Effects of food fortification on nutritional and functional status in frail elderly nursing home residents at risk of malnutrition

Physical Exercise Intervention Characteristics and Outcomes in Frail and Pre-Frail Older Adults

(1) Background: Frailty is a multifactorial syndrome that significantly impacts the functional abilities of older adults, making them more vulnerable to falls, disabilities, and dependence. Exercise can serve as an effective intervention for pre-frail and frail older adults, improving muscle strength and reducing the risk of falls. This research aims to clarify the physical exercise protocols and their outcomes for this population. (2) Methods: A scoping review was conducted to summarize the evidence on physical activity parameters for frail and pre-frail older adults. The search included primary evidence sources published in PubMed, PEDro, Biomed, Scopus, and Springer, as well as search engines like Google Scholar and Dialnet. The keywords used were ([frailty] OR [frail] AND [exercise]). The PEDro and MINORS scales were used to assess the quality of the evidence and evaluate the risk of bias. (3) Results: Eighteen studies met the eligibility criteria. The most commonly reported exercise program was multicomponent, which included aerobic activities at 70% of the maximum effort and strength exercises at 20% to 80% of the participants' maximum capacity. This approach proved effective for this population. (4) Conclusions: The studies suggest that exercise is a successful intervention strategy for addressing frailty. However, not all the articles provided adequate information regarding the dosing of their interventions.

Prevention and Treatment of Malnutrition in Older Adults Living in Long-Term Care or the Community: An Evidence-Based Nutrition Practice Guideline

Malnutrition in older adults can decrease quality of life and increase risk of morbidities and mortality. Accurate and timely identification of malnutrition, as well as subsequent implementation of effective interventions, are essential to decrease poor outcomes associated with malnutrition in older adults. The Academy of Nutrition and Dietetics Evidence Analysis Center conducted a systematic review of the literature to develop an evidence-based nutrition practice guideline for the prevention and treatment of malnutrition in older adults. The objective of this guideline was to provide evidence-based recommendations to identify, prevent, or treat protein-energy malnutrition in older adults (mean age ≥65 years) living in long-term care and community settings. This guideline provides 11 nutrition recommendations to inform shared decision making among dietitians, members of the health care team, family members or caregivers, and older adults living in long-term care or the community to prevent or treat malnutrition. Topics include dietitian effectiveness, nutrition assessment tools, oral nutrition supplements, food fortification, and home-delivered and congregate meals. Guideline implementation should include consideration of the importance of comprehensive individualized nutrition care for older adults. Future research is needed to address gaps that were identified related to the validity, reliability, and feasibility of nutrition assessment tools, as well as the effectiveness of dietitian interventions on outcomes of interest in older adults living in long-term care and the community.

Impact of food-based fortification on nutritional outcomes and acceptability in older adults: systematic literature review

Background

"Do it yourself" (DIY) food-based fortification involves adding fortificants into everyday foods. It is a flexible solution that allows older people with reduced appetite to meet their nutritional needs.

Objectives

The aims of the systematic review are (a) to describe DIY fortified recipes, (b) to evaluate their acceptability, and (c) to evaluate whether they are effective levers to improve nutritional outcomes in older people.

Methods

A systematic search of 3 databases (Web of Science, PubMed, Scopus, last searched on January 2022) was undertaken. Main eligibility criteria include older adults aged ≥60 years living at home, in an institution or in hospital. Studies carried out for a specific medical condition or targeting only micronutrient fortification were excluded. After reviewing all titles/abstracts then full-text papers, key data were extracted and synthesized narratively. The quality of included studies was assessed using Kmet et al.

Results

Of 21,493 papers extracted, 44 original studies were included (3,384 participants), with 31 reporting nutritional outcomes, 3 reporting acceptability outcomes and 10 reporting both nutritional and acceptability outcomes. The review highlighted a wide variety of DIY fortified recipes, with additional energy ranging from 23 to 850 kcal/d (M = 403; SE = 62) and/or protein ranging from 4 to 40 g/d (M = 19; SE = 2). Compared to a standard diet, DIY fortification seems to be a valuable strategy for increasing energy and protein intake in older people. However, no strong evidence was observed on the nutritional status.

Implication for future

Further acceptability studies are crucial to ensure that DIY fortified foods are palatable and thus have a significant impact on the nutritional status. In addition, it would be useful for studies to better describe DIY recipes. This information would result in a better understanding of the factors that maximize the impact of DIY fortification on nutritional outcomes. Study registration: PROSPERO no. CRD42021244689.Systematic review registration: PROSPERO: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021244689.

Frailty-originated early rehabilitation reduces postoperative delirium in brain tumor patients: Results from a prospective randomized study

Objective

To investigate the impact of frailty-originated, evidence-based early activity training on postoperative delirium in patients who have undergone brain tumor resection.

Methods

A randomized controlled trial was conducted at the Second Affiliated Hospital of Zhejiang University School of Medicine, from July 2019 to June 2020. Data on the patients' general information, incidence and duration of delirium, duration of hospital stay, and activities of daily living were collected. From the first day after surgery, the patients were randomly assigned to either the traditional care group or the frailty-originated rehabilitation towards intracranial tumors using distinct evidence (FORTITUDE) group. Non-parametric, chi-square, and log-rank tests were used to compare the onset time and duration of postoperative delirium and activities of daily living performed by the participants between the two groups.

Results

In total, 291 patients, 150 and 141 in the control group and FORTITUDE group, respectively, participated in the study. Patients in the FORTITUDE group had a lower incidence of postoperative delirium (15.6% vs. 28.7%, P ​= ​0.007), delayed onset of delirium (Z ​= ​-2.108, P ​= ​0.035), shorter duration of postoperative delirium (χ² ​= ​26.67, P ​< ​0.001), shorter hospital stay (Z ​= ​-2.037, P ​= ​0.042), and higher scores in the activities of daily living one week (Z ​= ​-2.304, P ​= ​0.021) and one month (Z ​= ​-2.724, P ​= ​0.006) after surgery than in the control group.

Conclusions

The FORTITUDE program was safe and effective in reducing the incidence and duration of postoperative delirium and improving the quality of life of patients who underwent brain tumor resection.

Multidisciplinary Assessment and Individualized Nutritional Management of Dysphagia in Older Outpatients

INTRODUCTION

The evidence on the efficacy of nutrition therapy to prevent complications of dysphagia is based on observational studies that used different tools for nutritional and dysphagia assessment, and different scales for the definition of diet textures, rendering their results incomparable and the knowledge on dysphagia management inconclusive.

METHODS

This retrospective observational study was performed in 267 older outpatients who were assessed for dysphagia and nutritional status by a multidisciplinary team at the Clinical Nutrition Unit of IRCCS INRCA geriatric research hospital (Ancona, Italy) from 2018 to 2021. GUSS test and ASHA-NOMS measurement systems were used for dysphagia assessment, GLIM criteria for the assessment of nutritional status, and the IDDSI framework to describe the texture-modified diets. Descriptive statistics were used to summarize the characteristics of the subjects evaluated. Sociodemographic, functional and clinical parameters were compared between patients with and without BMI improvement overtime by an unpaired Student's t test, Mann-Whitney U test or Chi square test, as appropriate.

RESULTS

Dysphagia was diagnosed in more than 96.0% of subjects; 22.1% (n = 59) of dysphagic subjects were also malnourished. Dysphagia was treated exclusively by nutrition therapy, prevalently by individualized texture-modified diets (77.4%). For the classification of diet texture, the IDDSI framework was used. The follow-up visit was attended by 63.7% (n = 102) of subjects. Aspiration pneumonia was registered only in one patient (less than 1%), and BMI improved in 13 of 19 malnourished subjects (68.4%). The improvement of nutritional status was primarily reached in subjects whose energy intake was increased and texture of solids modified, in younger subjects, and in those taking less drugs and not reporting any weight loss before the first assessment.

CONCLUSIONS

The nutritional management of dysphagia must guarantee both an adequate consistency and energy-protein intake. Evaluations and outcomes should be described with universal scales, in order to allow for comparison between studies and contribute to the collection of a critical mass of evidence on the efficacy of texture-modified diets in the management of dysphagia and its complications.

Interaction between malnutrition and physical disability in older adults: is there a malnutrition-disability cycle?

Malnutrition and physical disability are urgent issues in super-aging societies and the 2 phenomena are closely linked in older adults. Both conditions have common underlying causes, including physiological changes due to aging and burdens imposed by disease or injury. Accordingly, a concept of the malnutrition-disability cycle was generated and a comprehensive literature search was performed. There was insufficient evidence to prove an interrelationship between malnutrition and physical disabilities, because of the study design and poor quality, among other factors. However, some evidence exists for the interaction between low body mass index and swallowing disorders, and the effects of some malnutrition and disability components. This review provides the rationale for this interaction, the concept of a malnutrition-disability cycle is proposed, and the available evidence is critically appraise.

Review of protein intake and suitability of foods for protein-fortification in older adults in the UK

Protein is a vital dietary component for combating negative health outcomes associated with malnutrition in older adults, including sarcopenia, functional decline and reduced quality of life. Yet, recommended daily protein intake is consistently unmet, as evidenced in the literature and reaffirmed in this review. Poor appetite is recognized as a major determinant of protein-energy undernutrition and thus fortification of regular food or drinks provides a flexible and relevant approach for older adults with reduced appetite. To increase the likelihood of fortified products being successfully incorporated into the diets of older adults, they must be adaptable to older adults eating patterns, cater for their preferences and take the specific age-related problems that complicate food intake into account. This paper aims to highlight older adults' current sources of protein, shopping habits, typical eating patterns and commonly consumed foods, and hence consider appropriate carriers for protein enrichment. Data were reanalyzed from a combination of freely available UK datasets, including the National Dietary and Nutrition Survey and the Food and You Survey, alongside data purchased from market research consultancy, Kantar. These insights draw attention to the potential suitability of foods for fortification purposes, with the ultimate objective to promote eating pleasure and prevent malnutrition.

Towards developing a Core Outcome Set for malnutrition intervention studies in older adults: a scoping review to identify frequently used research outcomes

PURPOSE

To conduct a scoping review to provide a systematic overview of outcomes used in nutritional intervention studies focused on the treatment of protein-energy malnutrition in older adults.

METHODS

A systematic search of four electronic databases (Medline, EMBASE, CINAHL and Cochrane Central Register of Controlled Trials (CENTRAL) was performed to retrieve randomized controlled trials (RCTs), published until March 9, 2020, that evaluated the effect of nutritional interventions to treat protein-energy malnutrition in older adults and those at risk for malnutrition. Two authors screened titles, abstracts and full texts independently. One author extracted data that were cross-checked by another author.

RESULTS

Sixty-three articles reporting 60 RCTs were identified. Most frequently used outcomes included body weight/body mass index (75.0% of RCTs), dietary intake (61.7%), functional limitations (48.3%), handgrip strength (46.7%), and body circumference (40.0%). The frequencies differed by setting (community, hospital and long-term care). For some outcomes there was a preferred assessment method (e.g., Barthel index for functional limitations), while for other outcomes (e.g., functional performance) a much greater variation was observed.

CONCLUSION

A large variation in outcomes, not only across but also within settings, was identified in nutritional intervention studies in malnourished older adults and those at risk. Furthermore, for many outcomes there was a large variation in the used assessment method. These results highlight the need for developing a Core Outcome Set for malnutrition intervention studies in older adults to facilitate future meta-analyses that may enhance our understanding on the effectiveness of treatment.

Physical and Motor Fitness Tests for Older Adults Living in Nursing Homes: A Systematic Review

This systematic review aimed to identify the physical/motor fitness tests for nursing home residents and to examine their psychometric properties. Electronic databases were searched for articles published between January 2005 and October 2021 using MeSh terms and relevant keywords. Of the total of 4196 studies identified, 3914 were excluded based on title, abstracts, or because they were duplicates. The remaining 282 studies were full-text analyzed, and 41 were excluded, resulting in 241 studies included in the review. The most common physical component assessed was muscle strength; 174 (72.2%) studies assessed this component. Balance (138 studies, 57.3%) and agility (102 studies, 42.3%) were the second and third components, respectively, most widely assessed. In this review, we also describe the most used assessment tests for each physical/motor component. Some potentially relevant components such as manual dexterity and proprioception have been little considered. There are few studies assessing the psychometric properties of the tests for nursing home residents, although the data show that, in general, they are reliable. This review provides valuable information to researchers and health-care professionals regarding the physical/motor tests used in nursing home residences, helping them select the screening tools that could most closely fit their study objectives.

Association between dietary protein intake and changes in health-related quality of life in older adults: findings from the AusDiab 12-year prospective study

Background

Adequate dietary protein intake is recommended for older adults to optimise muscle health and function, and support recovery from illness, however, its effect on health-related quality of life (HRQoL) is unclear. The aim of this study was to examine the association between total protein intake and different sources of dietary protein and HRQoL in Australians aged 60 years and older over a 12-year period.

Methods

This study used data from the Australian Diabetes, Obesity and Lifestyle study (AusDiab), a 12-year population-based prospective study. The sample included 752 (386 females) adults aged 60 years and older. Protein intake was estimated at baseline (1999/2000) from a 74-item Food Frequency Questionnaire, and HRQoL using the 36-item Short-form Health Survey assessed at baseline (1999/2000) and after 12 years (2011/12). The association between protein intake and change in HRQoL was evaluated using multivariate regression analysis adjusted for relevant confounders. The difference in change in HRQoL between participants with total protein intakes of < 1.0 g/kg/day, intakes of between 1.0–1.2 g/kg/day and intakes of > 1.2 g/kg/day were assessed using one-way ANCOVA.

Results

Total protein intake at baseline was not associated with 12-year changes in physical component summary (PCS) or mental component summary (MCS) scores of HRQoL. Higher animal, red meat and processed animal protein intakes were associated with deteriorations in PCS scores after adjusting for relevant confounders (β = − 0.04; 95% CI: − 0.07, −0.01 ; p = 0.009; β = − 0.05; 95% CI: − 0.08, − 0.01; p = 0.018; β = − 0.17; 95% CI: − 0.31, − 0.02; p = 0.027 respectively). Higher red meat protein intake was associated with deteriorations in MCS scores after adjusting for relevant confounders (β = − 0.04; 95% CI: − 0.08, − 0.01; p = 0.011). There was no difference in 12-year changes in PCS or MCS between participants consuming total protein of < 1.0 g/kg/day, 1.0–1.2 g/kg/day and intakes of > 1.2 g/kg/day.

Conclusion

There was no relationship between total dietary protein intake and HRQoL, but higher protein intakes from animal, red meat and processed animal sources were associated with a deterioration in HRQoL scores over 12 years. Due to the number of associations examined and high drop out of older less healthy participants, further research is required to confirm the associations detected in healthy and less healthy participants, with a view to making protein intake recommendations for older adults.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02894-y.

Dietary advice with or without oral nutritional supplements for disease-related malnutrition in adults

BACKGROUND

Disease-related malnutrition has been reported in 10% to 55% of people in hospital and the community and is associated with significant health and social-care costs. Dietary advice (DA) encouraging consumption of energy- and nutrient-rich foods rather than oral nutritional supplements (ONS) may be an initial treatment.

OBJECTIVES

To examine evidence that DA with/without ONS in adults with disease-related malnutrition improves survival, weight, anthropometry and quality of life (QoL).

SEARCH METHODS

We identified relevant publications from comprehensive electronic database searches and handsearching. Last search: 01 March 2021.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of DA with/without ONS in adults with disease-related malnutrition in any healthcare setting compared with no advice, ONS or DA alone.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study eligibility, risk of bias, extracted data and graded evidence.

MAIN RESULTS

We included 94, mostly parallel, RCTs (102 comparisons; 10,284 adults) across many conditions possibly explaining the high heterogeneity.  Participants were mostly older people in hospital, residential care and the community, with limited reporting on their sex. Studies lasted from one month to 6.5 years.  DA versus no advice - 24 RCTs (3523 participants) Most outcomes had low-certainty evidence. There may be little or no effect on mortality after three months, RR 0.87 (95% confidence interval (CI) 0.26 to 2.96), or at later time points. We had no three-month data, but advice may make little or no difference to hospitalisations, or days in hospital after four to six months and up to 12 months. A similar effect was seen for complications at up to three months, MD 0.00 (95% CI -0.32 to 0.32) and between four and six months. Advice may improve weight after three months, MD 0.97 kg (95% CI 0.06 to 1.87) continuing at four to six months and up to 12 months; and may result in a greater gain in fat-free mass (FFM) after 12 months, but not earlier. It may also improve global QoL at up to three months, MD 3.30 (95% CI 1.47 to 5.13), but not later. DA versus ONS - 12 RCTs (852 participants) All outcomes had low-certainty evidence. There may be little or no effect on mortality after three months, RR 0.66 (95% CI 0.34 to 1.26), or at later time points. Either intervention may make little or no difference to hospitalisations at three months, RR 0.36 (95% CI 0.04 to 3.24), but ONS may reduce hospitalisations up to six months. There was little or no difference between groups in weight change at three months, MD -0.14 kg (95% CI -2.01 to 1.74), or between four to six months. Advice (one study) may lead to better global QoL scores but only after 12 months. No study reported days in hospital, complications or FFM. DA versus DA plus ONS - 22 RCTs (1286 participants) Most outcomes had low-certainty evidence. There may be little or no effect on mortality after three months, RR 0.92 (95% CI 0.47 to 1.80) or at later time points. At three months advice may lead to fewer hospitalisations, RR 1.70 (95% CI 1.04 to 2.77), but not at up to six months. There may be little or no effect on length of hospital stay at up to three months, MD -1.07 (95% CI -4.10 to 1.97). At three months DA plus ONS may lead to fewer complications, RR 0.75 (95% CI o.56 to 0.99); greater weight gain, MD 1.15 kg (95% CI 0.42 to 1.87); and better global QoL scores, MD 0.33 (95% CI 0.09 to 0.57), but this was not seen at other time points. There was no effect on FFM at three months. DA plus ONS if required versus no advice or ONS - 31 RCTs (3308 participants) Evidence was moderate- to low-certainty. There may be little or no effect on mortality at three months, RR 0.82 (95% CI 0.58 to 1.16) or at later time points. Similarly, little or no effect on hospitalisations at three months, RR 0.83 (95% CI 0.59 to 1.15), at four to six months and up to 12 months; on days in hospital at three months, MD -0.12 (95% CI -2.48 to 2.25) or for complications at any time point. At three months, advice plus ONS probably improve weight, MD 1.25 kg (95% CI 0.73 to 1.76) and may improve FFM, 0.82 (95% CI 0.35 to 1.29), but these effects were not seen later. There may be little or no effect of either intervention on global QoL scores at three months, but advice plus ONS may improve scores at up to 12 months. DA plus ONS versus no advice or ONS - 13 RCTs (1315 participants) Evidence was low- to very low-certainty. There may be little or no effect on mortality after three months, RR 0.91 (95% CI 0.55 to 1.52) or at later time points. No study reported hospitalisations and there may be little or no effect on days in hospital after three months, MD -1.81 (95% CI -3.65 to 0.04) or six months. Advice plus ONS may lead to fewer complications up to three months, MD 0.42 (95% CI 0.20 to 0.89) (one study). Interventions may make little or no difference to weight at three months, MD 1.08 kg (95% CI -0.17 to 2.33); however, advice plus ONS may improve weight at four to six months and up to 12 months. Interventions may make little or no difference in FFM or global QoL scores at any time point.

AUTHORS' CONCLUSIONS

We found no evidence of an effect of any intervention on mortality. There may be weight gain with DA and with DA plus ONS in the short term, but the benefits of DA when compared with ONS are uncertain. The size and direction of effect and the length of intervention and follow-up required for benefits to emerge were inconsistent for all other outcomes.  There were too few data for many outcomes to allow meaningful conclusions. Studies focusing on both patient-centred and healthcare outcomes are needed to address the questions in this review.

Effects of an individualised nutritional intervention to tackle malnutrition in nursing homes: a pre-post study

PURPOSE

Individualised interventions are recommended to tackle malnutrition in older adults, but approaches for nursing home (NH) residents are scarce. This study investigated the effects of an individualised nutritional intervention in NH residents with (risk of) malnutrition.

METHODS

In a pre-post study, 6 weeks (w) of usual care were followed by 6w of intervention. The intervention consisted of up to three supplement modules (sweet and savoury protein creams and protein-energy drink, single or combined) and, if required, reshaped texture-modified meals (RTMM).

RESULTS

Fifty residents completed the study (84 ± 8 years, 74% female). One-third (32%) received RTMM. Additional 258 ± 167 kcal/day and 23 ± 15 g protein/day were offered. Mean daily energy intake increased by 207 (95%CI 47-368, p = 0.005) kcal and protein intake by 14 (7-21, p < 0.001) g (w12 vs w1). Quality of life (QoL) increased in the subscale "care relationship" (+ 9 (3-15) points, p = 0.002, w12 vs w6). Body weight, handgrip strength, and other QoL subscales did not change.

CONCLUSION

Our intervention improved dietary intake and one QoL subscale in NH residents with (risk of) malnutrition. As a next step, randomized controlled trials are needed to investigate the impact of individualised interventions more comprehensively.

Can fortified, nutrient-dense and enriched foods and drink-based nutrition interventions increase energy and protein intake in residential aged care residents? A systematic review with meta-analyses

BACKGROUND

Food fortification as part of the food-first approach in nursing homes is a strategy that may increase energy and protein intake.

OBJECTIVES

This review aimed to determine the effect of nutrition interventions using fortification, nutrient-dense or enriched food and/or drinks on energy and protein intake in residents living in nursing homes, compared to the standard menu with or without oral nutritional support products. The secondary aim was to identify and synthesise outcomes of these interventions on weight change, nutritional status, acceptability, cost-effectiveness, and cost-benefit.

METHODS

A systematic search of seven databases was undertaken. After reviewing all titles/abstracts then full-text papers, key data were extracted and synthesised narratively and through meta-analysis. The quality of included studies was assessed using the Quality Criteria Checklist for Primary Research.

RESULTS

Of 3,098 articles retrieved, 16 were included, 13 in the meta-analysis. There were 891 participants, with the study duration ranging from four to 26 weeks. The groups receiving the fortified diet had a significantly higher energy intake (Hedges' g = 0.69 (CI 0.36-1.03), p < 0.0001) and protein intake (Hedges' g = 0.46 (CI 0.17-0.74), p = 0.003) compared with the groups receiving the standard menu +/- ONS. The meta-analysis revealed I² values of 77% for energy (p < 0.0001) and 60% for protein (p = 0.003), indicating considerable statistical heterogeneity across included studies. Benefits to weight and nutritional status of residents were recorded in some studies. Where reported, cost-effectiveness and cost-benefit of menu fortification/supplementation were variable.

CONCLUSIONS

This systematic review with meta-analyses has shown that fortified menus may significantly increase energy and protein intakes compared with standard menus in nursing homes. As such, the findings of this review support further use of fortified diets in this setting. Further research is warranted comparing food fortification to standard menus, with a particular focus on evaluating the effect on weight, nutritional status and cost-effectiveness of the intervention.

STUDY REGISTRATION

PROSPERO no. CRD42020162796.

The Nutritional Status of Long-Term Institutionalized Older Adults Is Associated with Functional Status, Physical Performance and Activity, and Frailty

Among older adults living in long-term nursing homes (LTNHs), maintaining an adequate functional status and independence is a challenge. Whilst a poor nutritional status is a potential risk factor for a decreased function in this population, its role is not fully understood. Here, using a transversal multicenter study of 105 older adults living in 13 LTNHs, we analyzed the associations between nutritional status, as measured by the Mini Nutritional Assessment (MNA), and the parameters of functional status, physical performance, physical activity, and frailty as well as comorbidity and body composition. The MNA scores were positively correlated with the Barthel Index, handgrip strength, Short Physical Performance Battery (SPPB) scores, absolute muscle power, and Assessment of Physical Activity in Frail Older People (APAFOP) scores and were negatively correlated with dynamic balance and frailty. In a multiple linear regression model controlling for gender and age, the APAFOP score (β = 0.386), BMI (β = 0.301), and Barthel Index (β = 0.220) explained 31% of the variance in the MNA score. Given the observed close relationship between the MNA score and functional status, physical performance and activity, and frailty, interventions should jointly target improvements in both the nutritional status and functional status of LTNH residents. Strategies designed and implemented by interdisciplinary professional teams may be the most successful in improving these parameters to lead to better health and quality of life.

Nutrition Assessment and Interventions for the Prevention and Treatment of Malnutrition in Older Adults: An Evidence Analysis Center Scoping Review

Older adults living in the community or long-term residence such as a nursing home are at increased risk for malnutrition due to factors such as depression and isolation. The purpose of this scoping review is to identify the best available research that evaluates the validity and reliability of nutrition assessment tools, and the effectiveness of nutrition interventions to prevent or treat malnutrition among older adults. A literature search was conducted in Medline, Embase, CINAHL, and Cochrane Central databases to identify clinical trials, published in the English language, evaluating assessment and intervention methods aimed to treat or prevent malnutrition among older adults living in the community or their long-term residence such as nursing homes. Articles were screened by 2 reviewers, then data were extracted and narratively synthesized. The literature search retrieved 20,937 articles and 197 articles were included in narrative synthesis. A total of 73 assessment articles were identified, 36 of which were validity and reliability trials. A total of 122 intervention articles were identified, the majority of which were randomized controlled trials. A few of the most commonly evaluated interventions were oral nutrition supplements, medical nutrition therapy, fortification and enrichment, and nutrition education. Several systematic reviews were identified, however, that did not meet the criteria of this review. There is a need to conduct systematic reviews for nutrition assessment and intervention trials to guide development of evidence-based nutrition practice recommendations for older adults living in the community or their long-term residence.

The effectiveness of nutrition interventions in improving frailty and its associated constructs related to malnutrition and functional decline among community-dwelling older adults: A systematic review

BACKGROUND

The present study aimed to evaluate the effectiveness of nutrition interventions on frailty and factors related to frailty, including malnutrition, sarcopenia and functional ability, among community dwelling older adults. A secondary aim was to synthesise current clinical guidelines for the identification and management of frailty, and then identify whether they aligned with the findings of the literature review.

METHODS

A systematic literature review was undertaken using four electronic databases to identify randomised controlled clinical trials that assessed the effect of nutrition interventions on frailty and outcomes related to frailty in community-dwelling older adults (PROSPERO #CRD42017069094). The quality of the included studies was appraised. A rapid review was conducted using the Google Scholar database to identify existing clinical recommendations relating to the second aim.

RESULTS

The search strategy identified 13 studies. Multifactorial interventions with nutritional education and protein-energy supplementation improved frailty stratus and physical performance in 75% and 58% of studies, respectively. Weight and nutritional status improved in 80% of studies that used oral nutritional support. The recommended process for clinical management of frailty involves screening, followed by full assessment using validated instruments and the development of a comprehensive management plan with a multidisciplinary team.

CONCLUSIONS

Multifactorial interventions were found to be more effective than nutrition intervention alone for improving frailty and physical performance. Protein-energy supplementation tended to be effective only in malnourished older adults. The results were inconclusive for the use of micronutrient supplementation for frailty and outcomes related to frailty. Existing clinical guidelines are aligned with the evidence recommending comprehensive interventions to improve frailty.

Overcoming protein-energy malnutrition in older adults in the residential care setting: A narrative review of causes and interventions

Malnutrition, in particular protein-energy malnutrition, is a highly prevalent condition in older adults, and is associated with low muscle mass and function, and increased prevalence of physical frailty. Malnutrition is often exacerbated in the residential care setting due to factors including lack of dentition and appetite, and increased prevalence of dementia and dysphagia. This review aims to provide an overview of the available literature in older adults in the residential care setting regarding the following: links between sarcopenia, frailty, and malnutrition (in particular, protein-energy malnutrition (PEM)), recognition and diagnosis of malnutrition, factors contributing to PEM, and the effectiveness of different forms of protein supplementation (in particular, oral nutritional supplementation (ONS) and protein-fortified foods (PFF)) to target PEM. This review found a lack of consensus on effective malnutrition diagnostic tools and lack of universal requirement for malnutrition screening in the residential care setting, making identifying and treating malnutrition in this population a challenge. When assessing the use of protein supplementation in the residential care setting, the two primary forms of supplementation were ONS and PFF. There is evidence that ONS and PFF increase protein and energy intakes in residential care setting, yet compliance with supplementation and their impact on functional status is unclear and conflicting. Further research comparing the use of ONS and PFF is needed to fully determine feasibility and efficacy of protein supplementation in the residential care setting.

Usual Protein Intake Amount and Sources of Nursing Home Residents with (Risk of) Malnutrition and Effects of an Individualized Nutritional Intervention: An enable Study

Nursing home (NH) residents with (risk of) malnutrition are at particular risk of low protein intake (PI). The aim of the present analysis was (1) to characterize usual PI (total amount/day (d) and meal, sources/d and meal) of NH residents with (risk of) malnutrition and (2) to evaluate the effects of an individualized nutritional intervention on usual PI. Forty residents (75% female, 85 ± 8 years) with (risk of) malnutrition and inadequate dietary intake received 6 weeks of usual care followed by 6 weeks of intervention. During the intervention phase, an additional 29 ± 11 g/d from a protein-energy drink and/or 2 protein creams were offered to compensate for individual energy and/or protein deficiencies. PI was assessed with two 3-day-weighing records in each phase and assigned to 4 meals and 12 sources. During the usual care phase, mean PI was 41 ± 10 g/d. Lunch and dinner contributed 31 ± 11% and 32 ± 9% to daily intake, respectively. Dairy products (median 9 (interquartile range 6–14) g/d), starchy foods (7 (5–10) g/d) and meat/meat products (6 (3–9) g/d) were the main protein sources in usual PI. During the intervention phase, an additional 18 ± 10 g/d were consumed. Daily PI from usual sources did not differ between usual care and intervention phase (41 ± 10 g/d vs. 42 ± 11 g/d, p = 0.434). In conclusion, daily and per meal PI were very low in NH residents with (risk of) malnutrition, highlighting the importance of adequate intervention strategies. An individualized intervention successfully increased PI without affecting protein intake from usual sources.

Texture-Modified Diets, Nutritional Status and Mealtime Satisfaction: A Systematic Review

While the association between dysphagia and malnutrition is well established, there is a lack of clarity regarding the nutritional status and mealtime satisfaction of those consuming texture-modified diets (TMDs). This systematic review summarises and critically appraises the nutritional status and mealtime satisfaction of adults consuming TMDs. A systematic database search following PICO criteria was conducted using Cochrane Central (via Ovid), MEDLINE, CINAHL, EMBASE and Scopus. Nutritional status, mealtime satisfaction and costs were identified as primary outcomes. Eligible studies were grouped according to outcome measurement. In total, 26 studies met the inclusion criteria. Twenty studies evaluated the nutritional status by weight change or using malnutrition screening tools and found the consumption of TMDs correlated with weight loss or malnutrition. Nine studies evaluated mealtime satisfaction, with two reporting poor satisfaction for people on thickened fluids (TFs). Nutrition intervention through adjusting texture and consistency and nutrition enrichment showed positive effects on weight and mealtime satisfaction. The majority of the studies were rated as 'neutral' quality due to the limited number of experiments. TMD consumers had compromised nutritional status and poor mealtime satisfaction. More research input is required to identify promising strategies for improving the nutritional status and mealtime satisfaction of this population. Food services need to consider texture, consistency and fortification in designing menus for people on TMDs to avoid weight loss and malnutrition, and to enhance mealtime enjoyment.

Results of High-Protein, High-Calorie Oral Nutritional Supplementation in Malnourished Older People in Nursing Homes: An Observational, Multicenter, Prospective, Pragmatic Study (PROT-e-GER)

OBJECTIVES

To assess if the impact of oral nutritional supplements (ONS) on nutritional and functional status in malnourished older persons living in nursing homes shown by clinical trials are also found outside a trial setting.

DESIGN

Observational, multicenter, prospective, pragmatic study.

SETTING AND PARTICIPANTS

This study was carried out in 38 nursing homes throughout Spain. Nursing home physicians recruited consecutive residents, older than 65 years, with a diagnosis of malnutrition, when a clinical decision to start ONS had been taken after unsuccessful initial management with dietary interventions.

INTERVENTION

The participants received daily 2 bottles of an energy-rich, high-protein commercial ONS for 3 months.

MEASURES

Primary outcomes were changes in nutritional status [body weight, body mass index (BMI), and Mini Nutritional Assessment-Short Form (MNA-SF)]; secondary outcomes were functional changes [Functional Ambulation Classification, Barthel index, handgrip strength, and Short Physical Performance Battery (SPPB)], as well as safety and adherence after 12 weeks of follow-up.

RESULTS

A total of 282 residents (median age 86 years, 67% women) were included, and 244 (86.5%) completed the follow-up. At baseline, 77.3% of the participants were malnourished (BMI 19.7 kg/m², interquartile range 18.3-21.8). After 12 weeks of follow-up, participants experienced significant increases in body weight (2.6 ± 3.1 kg, 5.2 ± 5.9%), BMI (1.0 ± 1.2 kg/m²) and MNA-SF (4.0 ± 2.5 points). There were also significant improvements in functional status measured by the Barthel index, handgrip strength, SPPB, and gait speed. Good adherence was registered in 94.6% of the participants. No relevant side effects were found.

CONCLUSIONS AND IMPLICATIONS

Improvements in nutritional and functional status can be found when using a high-protein, high-calorie ONS in older undernourished people living in nursing homes.

Effectiveness of Oral Nutritional Supplements on Older People with Anorexia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Nutrition plays an important role in maintaining the overall health of older people. Inadequate intake may lead to impaired body function, higher morbidity, and mortality. Oral nutritional supplements (ONS) showed positive effect on the nutritional status of the elderly; however, systematic evidence is currently lacking on the effect of ONS on the elderly with anorexia.

AIMS

The current systematic review and meta-analysis included randomized controlled trial (RCT) articles to investigate the effectiveness of ONS on the main aspects of anorexia of aging (AA).

METHODS

By using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method, researchers independently searched PubMed/MEDLINE, EMBASE, CINAHL, PsycINFO, the Cochrane Library, China National Knowledge Infrastructure (CNKI) and other gray literature resources for publications that met the inclusion criteria by October 2020. The Cochrane Risk of Bias Tools were used for quality assessment. The inverse-variance method was used for the fixed model (FM) while the DerSimonian-Laird method was used for the random model (RM). Respective 95% confidence intervals (95% CIs), mean difference (MD) or standardized mean difference (SMD) was used for indices in terms of effect size (ES).

RESULTS

2497 records were found through the systematic search, while 17 RCTs (n = 1204) were included, with a mean age of 81.9 years (range: 74-87 years). Supplementation occurred in the morning, mid-day, and evening, while the times varied from one to three times a day. The results of meta-analysis showed that, generally, ONS had a positive effect on the overall appetite, MD = 0.18, 95% CI (0.03, 0.33), p = 0.02, and consumption, MD = 1.43, 95% CI (0.01, 2.86), p = 0.05; but not significant in terms of other aspects of appetite: hunger, p = 0.73; fullness, p = 0.60; desire to eat, p = 0.80; preoccupation, p = 0.15. Additionally, it showed an increase in the overall energy intake, SMD = 0.46, 95% CI (0.29, 0.63), p < 0.001, in protein intake, SMD = 0.59, 95% CI (0.16, 1.02), p = 0.007, and in fat intake, MD = 3.47, 95% CI (1.98, 4.97), p < 0.001, while no positive effect was found on carbohydrates intake, p = 0.06. Significance differences were also found in the body weight, SMD = 0.53, 95% CI (0.41, 0.65), p < 0.001, and body mass index (BMI), MD = 0.53, 95% CI (0.12, 0.95), p = 0.01. Moreover, subgroup analyses were conducted according to the nutrient density with no positive results showed except for the low-density ONS on overall energy intake.

CONCLUSIONS

The results of the present study indicated that ONS had beneficial effects on overall appetite, energy intake, body weight and BMI.

Daily Supplementation With Whey, Soy, or Whey-Soy Blended Protein for 6 Months Maintained Lean Muscle Mass and Physical Performance in Older Adults With Low Lean Mass

BACKGROUND

Few studies have investigated the effect of long-term protein supplementation alone on muscle health in older adults with low lean mass.

OBJECTIVE

To determine the effect of whey, soy or whey-soy blended protein supplementation on lean muscle mass and physical performance in older adults with low lean mass.

DESIGN

A 4-arm randomized controlled trial.

PARTICIPANTS/SETTING

Chinese older adults (n = 123, 65-79 years) with low lean mass (appendicular skeletal muscle index < 7.0 kg/m² in men and < 5.4 kg/m² in women) living in the urban area of Guangzhou participated between October 2015 and June 2016.

INTERVENTION

Participants were randomly assigned to receive approximately 16 g/d of whey, soy, or whey-soy blend protein or maintained habitual diets in control group for 6 months.

MAIN OUTCOME MEASURES

Lean mass, handgrip strength, and physical performance (gait speed, chair stand test, and Short Physical Performance Battery) were assessed at baseline and 6 months.

STATISTICAL ANALYSES

Two-way analysis of variance with the main effects of treatment and time and treatment × time interaction and analysis of covariance was used to determine differences in outcomes.

RESULTS

Appendicular skeletal muscle index, lean mass, percent lean mass in legs and appendicular areas, gait speed, and Short Physical Performance Battery score were maintained in the treatment groups and decreased in the control group, resulting in significant reduction in these variables from baseline in the control compared with treatment groups (all P < .01; percent differences between treatment and control groups ranged from 80% to 156%). The chair stand test time at month 6 decreased from baseline in the treatment groups and increased in the control group, resulting in a significant increase in the control compared with treatment groups (all P < .01; percent differences between treatment and control groups ranged from 132% to 155%). Handgrip strength remained unchanged. There were no significant differences in outcomes among treatment groups.

CONCLUSIONS

Supplementation with whey, soy, or whey-soy blended protein for 6 months equally maintained lean muscle mass and physical performance in older adults with low lean mass.

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.

Nutritional interventions for the management of frailty in older adults: systematic review and meta-analysis of randomized clinical trials

CONTEXT

Although nutrition is considered an important intervention for the management of frailty, the actual effectiveness of interventions addressing nutrition in frail older people remains unclear.

OBJECTIVE

The aim for this systematic review was to appraise the evidence regarding the effectiveness of nutritional interventions for the management of frailty in older adults.

DATA EXTRACTION

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Web of Science, and Latin American and Caribbean Health Sciences Literature databases were searched from January 2001 to November 2019. Two independent reviewers extracted relevant data. From 2370 initial records, 19 publications presenting data from 17 studies (1564 individuals; follow-up: 7-96 weeks) were included.

DATA ANALYSIS

None of the Bayesian random-effects meta-analyses comparing nutritional supplements with placebo regarding mortality, body mass index, weight, frailty status, muscle strength, gait speed, body composition, and cognitive function showed statistically significant differences. The same applies to a single meta-analysis comparing nutritional education with general health advice regarding muscle strength.

CONCLUSION

Our results suggest, mostly with low to very low degrees of certainty, that nutritional supplements or nutritional education delivered in isolation may not be effective for the management of frailty in older people.

REVIEW REGISTRATION NUMBER

CRD42018111510 (PROSPERO).

Impact of the Serum Level of Albumin and Self-Assessed Chewing Ability on Mortality, QOL, and ADLs for Community-Dwelling Older Adults at the Age of 85: A 15 Year Follow up Study

Quality of life (QOL) and mortality are true endpoints of epidemiological or medical research, especially for community-dwelling older adults. Nutritional status and activities of daily living (ADLs) are associated with QOL and mortality. Good oral health status supports a good nutritional status. The aim of this study was to elucidate the complex structure of these important health-related factors. We surveyed 354 healthy older adults at the age of 85. Nutritional status was evaluated by the serum level of albumin. QOL, ADLs, self-assessed chewing ability, serum albumin level, and mortality during the 15 year follow up period were analyzed. Self-assessed chewing ability was associated with QOL and ADLs. Self-assessed chewing ability for slight-hard foods was associated with mortality in men. However, it was not associated with the serum albumin level. The serum albumin level was associated with mortality in women. These results indicate that maintaining good oral function is not enough. Nutritional instruction in accordance with oral function is indispensable for health promotion in older adults. When planning health promotion strategies for older adults, different strategies are needed for men and women.

An investigation of recommended serve food portions and attaining energy and protein requirements in older adults living in residential care

BACKGROUND

Ageing populations show a propensity for reduced food intake, which impacts nutritional adequacy. Nutrition guidelines for residential care homes (RCHs) are currently based on serve size of core food groups and do not consider nutrient density. The present study aimed to investigate the weight of foods served/consumed compared to recommended serve sizes and to compare energy and protein intake with individual requirements.

METHODS

This was an observational study of older adults living in four RCHs. Dietary intake was estimated through the difference between weighed reference meals and a single, double-weighed 24-h food plate waste collected from each participant. FoodWorks9^® (Xyris^® Software, Brisbane, Australia) was used to calculate energy, protein and serves of core food groups from food intake and the menu provided to recommended serve sizes. Individual intake was compared with nutrition guidelines and estimated energy and protein requirements.

RESULTS

Across 420 participants, 9.8% completed a main meal (lunch or dinner). The servings provided [248 g; interquartile range (IQR) = 206-290 g] were less than the recommended servings for a main meal (306 g = protein/starch/two vegetables), with 157 g (IQR = 109-221 g) consumed. The menu provided for minimum serves of all core food groups except for dairy. Median energy intake (n = 389) (5272 kJ day^-1 , IQR = 4229-6720 kJ) and protein intake (47.3 g day^-1 , IQR = 35.9-60.8 g) were less than estimated requirements (8181 kJ day^-1 , IQR = 7300-9338 kJ day^-1 ; 76.7 g day^-1 , IQR = 66.7-90.8 g).

CONCLUSIONS

Nutritional needs were not met in this cohort. The findings of the present study highlight the need for smaller, nutrient-dense meals and revised menu standards to ensure nutritional adequacy in this vulnerable population.

Frailty Intervention through Nutrition Education and Exercise (FINE). A Health Promotion Intervention to Prevent Frailty and Improve Frailty Status among Pre-Frail Elderly-A Study Protocol of a Cluster Randomized Controlled Trial

The ageing process has been associated with various geriatric issues including frailty. Without early prevention, frailty may cause multiple adverse outcomes. However, it potentially may be reversed with appropriate interventions. The aim of the study is to assess the effectiveness of nutritional education and exercise intervention to prevent frailty among the elderly. A 3-month, single-blind, two-armed, cluster randomized controlled trial of the frailty intervention program among Malaysian pre-frail elderly will be conducted. A minimum of total 60 eligible respondents from 8 clusters (flats) of Program Perumahan Rakyat (PPR) flats will be recruited and randomized to the intervention and control arm. The intervention group will receive a nutritional education and a low to moderate multi-component exercise program. To date, this is the first intervention study that specifically targets both the degree of frailty and an improvement in the outcomes of frailty using both nutritional education and exercise interventions among Malaysian pre-frail elderly. If the study is shown to be effective, there are major potential benefits to older population in terms of preventing transition to frailty. The findings from this trial will potentially provide valuable evidence and serve as a model for similar future interventions designed for elderly Malaysians in the community.

Leucine-Enriched Protein Supplementation Increases Lean Body Mass in Healthy Korean Adults Aged 50 Years and Older: A Randomized, Double-Blind, Placebo-Controlled Trial

Early prevention of sarcopenia could be an important strategy for muscle retention, but most studies have focused on subjects aged 65 or older. Therefore, in this study we investigated the effects of leucine-enriched protein supplementation on muscle condition in a sample including late middle-aged adults. A 12-week intervention was performed for 120 healthy community-dwelling adults by providing either leucine-enriched protein supplement [leucine 3 g, protein mixture (casein 50% + whey 40% + soy 10%) 17 g, vitamin D 800IU (20 µg), calcium 300 mg, fat 1.1 g, carbohydrate 2.5 g] or isocaloric carbohydrate supplement twice per day. Appendicular skeletal muscle mass index (ASMI) and lean body mass (LBM) were measured by dual-energy X-ray absorptiometry. A total of 111 participants completed the study, with a dropout rate of 9.2%. LBM normalized by height and body weight (LBM/Wt) was significantly increased (p < 0.001) in the intervention group (0 wk: 633.9 ± 8.5 vs. 12 wk 636.9 ± 8.4 in the intervention group; 0 wk: 638.6 ± 8.3 vs. 12 wk: 632.9 ± 8.1 in the control group). In subgroup analyses, significant differences remained only in subjects between 50 and 64 years of age. We concluded that leucine-enriched protein supplementation can have beneficial effects by preventing muscle loss, mainly for late middle-aged adults.

Higher protein intake is associated with a lower likelihood of frailty among older women, Kuopio OSTPRE-Fracture Prevention Study

PURPOSE

Nordic nutrition recommendations (2012) suggest protein intake ≥ 1.1 g/kg body weight (BW) to preserve physical function in Nordic older adults. However, no published study has used this cut-off to evaluate the association between protein intake and frailty. This study examined associations between protein intake, and sources of protein intake, with frailty status at the 3-year follow-up.

METHODS

Participants were 440 women aged 65─72 years enrolled in the Osteoporosis Risk Factor and Prevention-Fracture Prevention Study. Protein intake g/kg BW and g/d was calculated using a 3-day food record at baseline 2003─4. At the 3-year follow-up (2006─7), frailty phenotype was defined as the presence of three or more, and prefrailty as the presence of one or two, of the Fried criteria: low grip strength adjusted for body mass index, low walking speed, low physical activity, exhaustion was defined using a low life-satisfaction score, and weight loss > 5% of BW. The association between protein intake, animal protein and plant protein, and frailty status was examined by multinomial regression analysis adjusting for demographics, chronic conditions, and total energy intake.

RESULTS

At the 3-year follow-up, 36 women were frail and 206 women were prefrail. Higher protein intake ≥ 1.1 g/kg BW was associated with a lower likelihood of prefrailty (OR = 0.45 and 95% confidence interval (CI) = 0.01-0.73) and frailty (OR = 0.09 and CI = 0.01-0.75) when compared to protein intake < 1.1 g/kg BW at the 3-year follow-up. Women in the higher tertile of animal protein intake, but not plant protein, had a lower prevalence of frailty (P for trend = 0.04).

CONCLUSIONS

Protein intake ≥ 1.1 g/kg BW and higher intake of animal protein may be beneficial to prevent the onset of frailty in older women.

Individualized home-based exercise and nutrition interventions improve frailty in older adults: a randomized controlled trial

BACKGROUND

Frail older adults are predisposed to multiple comorbidities and adverse events. Recent interventional studies have shown that frailty can be improved and managed. In this study, effective individualized home-based exercise and nutrition interventions were developed for reducing frailty in older adults.

METHODS

This study was a four-arm, single-blind, randomized controlled trial conducted between October 2015 and June 2017 at Miaoli General Hospital in Taiwan. Overall, 319 pre-frail or frail older adults were randomly assigned into one of the four study groups (control, exercise, nutrition, and exercise plus nutrition [combination]) and followed up during a 3-month intervention period and 3-month self-maintenance period. Improvement in frailty scores was the primary outcome. Secondary outcomes included improvements in physical performance and mental health. The measurements were performed at baseline, 1 month, 3 months, and 6 months.

RESULTS

At the 6-month measurement, the exercise (difference in frailty score change from baseline: - 0.23; 95% confidence interval [CI]: - 0.41, - 0.05; p = 0.012), nutrition (- 0.28; 95% CI: - 0.46, - 0.11; p = 0.002), and combination (- 0.34; 95% CI: - 0.52, - 0.16; p <  0.001) groups exhibited significantly greater improvements in the frailty scores than the control group. Significant improvements were also observed in several physical performance parameters in the exercise, nutrition, and combination groups, as well as in the 12-Item Short Form Health Survey mental component summary score for the nutrition group.

CONCLUSIONS

The designated home-based exercise and nutrition interventions can help pre-frail or frail older adults to improve their frailty score and physical performance.

TRIAL REGISTRATION

Retrospectively registered at ClinicalTrials.gov (identifier: NCT03477097); registration date: March 26, 2018.

Assessment of Sarcopenia Among Community-Dwelling At-Risk Frail Adults Aged 65 Years and Older Who Received Multidomain Lifestyle Interventions: A Secondary Analysis of a Randomized Clinical Trial

IMPORTANCE

There is little understanding of the outcomes associated with active lifestyle interventions for sarcopenia among older persons.

OBJECTIVE

To determine the association of 6-month multidomain lifestyle interventions (physical exercise, nutritional enhancement, cognitive training, combined treatment, and standard care) with change in sarcopenia status and physical function among adults 65 years and older.

DESIGN, SETTING, AND PARTICIPANTS

Post hoc secondary analysis of a parallel-group randomized clinical trial conducted from September 1, 2012, to September 1, 2014, at community centers providing services to elderly individuals in Singapore. Participants included a subsample of 92 community-dwelling prefrail or frail older persons with sarcopenia aged 65 years and older. Data were analyzed from June 1, 2017, to January 1, 2018.

INTERVENTIONS

The 5 intervention groups were a 6-month duration of physical exercise that included resistance and balance training, nutritional enhancement with a commercial oral nutrition supplement formula, cognitive training, a combination of the preceding 3 interventions, and standard care (control).

MAIN OUTCOMES AND MEASURES

Primary outcomes were changes in sarcopenia status and its components, appendicular skeletal muscle index (ASMI), knee extension strength (KES), and gait speed (GS) at 3 months and 6 months following the intervention. Sarcopenia was defined as the presence of both low ASMI and low KES and/or GS.

RESULTS

In 92 participants with sarcopenia, the mean (SD) age was 70.0 (4.7) years and 59 (64.1%) were female. Seventy-eight participants received active interventions and 14 received standard care. Of 92 total participants, the number who remained sarcopenic was reduced to 48 (of 73) after 3 months and 51 (of 75) after 6 months of intervention, indicating that 25 of 92 participants (27.2%) experienced sarcopenia reduction at 3 months and 24 of 92 (26.1%) had sarcopenia reduction at 6 months. Low KES was present in 88 of 92 patients (95.6%), and low GS in 30 of 92 patients (32.6%) at baseline. Among the components of sarcopenia, GS had the greatest change associated with active interventions, with 22 of 30 participants (73.3%) free of low GS at 6 months; in comparison, 17 of 88 participants (19.3%) were free of low KES at 6 months and 7 of 92 participants (7.6%) were free of low ASMI at 6 months. Men experienced greater reduction in sarcopenia than women (χ2 = 5.925; P = .02), as did those with younger age (t = -2.078; P = .04) or higher ASMI (mean [SD] ASMI, 5.74 [0.77] vs 5.14 [0.77] kg/m2; P = .002). Participants in the active intervention group experienced statistically significant decreases in sarcopenia score and its components at 3 months and 6 months from baseline (F = 14.138; P < .001), but the intervention was not associated with significant differences in ASMI, KES, and GS vs standard care.

CONCLUSIONS AND RELEVANCE

This study suggests that older persons with sarcopenia are responsive to the effects of multidomain lifestyle interventions. Sarcopenia reduction was most pronounced through improved gait speed, and occurred more among those who were male, were younger, or had greater muscle mass.

Effects of a Texture-Modified, Enriched, and Reshaped Diet on Dietary Intake and Body Weight of Nursing Home Residents with Chewing and/or Swallowing Problems: An Enable Study

This proof-of-concept study investigated the effects of an innovative nutrition concept, comprising texture modification, enrichment, and reshaping, on dietary intake and nutritional status of 16 nursing home residents with chewing and/or swallowing problems (mean age 86.5 ± 7.4 years) in a pre-test post-test design. During 6 weeks with usual texture-modified diet (P1) energy and protein intake were constant. After the implementation of the innovative diet, daily energy intake increased by 204.2 (median) [interquartile range 95.8-444.4] kcal (P = 0.011), and protein intake by 18.3 [9.9-26.3] g (P < 0.001) and remained constant during the following 6 weeks (P2). Body weight decreased during P1 (-0.5 [-1.4 to 0.2] kg), and increased during P2 (+1.1 [0.0 to 1.7] kg, P = 0.004). The present nutrition concept turned out to be a promising strategy for nutritional management of chewing and/or swallowing problems, however, the effects need to be confirmed in larger studies.

Can foodservices in aged care homes deliver sustainable food fortification strategies? A review

Food fortification is used as a nutrition support strategy in aged care homes, for residents who are malnourished or at risk of malnutrition. The aim of this review was to determine the scope and strength of published works exploring relationships between food fortification strategies, mode of delivery and sustainability in aged care homes. Literature from four databases and grey literature was searched. A total of 3152 articles were screened. Seventeen studies were included. Results showed that the majority of studies used pre-made food fortification, rather than fortifying foods on-site. There was heterogeneity across studies, including the mode of delivery and ingredients used for food fortification. Only two studies measured any aspect of costs. No clear sustainable strategies for implementing food fortification in this setting could be identified. Research is required to provide further insight into the acceptability and sustainability of food fortification interventions.

Protein and energy intake improved by in-between meals: An intervention study in hospitalized patients

BACKGROUND/AIM

Disease related malnutrition is a major problem in hospitals. Malnutrition in hospitalized patients is caused by many factors. Among these factors are decreased appetite and early satiety, and reaching nutritional requirements in nutritional risk patients is a challenge when using ordinary energy and protein dense food. The aim of this study was to examine if total protein and energy intake in medical and surgical patients at nutritional risk could be improved by protein fortified and energy rich in-between meals.

METHODS

An assortment of fortified in-between meals including 10 g of protein was developed based on patient preferences and served in the Departments of Lung Medicine and Abdominal Surgery for a period of three months. Nutrition intake was recorded before and after intervention.

RESULTS

Food intake records were collected from a total of 92 patients, (46 before and 46 after intervention). The total amount of protein intake per in-between meal was increased from 2,6 g to 10,3 g. Total daily protein intake increased from 49% to 88% (p < 0.00) and total energy intake from 74% to 109% (p < 0.00) of requirements.

CONCLUSION

Protein and energy intake for surgical and medical patients at in-between meals as well as total daily intake increased significantly. Recommended average level for individually measured requirements was reached.

Obesity, Dietary inflammation, and Frailty among Older Adults: Evidence from the National Health and Nutrition Examination Survey

Knowledge related to the relationship between obesity and frailty is limited. This study aimed to investigate associations between obesity, dietary inflammation, and frailty among older adults. Study data came from National Health and Nutrition Examination Survey (2007-2014) examinations of adults age ≥60 years (n = 7182). Dietary inflammatory potential was determined using the Dietary Inflammatory Index (DII^®) derived from 24-h dietary recall. We analyzed independent and joint associations of obesity and DII with frailty to evaluate interaction. Multivariable logistic regression revealed that both obesity (Odds Ratio [OR] = 2.24, 95% CI: 1.68, 2.99) and moderately pro-inflammatory DII (OR = 1.68, 95% CI: 1.10, 2.58) were independently associated with greater frailty prevalence. A negative multiplicative interaction between obesity and highest pro-inflammatory diet also was found (adjusted odds in non-obese and obese were 2.07 and 2.37, respectively; p = 0.046). Results indicate the importance of considering obesity and dietary inflammatory potential when screening for frailty or developing treatments.

Systematic review and meta-analysis of the effect of protein and amino acid supplements in older adults with acute or chronic conditions

The loss of lean body mass, muscle strength and physical function causes significant problems in older adults. Protein and amino acid supplements can preserve muscle strength but the effect on function is variable. We conducted a systematic literature review and meta-analysis to investigate the effect of protein and amino acid supplementation on fat-free mass, muscle strength and physical function in malnourished, frail, sarcopenic, dependent or elderly with acute or chronic conditions, with or without rehabilitation exercise. Databases searched included Medline, BIOSIS, CINAHL, Cochrane Library, EBM Reviews, Embase, Pre-Medline, ProQuest, PubMed and Scopus. Retrieved articles were assessed by two reviewers using the Cochrane Risk of Bias (ROB) Tool. In all, thirty nine randomised controlled trails (n 4274) were included. The studies used a range of protein or essential amino acid (EAA) supplements in a variety of settings, including hospital, community and long-term care. Only seven studies had low ROB and no effect of supplementation was found on any outcomes. Analysis of all thirty-nine studies suggest protein and EAA supplements may improve fat-free mass, muscle strength and physical function (standardised mean difference 0·21-0·27, all P<0·005), but significant heterogeneity and ROB was evident. Predetermined subgroup analysis found undernourished elderly benefitted most; EAA were the most effective supplements and small beneficial effects were seen without rehabilitation exercise. The high heterogeneity and few studies with low ROB limits the conclusions and more high quality studies are needed to determine the best nutritional strategies for the maintenance of strength and function with increasing age.

Efficacy of non-pharmacological interventions to treat malnutrition in older persons: A systematic review and meta-analysis. The SENATOR project ONTOP series and MaNuEL knowledge hub project

INTRODUCTION

We aimed to perform a review of SRs of non-pharmacological interventions in older patients with well-defined malnutrition using relevant outcomes agreed by a broad panel of experts.

METHODS

PubMed, Cochrane, EMBASE, and CINHAL databases were searched for SRs. Primary studies from those SRs were included. Quality assessment was undertaken using Cochrane and GRADE criteria.

RESULTS

Eighteen primary studies from seventeen SRs were included. Eleven RCTs compared oral nutritional supplementation (ONS) with usual care. No beneficial effects of ONS treatment, after performing two meta-analysis in body weight changes (six studies), mean difference: 0.59 (95%CI -0.08, 1.96) kg, and in body mass index changes (two studies), mean difference: 0.31 (95%CI -0.17, 0.79) kg/m2 were found. Neither in MNA scores, muscle strength, activities of daily living, timed Up&Go, quality of life and mortality. Results of other intervention studies (dietary counselling and ONS, ONS combined with exercise, nutrition delivery systems) were inconsistent. The overall quality of the evidence was very low due to risk of bias and small sample size.

CONCLUSIONS

This review has highlighted the lack of high quality evidence to indicate which interventions are effective in treating malnutrition in older people. High quality research studies are urgently needed in this area.

The association between dietary protein intake, energy intake and physical frailty: results from the Rotterdam Study

Sufficient protein intake has been suggested to be important for preventing physical frailty, but studies show conflicting results which may be explained because not all studies address protein source and intake of other macronutrients and total energy. Therefore, we studied 2504 subjects with data on diet and physical frailty, participating in a large population-based prospective cohort among subjects aged 45+ years (the Rotterdam Study). Dietary intake was assessed with a FFQ. Frailty was defined according to the frailty phenotype as the presence of at least three out of the following five symptoms: weight loss, low physical activity, weakness, slowness and fatigue. We used multinomial logistic regression models to evaluate the independent association between protein intake and frailty using two methods: nutrient residual models and energy decomposition models. With every increase in 10 g total, plant or animal protein per d, the odds to be frail were 1·06 (95 % CI 0·98, 1·15), 0·87 (95 % CI 0·71, 1·07) and 1·07 (95 % CI 0·99, 1·15), respectively, using the nutrient residual method. Using the energy partition model, we observed that the odds to be frail were lower with higher vegetable protein intake (OR per 418·4 kJ (100 kcal): 0·61, 95 % CI 0·39, 0·97), however, results disappeared when adjusting for physical activity. For energy intake from any source we observed that with every 418·4 kJ (100 kcal) increase, the odds to be frail were 5 % lower (OR: 0·95, 95 % CI 0·93, 0·97). Our results suggest that energy intake, but not protein specifically, is associated with less frailty. Considering other macronutrients, physical activity and diet quality seems to be essential for future studies on protein and frailty.

Protein supplementation improves muscle mass and physical performance in undernourished prefrail and frail elderly subjects: a randomized, double-blind, placebo-controlled trial

Background

Age-related loss of muscle mass and function is a major component of frailty. Nutrition supplementation with exercise is an effective strategy to decrease frailty by preventing sarcopenia, but the effect of protein alone is controversial.

Objective

The present study was performed to investigate a dose-dependent effect of protein supplementation on muscle mass and frailty in prefrail or frail malnourished elderly people.

Design

A 12-wk double-blind randomized controlled trial was conducted in elderly subjects aged 70-85 y with ≥1 of the Cardiovascular Health Study frailty criteria and a Mini Nutritional Assessment score ≤23.5 (n = 120). Participants were randomly assigned to 1 of 3 groups: 0.8, 1.2, or 1.5 g protein · kg-1 · d-1, with concealed allocation and intention-to-treat analysis. Primary outcomes were appendicular skeletal muscle mass (ASM) and skeletal muscle mass index (SMI) measured by dual-energy X-ray absorptiometry.

Results

After the 12-wk intervention, the 1.5-g protein · kg-1 · d-1 group had higher ASM (mean ± SD: 0.52 ± 0.64 compared with 0.08 ± 0.68 kg, P = 0.036) and SMI (ASM/weight: 0.87% ± 0.69% compared with 0.15% ± 0.89%, P = 0.039; ASM/BMI: 0.02 ± 0.03 compared with 0.00 ± 0.04, P = 0.033; ASM:fat ratio: 0.04 ± 0.11 compared with -0.02 ± 0.10, P = 0.025) than the 0.8-g protein · kg-1 · d-1 group. In addition, gait speed was improved in the 1.5-g protein · kg-1 · d-1 group compared with the 0.8-g protein · kg-1 · d-1 group (0.09 ± 0.07 compared with 0.04 ± 0.07 m/s, P = 0.039). There were no significant differences between the 1.2- and 0.8-g protein · kg-1 · d-1 groups in muscle mass and physical performance. No harmful adverse effects were observed.

Conclusions

The present study indicates that protein intake of 1.5 g · kg-1 · d-1 has the most beneficial effects in regard to preventing sarcopenia and frailty compared with protein intakes of 0.8 and 1.2 g · kg-1 · d-1 in prefrail or frail elderly subjects at risk of malnutrition. This trial was registered at cris.nih.go.kr as KCT0001923.

Are the therapeutic strategies in anorexia of ageing effective on nutritional status? A systematic review with meta-analysis

BACKGROUND

Anorexia of ageing (AA) may be considered as a risk factor for frailty and has an important impact on quality of life, morbidity and mortality.

METHODS

A systematic review and a meta-analysis were performed to summarise the results from several trials on the effectiveness of treatments in AA, as associated with depression, sensory impairment of taste and smell, decreased appetite or early satiety, and disability. Eligible studies were required to report baseline and follow-up values, the mean change (∆-change) from baseline, and/or the mean difference among intervention groups versus control group, concerning food intake (kcal/daily) and/or nutritional outcomes, such as body weight, body mass index, albumin and Mini Nutritional Assessment.

RESULTS

The systematic review included 20 papers based on different therapeutic approaches concerning food intake and/or nutritional outcomes. The results of the meta-analysis indicate that the interventions for AA have an important impact on body weight [+1.59 kg; 95% confidence interval (CI) = 1.48-+1.71 kg; P < 0.001) and on energy intake (+56.09 kcal; 95% CI = -54.05 to +166.25 kcal; P = 0.32). Regarding secondary outcomes, it was not possible to meta-analyse the limited amount of data availab le.

CONCLUSIONS

The different variants of AA need to be defined because diverse therapeutic approaches are available. A more precise definition of the functional impairments associated with AA may allow a more correct decision about the most appropriate therapy to be prescribed. Moreover, this may allow for a more effective performance of the different therapeutic approaches once they are better targeted to the different scenarios of AA.

Care home resident and staff perceptions of the acceptability of nutrition intervention trial procedures: a qualitative study embedded within a cluster randomised feasibility trial

OBJECTIVES

To examine care home resident and staff perceptions of the acceptability of participating in a feasibility trial evaluating nutritional interventions in the treatment of malnutrition.

DESIGN

Exploratory qualitative methodology was used to gather descriptions of resident and staff perceptions of trial procedures, using semi-structured interviews with residents and focus groups with staff. The interviews were used to explore individual perceptions of the acceptability of the assigned intervention and the outcomes measured. Focus groups were used to explore staff experiences of trial participation and perspectives of nutritional support interventions.

SETTING

The study was embedded within a cluster randomised feasibility trial, which randomised six care homes to provide standard care (SC), food-based (FB) intervention or oral nutritional supplement (ONS) intervention to residents with, or at risk of, malnutrition.

PARTICIPANTS

Residents in the trial with capacity to consent (n=7) formed the sampling frame for inclusion. Four agreed to be approached by the researcher and to take part in the individual interviews. All were women, representing two arms of the trial (ONS and SC). Twelve staff participated in six focus groups, one at each care home. All participants were women, representing all three arms of the trial.

RESULTS

Major themes that emerged from both interviews and focus groups included the perceived acceptability of trial involvement, the value of residents completing participant-reported outcome measures and the challenges associated with outcomes measurement in this setting. Themes that emerged from the focus groups alone, included the importance of individualising an intervention, and the perceived value of FB and ONS interventions and dietetic input.

CONCLUSIONS

Residents and staff perceived involvement in a trial evaluating nutritional interventions to be acceptable, although the challenges associated with research in this setting were acknowledged. Resident preferences were highlighted by staff as an important consideration when implementing a nutrition support plan.

TRIAL REGISTRATION NUMBER

ISRCTN38047922.

Frailty Screening and Interventions: Considerations for Clinical Practice

Frailty is recognized as a cornerstone of geriatric medicine. It increases the risk of geriatric syndromes and adverse health outcomes in older and vulnerable populations. Although multiple screening instruments have been developed and validated to improve feasibility in clinical practice, frequent lack of agreement between frailty instruments has slowed broad implementation of these tools. Despite this, interventions to improve frailty-related health outcomes developed to date include exercise, nutrition, multicomponent interventions, and individually tailored geriatric care models. Possible strategies to prevent frailty include lifestyle or behavioral interventions, proper nutrition, and increased activity levels and social engagement.

Nutritional and Frailty State Transitions in the Singapore Longitudinal Aging Study

BACKGROUND

Malnutrition is a major determinant of the physical frailty syndrome. Dynamic transitions in frailty states over time is well documented, but few studies have documented temporal changes in nutritional states and whether they influence frailty outcomes.

DESIGN

Longitudinal cohort study.

SETTING AND PARTICIPANTS

Community-dwelling older Singaporeans aged ≥55y with a 5-year follow-up (n=1162) in the Singapore Longitudinal Ageing Study 2 (SLAS-2).

MEASUREMENTS

The Mini Nutritional Assessment Short-Form (MNA-SF) was used to determine nutritional status, and the Fried's criteria (shrinking, weakness, slowness, exhaustion and inactivity) was used to assess physical frailty phenotype at both baseline and follow-up. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were adjusted for multiple baseline co-variables.

RESULTS

At baseline, being at risk of malnutrition/malnourished was associated with increased odds of prevalent pre-frailty (OR=2.76, 95% CI=1.86-4.10) and frailty (OR=4.10, 95% CI=1.41-11.9). Baseline robust individuals who were persistently at risk of malnutrition/malnourished showed an increased odds of conversion to being pre-frail/frail at follow-up (OR=3.45, 95% CI=1.00-11.9). Among baseline pre-frail/frail individuals, reversion to being robust were significantly less likely among those who were persistently at risk of malnutrition/malnourished (OR=0.26, 95% CI=0.10-0.67) and those whose baseline normal nutrition worsened at follow-up (OR=0.20, 95% CI=0.06-0.74).

CONCLUSION

Changes in nutritional states are associated with frailty state transitions, and monitoring changes in nutritional status is recommended for the prevention and severity reduction of frailty among older people in the community.

Effects of a Home-Based and Volunteer-Administered Physical Training, Nutritional, and Social Support Program on Malnutrition and Frailty in Older Persons: A Randomized Controlled Trial

OBJECTIVES

The aim of this study was to examine the effects of a home-based and volunteer-administered physical training and nutritional intervention program compared with social support intervention on nutritional and frailty status in prefrail and frail community-dwelling older persons.

DESIGN

This was a randomized controlled trial in which community-dwelling persons (mean age = 83 years) were recruited and randomly assigned to the physical training and nutritional intervention group (PTN, n = 39) and the social support group (SoSu, n = 41). The study was conducted by trained lay nonprofessionals.

SETTING

The community-dwelling older persons in both groups were visited twice a week by trained nonprofessional volunteers (buddies) in Vienna, Austria.

PARTICIPANTS

Eighty prefrail and frail adults aged 65 years or older.

INTERVENTION

In the PTN group, both the buddies and older persons performed 6 strength exercises within a circuit training session and discussed nutrition-related aspects. The active control group (SoSu) had the opportunity to perform cognitive training in addition to the social contact.

MEASUREMENTS

Outcome measures as nutritional (Mini Nutritional Assessment long form [MNA-LF]) and frailty status (Frailty Instrument for Primary Care of the Survey of Health, Ageing and Retirement in Europe [SHARE-FI]) were obtained at baseline and after 12 weeks.

RESULTS

Significant improvements in the MNA-LF score (1.54 points, 95% confidence interval [CI] 0.51-2.56; P = .004) and the SHARE-FI score (-0.71 discrete factor score values, 95% CI -1.07, -0.35; P < .001) were observed in the PTN group after 12 weeks. In both groups, the prevalence of impaired nutritional status and frailty decreased significantly over time. The prevalence of impaired nutritional status decreased by 25% in the PTN group and by 23% in the SoSu group. Moreover, the prevalence of frailty decreased by 17% in the PTN group and by 16% in the SoSu group. The presence of impaired nutritional status at baseline was independently associated with greater changes in the nutritional (adjusted odds ratio [OR] 3.18, 95% CI 1.26-7.98; P = .014) and frailty status (adjusted OR 3.16, 95% CI 1.01-9.93; P = .049) after 12 weeks.

CONCLUSION

The results indicate that a home-based physical training, nutritional, and social support intervention conducted by nonprofessionals is feasible and can help to tackle malnutrition and frailty in older persons living at home. Furthermore, social support alone also can result in improvement. In particular, older adults with impaired nutritional status at baseline can benefit more from the intervention. Such a home visit program might also have the potential to prevent future health risks and could allay isolation and loneliness.

Nutritional supplementation for activities of daily living and functional ability of older people in residential facilities: A systematic review

AIM

To review the best available evidence on nutritional supplementation for activities of daily living and functional ability of older people in residential facilities.

METHODS

Electronic searches were carried out using CENTRAL, MEDLINE and EMBASE databases for the years 2006-2016. Randomized controlled trials and cluster-randomized controlled trials that examined the effects of nutrition interventions aimed at improving the energy or protein intake alone or both in combination were included. Two authors independently reviewed all potential studies for inclusion against the eligibility criteria. We reviewed studies for outcome relevance and methodological rigor. Any disagreement was resolved by discussion.

RESULTS

A total of eight studies were included, containing four randomized controlled trials and four cluster-randomized controlled trials involving 698 participants. There was significant improvement in handgrip strength (mean difference 1.65 kg, 95% confidence interval 0.09-3.22 kg, P = 0.04), but no difference in activities of daily living (mean difference 2.06, 95% confidence interval -18.28-22.40, P = 0.84), balance (mean difference -1.10, 95% confidence interval -3.04-0.84, P = 0.27), gait velocity (mean difference 0.00, 95% confidence interval -0.03-0.03, P = 1.00) and death (RR 1.90, 95% confidence interval 0.61-5.99, P = 0.27).

CONCLUSIONS

Nutritional intervention with older people in residential facilities was effective in improving handgrip strength, but did not significantly improve scores for activities of daily living, balance, gait velocity or preventing death. Further studies with larger sample sizes and of high quality are required to investigate appropriate intervention methods and specific target participants. Geriatr Gerontol Int 2018; 18: 197-210.

Frailty and Malnutrition: Related and Distinct Syndrome Prevalence and Association among Community-Dwelling Older Adults: Singapore Longitudinal Ageing Studies

OBJECTIVE

The association between frailty and malnutrition is widely noted, but the common and distinct aspects of this relationship are not well understood. We investigated the prevalence of prefrailty/frailty and malnutrition/nutritional risk; their overlapping prevalence; compared their sociodemographic, physical, and mental health risk factors; and assessed their association, independently of other risk factors.

METHODS

Cross-sectional study of population-based cohort (Singapore Longitudinal Ageing Study [SLAS]-1 [enrolled 2003-2005] and SLAS-2 [enrolled 2010-2013]) of community-dwelling older Singaporeans aged ≥55 (n = 6045).

MEASUREMENTS

Mini Nutritional Assessment (MNA)-Short Form (SF), Nutritional Screening Initiative (NSI) Determine Checklist, Fried physical frailty phenotype.

RESULTS

The overall prevalence of MNA malnutrition was 2.8%, and at risk of malnutrition was 27.6%; the prevalence of frailty and prefrailty were 4.5%, and 46.0% respectively. Only 26.5% of participants who were malnourished were frail, but 64.2% were prefrail (totally 90.7% prefrail or frail). The prevalence of malnutrition among frail participants was 16.1%, higher than in other studies (10%); nearly one-third of the whole population sample had normal nutrition while being prefrail (27.7%) or frail (1.5%). The prevalence of risk factors for prefrailty/frailty and malnutrition/nutritional risk were remarkably similar. MNA at risk of malnutrition and malnutrition were highly significantly associated with prefrailty (odds ratio [OR] 2.11 and 6.71) and frailty (OR 2.72 and 17.4), after adjusting for many other risk factors. The OR estimates were substantially lower with NSI moderate and high nutritional risk for prefrailty (OR 1.39 and 1.74) and frailty (OR 1.27 and 1.93), but remain significantly elevated.

CONCLUSION

Frailty and malnutrition are related but distinct conditions in community-dwelling older adults. The contribution of poor nutrition to frailty in this population is notably greater. Both frail/prefrail elderly and those who are malnourished/at nutritional risk should be identified early and offered suitable interventions.

A foodservice approach to enhance energy intake of elderly subacute patients: a pilot study to assess impact on patient outcomes and cost

Background

effective strategies are required to support the nutritional status of patients.

Objectives

to evaluate a foodservice nutrition intervention on a range of participant outcomes and estimate its cost.

Design

parallel controlled pilot study.

Setting

subacute hospital ward.

Subjects

all consecutively admitted adult patients were eligible for recruitment under waiver of consent.

Methods

the intervention was a modified hospital menu developed by substituting standard items with higher energy options. The control was the standard menu. All participants received usual multidisciplinary care. Outcomes were change in weight and hand grip strength (HGS) between admission and day 14 and; energy and protein intake and patient satisfaction with the foodservice at day 14. The additional cost of the intervention was also estimated.

Results

the median (interquartile range) age of participants (n = 122) was 83 (75-87) years and length of stay was 19 (11-32) days. One-third (38.5%) were malnourished at admission. There was no difference in mean (SD) HGS change (1.7 (5.1) versus 1.4 (5.8) kg, P = 0.798) or weight change (-0.55 (3.43) versus 0.26 (3.33) %, P = 0.338) between the intervention and control groups, respectively. The intervention group had significantly higher mean (SD) intake of energy (132 (38) versus 105 (34) kJ/kg/day, P = 0.003) and protein (1.4 (0.6) versus 1.1 (0.4) g protein/kg/day, P = 0.035). Both groups were satisfied with the foodservice. The additional cost was £4.15/participant/day.

Conclusions

in this pilot, the intervention improved intake and may be a useful strategy to address malnutrition. Further consideration of clinical and cost implications is required in a fully powered study.