. The sample consisted of elderly patients using home enteral nutritional therapy via the probe or the stomach. For the statistical analysis, the Statistical Package for the Social Sciences program was used, adopting the level of significance of 5%.

RESULTS

the sample was 218 participants, with a mean age of 76 ± 10.12 years, of which 54.1% were female. The main morbidity was the stroke sequelae. Malnutrition was the nutritional diagnosis and the overall subjective assessment, the main instrument of nutritional evaluation. The route of administration of the most prevalent diet was the nasoenteric/nasogastric tube, however, after one year of follow-up, gastrostomy became the main route. It was observed the predominance of general condition maintenance and the most prevalent clinical outcome was death.

CONCLUSION

the majority of patients in home enteral nutrition therapy presented maintenance and / or improvement of clinical and nutritional status. Therefore, this therapy may contribute to a better clinical and nutritional evolution.

Prevalence of Malnutrition or Risk in Residents in Long Term Care: Comparison of Four Tools

The ideal tool for determination of malnutrition risk or malnutrition in long term care (LTC) is elusive. This study compares prevalence, association with resident risk factors and sensitivity (SE) and specificity (SP) of malnutrition or risk categorization in 638 residents from 32 LTC homes in Canada using four tools: the Mini-Nutritional Assessment Short Form (MNA-SF); Patient-Generated Subjective Global Assessment (PG-SGA) Global Category Rating and the Pt-Global webtool; and the interRAI Long Term Care Facility undernutrition trigger. Prevalence was most common with MNA-SF (53.7%) and lowest with InterRAI (28.9%), while the PG-SGA Global Category Rating (44%) was higher than the Pt-Global webtool (33.4%). Tools were consistently associated with resident covariates with few exceptions. The PG-SGA Global Category Rating demonstrated the best sensitivity and specificity when compared to all other tools. Further work to determine the predictive validity of this tool in LTC residents is required.

Malnutrition in Older Adults with Cancer

PURPOSE OF REVIEW

Malnutrition is a common and under-recognized geriatric condition in older adults with cancer. This review describes the public health burden, malnutrition prevention, and the relationship among cancer cachexia, malnutrition, and sarcopenia. Finally, clinical practice recommendations on malnutrition and prevention are presented.

RECENT FINDINGS

Advanced age and cancer stage, frailty, dementia, major depression, functional impairment, and physical performance are important risk factors for malnutrition in older adults with cancer. The Mini Nutrition Assessment (MNA), Malnutrition Universal Screening Tool (MUST), and Patient Generated Subjective Global Assessment (PG-SGA) are the most commonly used assessment tools in older adults with cancer. In addition, malnutrition is independently associated with poor overall survival and quality of life, longer hospital stays, greater hospital cost, and hospital readmission. Comprehensive malnutrition prevention is required for improving the nutrition status among older adults with cancer.

An evaluation of the validity of nutrition screening and assessment tools in patients admitted to a vascular surgery unit

Vascular surgery patients are nutritionally vulnerable. Various malnutrition screening and assessment tools are available; however, none has been developed or validated in vascular patients. The present study aimed to: (1) investigate the validity of four commonly administered malnutrition screening tools (Malnutrition Screening Tool (MST), Malnutrition Universal Screening Tool (MUST), Nutrition Risk Screen-2002 (NRS-2002) and the Mini-Nutritional Assessment - Short Form (MNA-SF) and an assessment tool (the Patient-Generated Subjective Global Assessment (PG-SGA)) compared against a comprehensive dietitian's assessment and (2) evaluate the ability of the instruments to predict outcomes. Vascular inpatients were screened using the four malnutrition screening tools and assessed using the PG-SGA. Each was assessed by a dietitian incorporating nutritional biochemistry, anthropometry and changes in dietary intake. Diagnostic accuracy, consistency and predictive ability were determined. A total of 322 (69·3 % male) patients participated, with 75 % having at least one parameter indicating nutritional deficits. No instrument achieved the a priori levels for sensitivity (14·9-52·5 %). Neither tool predicted EuroQoL 5-dimension 5-level score. All tools except the MNA-SF were associated with length of stay (LOS); however, the direction varied with increased risk of malnutrition on the MUST and NRS-2002 being associated with shorter LOS (P=0·029 and 0·045) and the reverse with the MST and PG-SGA (P=0·005 and <0·001). The NRS-2002 was associated with increased risk of complications (P=0·039). The MST, NRS-2002 and PG-SGA were predictive of discharge to an institution (P=0·004, 0·005 and 0·003). The tools studied were unable to identify the high prevalence of undernutrition; hence, vascular disease-specific screening and/or assessment tools are warranted.

Family in Rehabilitation, Empowering Carers for Improved Malnutrition Outcomes: Protocol for the FREER Pilot Study

BACKGROUND

Interventions to improve the nutritional status of older adults and the integration of formal and family care systems are critical research areas to improve the independence and health of aging communities and are particularly relevant in the rehabilitation setting.

OBJECTIVE

The primary outcome aimed to determine if the FREER (Family in Rehabilitation: EmpowERing Carers for improved malnutrition outcomes) intervention in malnourished older adults during and postrehabilitation improve nutritional status, physical function, quality of life, service satisfaction, and hospital and aged care admission rates up to 3 months postdischarge, compared with usual care. Secondary outcomes evaluated include family carer burden, carer services satisfaction, and patient and carer experiences. This pilot study will also assess feasibility and intervention fidelity to inform a larger randomized controlled trial.

METHODS

This protocol is for a mixed-methods two-arm historically-controlled prospective pilot study intervention. The historical control group has 30 participants, and the pilot intervention group aims to recruit 30 patient-carer pairs. The FREER intervention delivers nutrition counseling during rehabilitation, 3 months of postdischarge telehealth follow-up, and provides supportive resources using a novel model of patient-centered and carer-centered nutrition care. The primary outcome is nutritional status measured by the Scored Patient-Generated Subjective Global Assessment Score. Qualitative outcomes such as experiences and perceptions of value will be measured using semistructured interviews followed by thematic analysis. The process evaluation addresses intervention fidelity and feasibility.

RESULTS

Recruitment commenced on July 4, 2018, and is ongoing with eight patient-carer pairs recruited at the time of manuscript submission.

CONCLUSIONS

This research will inform a larger randomized controlled trial, with potential for translation to health service policies and new models of dietetic care to support the optimization of nutritional status across a continuum of nutrition care from rehabilitation to home.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry Number (ACTRN) 12618000338268; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374608&isReview=true (Archived by WebCite at http://www.webcitation.org/74gtZplU2).

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/12647.

Senior Sway: Using a Mobile Application to Measure Fall Risk

BACKGROUND AND PURPOSE

The Senior Sway mobile application uses the iPhone/iPad gyroscope to assess postural sway and motion reaction time. Impairment in postural sway and motion reaction time have the potential to increase risk for future falls. Senior Sway thereby has the potential to provide a quick, easy to use, objective measure for predicting falls in older adults. The purpose of this study was to evaluate the feasibility of the Senior Sway mobile application and its associations with fall risk in community-dwelling older adults.

METHODS

Adults older than 62 years were recruited from senior centers and community events. Descriptive and bivariate statistics were used to examine feasibility on the basis of enrollment, time required, satisfaction with application, and association with fall risk.

RESULTS AND DISCUSSION

Fifty-seven adults were recruited. Use of the Senior Sway mobile application was feasible. Ninety-one percent said that they liked the application and reported length of time of assessment was "just right." The average Senior Sway score was 64.0 (range: 47.8-84.0), which was significantly associated with the 30-second sit-to-stand test. In addition, the motor reaction time score was associated with the Timed Up and Go.

CONCLUSIONS

Senior Sway is a promising application to improve identification of adults at risk for falls and need for rehabilitation but warrants further research.

Relationship between nutritional status and improved ADL in individuals with cervical spinal cord injury in a convalescent rehabilitation ward

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To investigate the relationship of nutritional status with improvement of activities of daily living in individuals with cervical spinal cord injury.

SETTING

A convalescent rehabilitation ward at the Toyama Prefectural Rehabilitation Hospital and Support Center for Children with Disabilities in Japan.

METHODS

This retrospective analysis investigated adults (age ≥20 years) with cervical spinal cord injury who were consecutively admitted to a convalescent rehabilitation ward between 2006 and 2015. Data of 154 patients were analyzed. Nutritional status was evaluated using the Subjective Global Assessment (SGA; 3 groups: well-nourished, suspected of being malnourished or moderately malnourished, severely malnourished) and body mass index (BMI; 3 groups: underweight, standard, and overweight and obese). The main outcome was functional independence measure (FIM) efficiency. Multiple regression analysis was performed to investigate the relationship of SGA and BMI to FIM efficiency.

RESULTS

FIM efficiency was significantly higher in the well-nourished group based on the SGA than in the two groups with malnutrition (P = .007: 0.32 vs. 0.26 vs. 0.10). Multivariate regression analysis revealed that FIM efficiency was similar in the underweight and standard group, but was significantly higher in the overweight and obese group (P = .006: 0.20 vs. 0.21 vs. 0.31).

CONCLUSIONS

SGA and BMI on admission may be independently associated with FIM efficiency in patients with cervical spinal cord injury.

A systematic review, meta-analysis and meta-regression of the prevalence of protein-energy malnutrition: associations with geographical region and sex

Background

protein-energy malnutrition is a major health concern in home-dwelling older adults, particularly in the context of an ageing population. Therefore, a systematic review and meta-analysis was undertaken to determine the prevalence of malnutrition among older adults living independently in the community according to geographical region, sampling frame, rurality and sex.

Methods

six electronic databases were searched until September 2016. Original research studies which used the Mini Nutritional Assessment, Patient-Generated Subjective Global Assessment or Subjective Global Assessment to determine nutrition status in community samples with a mean age of ≥65 years were critically appraised and pooled using meta-analysis. Meta-regression was used to explore predictors of malnutrition prevalence in pooled statistics with high heterogeneity.

Results

111 studies from 38 countries (n = 69,702 participants) were included. The pooled prevalence of malnutrition in the older community setting ranged from 0.8% (95% CI: 0.2-1.7%) in Northern Europe to 24.6% (95% CI: 0.0-67.9%) in South-East Asia. Of all sampling frames, participants receiving homecare services had the highest prevalence at 14.6% (95% CI: 9.9-20.0%). Malnutrition prevalence in rural communities (9.9%; 95% CI: 4.5-16.8%) was double that in urban communities (5.7%; 95% CI: 4.2-7.3%) and higher among females than males (odds ratio = 1.45 [95% CI: 1.27-1.66]; P < 0.00001).

Conclusions

the results of this review provide strategic insight to develop public and community health priorities for preventing malnutrition and associated poor health outcomes.

Comparison of Patient Food Intake, Satisfaction and Meal Quality Between Two Meal Service Styles in a Geriatric Inpatient Unit

This pilot study evaluated the introduction of a bistro evening meal service in a geriatric inpatient unit by comparing patient intake, satisfaction and meal quality of this new service to the usual central preplated service. Ten meals were observed under each condition (n = 30; mean age 79 years, 47% male). Data were collected on intake of each meal component (none, ¼, ½, ¾, all; converted to energy and protein using known food composition data), patient satisfaction with meals (meal flavor/taste, appearance, quality, staff demeanor; seven-point scale) and meal quality (sensory properties, temperature; five-point scale). Independent t-tests were used to compare energy and protein intakes between bistro and preplated services. There was no difference in mean energy or protein intake (energy: 2524 ± 927 kJ vs. 2692 ± 857 kJ, p = 0.612; protein: 29 ± 12 g vs. 27 ± 11 g, p = 0.699) patient satisfaction or meal quality between the bistro and preplated meal services. Patients were provided with fewer meal items during the bistro service, but ate a higher proportion of what was provided to them. Implementing a bistro service did not increase intake, satisfaction or meal quality in this study, suggesting that meal plating may be only one of many factors influencing intake and satisfaction of older inpatients.

Economic evaluation of an extended nutritional intervention in older Australian hospitalized patients: a randomized controlled trial

Background

Prevalence of malnutrition in older hospitalized patients is 30%. Malnutrition is associated with poor clinical outcomes in terms of high morbidity and mortality and is costly for hospitals. Extended nutrition interventions improve clinical outcomes but limited studies have investigated whether these interventions are cost-effective.

Methods

In this randomized controlled trial, 148 malnourished general medical patients ≥60 years were recruited and randomized to receive either an extended nutritional intervention or usual care. Nutrition intervention was individualized and started with 24 h of admission and was continued for 3 months post-discharge with a monthly telephone call whereas control patients received usual care. Nutrition status was confirmed by Patient generated subjective global assessment (PG-SGA) and health-related quality of life (HRQoL) was measured using EuroQoL 5D (EQ-5D-5 L) questionnaire at admission and at 3-months follow-up. A cost-effectiveness analysis was conducted for the primary outcome (incremental costs per unit improvement in PG-SGA) while a cost-utility analysis (CUA) was undertaken for the secondary outcome (incremental costs per quality adjusted life year (QALY) gained).

Results

Nutrition status and HRQoL improved in intervention patients. Mean per included patient Australian Medicare costs were lower in intervention group compared to control arm (by $907) but these differences were not statistically significant (95% CI: -$2956 to $4854). The main drivers of higher costs in the control group were higher inpatient ($13,882 versus $13,134) and drug ($838 versus $601) costs. After adjusting outcomes for baseline differences and repeated measures, the intervention was more effective than the control with patients in this arm reporting QALYs gained that were higher by 0.0050 QALYs gained per patient (95% CI: -0.0079 to 0.0199). The probability of the intervention being cost-effective at willingness to pay values as low as $1000 per unit improvement in PG-SGA was > 98% while it was 78% at a willingness to pay $50,000 per QALY gained.

Conclusion

This health economic analysis suggests that the use of extended nutritional intervention in older general medical patients is likely to be cost-effective in the Australian health care setting in terms of both primary and secondary outcomes.

Trial registration

ACTRN No. 12614000833662. Registered 6 August 2014.