Effectiveness and cost-effectiveness of oral nutritional supplements in frail older people who are malnourished or at risk of malnutrition: a systematic review and meta-analysis

A systematic review of diet and medication use among centenarians and near-centenarians worldwide

Centenarians represent a phenomenon of successful aging. This systematic review aimed to understand lifestyles and health practices, focusing on diet and medication use for healthy longevity in community-based adults 95 years or over. Medline, CINAHL, Scopus, and gray literature were searched from 1 January 2000 to 10 December 2022. Study quality was assessed using the Modified Newcastle-Ottawa Scale (mNOS). Pooled prevalence [%; 95% confidence interval] for categorical variables and pooled mean for continuous variables were estimated for demographics, weight status, lifestyle factors, medications, and health conditions. Of 3392 records screened, 34 studies were included in the review, and 71% (24/34) met the 6/8 criteria in mNOS. Centenarians/near-centenarians' ages ranged from 95 to 118 years, with 75% (71-78%) female and 78% (68-88%) living in rural areas. They had an overall healthy lifestyle: current smoking (7%; 5-9%), drinking (23%; 17-30%), normal weight (52%; 42-61%), overweight (14%; 8-20%), physical activity (23%; 20-26%), and sleep satisfaction (68%; 65-72%). Diet averaged 59.6% carbohydrate, 18.5% protein, and 29.3% fat; over 60% consumed a diverse diet, and < 20% preferred salty food, contributing to lower mortality risks and functional decline. About half used antihypertensives (49%; 14-84%) or other cardiovascular drugs (48%; 24-71%), with an average of 4.6 medications. Common health issues included impaired basic activities of daily living (54%; 33-74%), hypertension (43%; 21-65%), and dementia (41%; 23-59%). The findings of this systemic review underscore the pivotal role of dietary practice and weight management in healthcare strategies to promote healthy ageing. It also recognises rural living styles and sleep hygiene as potential factors contributing to healthy longevity.

The Impact of Preoperative and Postoperative Nutritional Interventions on Treatment Outcomes and Quality of Life in Colorectal Cancer Patients-A Comprehensive Review

Colorectal cancer (CRC) is one of the most prevalent cancers worldwide, with high morbidity and mortality rates. Nutritional status has emerged as a significant factor influencing the prognosis and survival of CRC patients. This comprehensive literature review examines the role of nutritional support in improving treatment outcomes, including the efficacy of interventions, patient quality of life (QoL), and the modulation of inflammatory responses. The findings suggest that tailored nutritional interventions improve clinical outcomes, enhance QoL, and reduce treatment-related complications, particularly by attenuating inflammation. Furthermore, the review highlights the cost-effectiveness of nutritional strategies and identifies key methods to enhance patient compliance with dietary recommendations. In conclusion, integrating nutritional support into CRC treatment plans is crucial for optimizing clinical management and improving patient well-being.

Effectiveness of High-Protein Energy-Dense Oral Supplements on Patients with Malnutrition Using Morphofunctional Assessment with AI-Assisted Muscle Ultrasonography: A Real-World One-Arm Study

Background: User-friendly tools for assessing nutrition status and interventions in malnourished patients are crucial. This study evaluated the effectiveness of a personalised nutrition intervention using a novel oral nutritional supplement and AI-supported morphofunctional assessment to monitor clinical outcomes in patients with disease-related malnutrition (DRM). Methods: This prospective observational study involved patients receiving concentrated high-protein, high-calorie ONS (cHPHC-ONS), per usual clinical practice. Comprehensive assessments were performed at baseline (B0) and three months (M3) post-intervention. Results: 65 patients participated in the study. Significant decreases were observed in the percentage weight loss from B0 (-6.75 ± 7.5%) to M3 (0.5 ± 3.48%) (p < 0.01), in the prevalence of malnutrition (B0: 93.4%; M3: 78.9%; p < 0.01), severe malnutrition (B0: 60.7%; M3: 40.3%; p < 0.01), and sarcopenia (B0: 19.4%; M3: 15.5%; p < 0.04). Muscle area increased (p = 0.03), and there were changes in the echogenicity of the rectus femoris muscle (p = 0.03) from B0 to M3. In patients aged ≥60, an increase in muscle thickness (p = 0.04), pennation angle (p = 0.02), and handgrip strength (p = 0.04) was observed. There was a significant reduction in the prevalence of malnutrition (B0: 93.4%; M3: 78.9%; p < 0.01) and severe malnutrition (B0: 60.7%; M3: 40.3%; p < 0.01). Conclusions: In patients with DRM, a personalised intervention with cHPHC-ONS significantly reduces the prevalence of malnutrition, severe malnutrition, and sarcopenia and improves muscle mass and function.

Oral nutritional supplements improve clinical outcomes and are cost-effective for hospitalized patients in China

OBJECTIVE

This study assessed the therapeutic benefits and modeled the cost-effectiveness of oral nutritional supplements (ONS) in China.

METHODS

Data were collected from 27 152 adult inpatients between January 1, 2018, and December 31, 2020. Propensity score matching was used for balancing the baseline characteristics between the ONS group and non-ONS group. A decision-tree model was developed to assess the cost-effectiveness of ONS for patients with nutritional risk, and the incremental cost-effectiveness ratio was the metric to determine the most cost-effective strategy. One-way sensitivity and probabilistic sensitivity analyses were conducted to assess the model's stability. In addition, subgroup analysis was conducted based on clinical characteristics. Differences in clinical outcomes between the groups were compared using Student's t test, Mann-Whitney U test, or chi-square test.

RESULTS

The ONS group displayed significantly lower levels of prealbumin, albumin, hemoglobin, and BMI than the non-ONS group at admission. The incidence of malignant tumors, intestinal obstruction, and inflammatory bowel disease was significantly higher in the ONS group than the non-ONS group. The ONS group had a significantly higher effective rate than the non-ONS group (51.7% versus 50.3%, P < 0.05). Analysis of the decision-tree model revealed that the ONS group experienced an increase in cost of 19 850.96 yuan but achieved an additional 1.3406 effectiveness rate, resulting in an incremental cost-effectiveness ratio of 14 807.51, which fell below China's 2020 per capita gross domestic product of 71 965 yuan. Sensitivity analysis further confirmed the robustness of the model.

CONCLUSIONS

ONS are demonstrated a high rate of efficacy, although patients currently using ONS are typically in a severe disease state. In addition, ONS is cost-effective. We suggest that the reimbursement coverage of ONS be expanded to include in-hospital patients who are at high nutritional risk.

Frailty and nutrition

As the ageing population grows and forms a significant category of over 65s in many societies, along with it comes the risk of developing physical and psychological degenerative changes. This presents many challenges for health and social care services in not only identifying those at risk but also managing that risk to try to preserve health and independence for as long as possible. Screening for frailty has supported services to identify those that may be at risk of hospitalisation, requiring long term care or support services at home in older age. Frailty can be exacerbated by the risk of nutritional deficiencies and more severe malnutrition. Therefore, screening for frailty should also include a nutritional assessment, which can be supported by a recognition of the need for nutritional support along with other holistic frailty management.

Nutrition Management in Geriatric Patients with CKD

Sarcopenia, defined as age-related decline in skeletal muscle mass and functional capacity, is a hallmark nutritional abnormality observed in patients with moderate-to-advanced CKD. Uremic state and associated medical conditions also predispose older patients with CKD to protein-energy wasting, a nutritional abnormality that could include sarcopenia. Prevention of protein and energy depletion and replenishing the already low nutritional reserves elderly patients with CKD should focus on conventional and innovative strategies. This review aims to provide an overview of the mainstay of nutritional therapy in this patient population, such as intake of adequate amounts of protein and energy along with preserving fluid, electrolyte, and mineral balance, and to discuss more innovative interventions to aid these approaches.

Meta-analysis and moderator analysis of the prevalence of malnutrition and malnutrition risk among older adults with dementia

BACKGROUND

Aging and dementia are common and closely related health problems in older adults, affecting their ability to maintain a healthy diet and ultimately resulting in malnutrition.

OBJECTIVE

In this study, we estimated the global prevalence of malnutrition and malnutrition risk in older adults with dementia.

DESIGN

Meta-analysis.

DATA SOURCES

Embase, Ovid MEDLINE, PubMed, CINAHL, Scopus, and Web of Science were comprehensively searched for articles published from database inception to October 2022.

METHODS

Pooled prevalence analysis was conducted using a generalized linear mixed model and a random-effects model. I2 and Cochran's Q statistics were used for identifying heterogeneity. Publication bias was evaluated using Peters' regression test and a funnel plot. Moderator analyses were conducted to investigate variations in the prevalence estimates of the included studies. All statistical analyses were conducted using R software.

RESULTS

A total of 16 studies involving a total of 6513 older adults with dementia were included in the analysis. The results indicated that 32.52 % (95 % confidence interval: 19.55-45.49) of all included older adults with dementia had malnutrition, whereas 46.80 % (95 % confidence interval: 38.90-54.70) had a risk of malnutrition. The prevalence of malnutrition was found to be high among older patients living in institutionalized settings (46.59 %) and those with Alzheimer's disease (12.26 %). The factors moderating the prevalence of malnutrition included adequate vitamin B12 consumption, risk behaviors, medical comorbidities, and certain neuropsychiatric symptoms. The prevalence of malnutrition risk was high among women (29.84 %) and patients with Alzheimer's disease (26.29 %). The factors moderating the prevalence of malnutrition risk included total cholesterol level, vitamin B12 consumption, risk behaviors, medical comorbidities, and certain neuropsychiatric symptoms.

CONCLUSIONS

Approximately one-third of older adults with dementia are malnourished and nearly half of older adults are at a risk of malnutrition. Encouraging collaboration among health-care professionals and ensuring early assessment and effective management of malnutrition are crucial for maintaining a favorable nutritional status in older adults with dementia.

REGISTRATION

This study was registered with the International Prospective Register of Systematic Reviews (PROSPERO: CRD42022369329).

TWEETABLE ABSTRACT

Globally, approximately 32.52 % of older adults with dementia are malnourished and approximately 46.80 % are at a risk of malnutrition.

Associations Between Patient Characteristics and Unplanned or Delayed Discharges From Geriatric Rehabilitation: A Retrospective Chart Review

ABSTRACT

Returning home is considered an indicator of successful rehabilitation for community-dwelling older adults. However, the factors associated with unplanned discharge remain uncertain. This retrospective chart review included patients 65 yrs and older admitted to a geriatric rehabilitation unit from medical and surgical wards in an academic hospital. Patient characteristics and outcomes were abstracted from the electronic medical record. The primary outcome was unplanned discharge destination defined as anything other than return to patients' preexisting residence. The associations between patient variables and unplanned discharge destination were analyzed using Pearson χ 2 and univariate logistic regression. Of the 251 charts screened, 25 patients (10.0%) had an unplanned discharge destination, and 74 of the remaining 226 (32.7%) experienced a delayed discharge (beyond 20 days). Requiring assistance for activities of daily living (odds ratio [OR], 2.80; 95% confidence interval [CI], 1.17-7.47), a diagnosis of chronic obstructive pulmonary disease (OR, 4.04; 95% CI, 1.63-9.71), and lower serum albumin level (OR, 1.67; 95% CI, 1.06-2.72) were associated with unplanned discharge. Variables commonly associated with worse outcomes such as age, cognitive scores, delirium, and number of comorbidities were not barriers to returning home and should therefore not be used on their own to limit access to geriatric rehabilitation.

Association of Malnutrition and High Bleeding Risk with Long-Term Prognosis in Patients with Acute Coronary Syndrome following Percutaneous Coronary Intervention

BACKGROUND

Malnutrition in cardiovascular disease is associated with poor prognosis, especially in patients with heart failure and acute coronary syndrome (ACS). High bleeding risk is also linked to coronary artery disease prognosis, including ACS. However, whether the extent of malnutrition and high bleeding risk have a cumulative impact on the long-term prognosis of patients with ACS who undergo percutaneous coronary intervention remains unclear.

METHODS

We analyzed 275 patients with ACS treated with percutaneous coronary intervention. The Controlling Nutritional Status score and Japanese version of the Academic Research Consortium for High Bleeding Risk criteria (J-HBR) were retrospectively evaluated. The primary and secondary outcomes were adjusted using the inverse probability treatment weighting method.

RESULTS

The prevalence of moderate or severe malnutrition in this cohort was 16%. Kaplan-Meier analysis showed a significantly higher incidence of major adverse cardiovascular and cerebrovascular events in patients who were moderately or severely malnourished than in those who were not. Notably, the incidence of these major events was similar between severely malnourished patients with J-HBR and those without.

CONCLUSION

Moderate or severe malnutrition has a significant impact on the long-term prognosis of patients with ACS who undergo percutaneous coronary intervention.

Optimized Refeeding vs. Standard Care in Malnourished Older Hospitalized Patients: A Prospective, Non-Randomized Cluster-Controlled Study in Geriatric Acute Care

Malnutrition is a prevalent geriatric syndrome with adverse health outcomes. This study aimed to assess the effectiveness of an optimized protocol for treatment of malnutrition in older hospitalized patients. We conducted a prospective, non-randomized cluster-controlled study with 156 malnourished patients in the intervention and 73 in the control group, determined using the Mini Nutritional Assessment-Short-Form. The intervention group received individualized nutritional care, including electrolyte and micronutrients monitoring, while the control received standard care. We primarily focused on complications such as infections, falls, unplanned hospital readmissions, and mortality, and secondarily focused on functional status and mobility improvements. Post-discharge follow-ups occurred at 3 and 6 months. Our findings demonstrated that the intervention group (age 82.3 ± 7.5 y, 69% female), exhibited greater previous weight loss (11.5 kg vs. 4.7 kg), more cognitive impairment and a longer hospital stay (19 days vs. 15 days). Binary logistic regression showed no difference in primary endpoint outcomes between groups during hospitalization. At 3- and 6-month follow-ups, the control group exhibited fewer adverse outcomes, particularly falls and readmissions. Both groups showed in-hospital functional improvements, but only controls maintained post-discharge mobility gains. The study concludes that the nutritional intervention did not outperform standard care, potentially due to study limitations and high-quality standard care in control group geriatric departments.

Effect of dietary supplementation with multinutrient soy flour on body composition and cognitive function in elderly individuals at the risk of low protein: a randomized, double-blind, placebo-controlled study

Insufficient protein intake and cognitive decline are common in older adults; however, there have been few studies on low protein risk screening and complex nutrient interventions for elderly individuals in rural communities. This study aimed to evaluate the effect of dietary multinutrient soy flour (MNSF) on body composition and cognitive function in elderly individuals who are at risk of protein deficiency in a randomized, double-blind, placebo-controlled clinical trial. Nutritional interventions were given to those found to have low protein levels using bioelectrical impedance analysis (BIA). Among 733 older adults screened, 62 participants were included and randomly assigned into two groups, one taking soy flour and the other taking MNSF for 12 weeks. A previous cross-sectional survey found that 35.1% of the elderly people with an average age of 71.61 ± 5.94 years had an inadequate body protein mass proportion. After the intervention, the MNSF group demonstrated a significant improvement in protein mass, muscle mass, mineral levels, skeletal muscle mass, and fat-free mass compared with baseline (all P < 0.05), as well as a better upward trend compared with the soy flour group (P = 0.08; P = 0.07; P = 0.05; P = 0.08; P = 0.07). Regarding the mini-mental state examination (MMSE) scores, the MNSF group showed a significant decrease after 12 weeks (P < 0.05), which were significantly different compared with the soy flour group (P < 0.05). In the future, the application of MNSF as a food-based supplement to improve nutrition and delay cognitive decline in older adults at the risk of protein deficiency may be considered.

Perioperative Optimization of the Cardiac Surgical Patient

Perioperative optimization of cardiac surgical patients is imperative to reduce complications, utilize health care resources efficiently, and improve patient recovery and quality of life. Standardized application of evidence-based best practices can lead to better outcomes. Although many practices should be applied universally to all patients, there are also opportunities along the surgical journey to identify patients who will benefit from additional interventions that will further ameliorate their recovery. Enhanced recovery programs aim to bundle several process elements in a standardized fashion to optimize outcomes after cardiac surgery. A foundational concept of enhanced recovery is attaining a better postsurgical end point for patients, in less time, through achievement and maintenance in their greatest possible physiologic, functional, and psychological state. Perioperative optimization is a broad topic, spanning multiple phases of care and involving a variety of medical specialties and nonphysician health care providers. In this review we highlight a variety of perioperative care topics, in which a comprehensive approach to patient care can lead to improved results for patients, providers, and the health care system. A particular focus on patient-centred care is included. Although existing evidence supports all of the elements reviewed, most require further improvements in implementation, as well as additional research, before their full potential and usefulness can be determined.

Risk of Malnutrition in Hospitalized COVID-19 Patients: A Systematic Review and Meta-Analysis

(1) Background: Studies have reported that COVID-19 may increase the risk of malnutrition among patients. However, the prevalence of such risk in hospitalized COVID-19 patients is uncertain due to the inconsistent use of assessment methods. (2) Methods: PubMed, Web of Science, and EMBASE were searched to identify studies on the nutritional status of hospitalized COVID-19 patients. A pooled prevalence of malnutrition risk evaluated by Nutrition Risk Score (NRS-2002) was obtained using a random effects model. Differences by study-level characteristics were examined by hospitalization setting, time of assessment, age, and country. Risk of bias was assessed using the Newcastle−Ottawa Scale. (3) Results: 53 studies from 17 countries were identified and summarized. A total of 17 studies using NRS-2002, including 3614 COVID-19 patients were included in the primary meta-analysis. The pooled prevalence of risk of malnutrition was significantly higher among ICU patients (92.2%, 95% CI: 85.9% to 96.8%) than among general ward patients (70.7%, 95% CI: 56.4% to 83.2%) (p = 0.002). No significant differences were found between age groups (≥65 vs. <65 years, p = 0.306) and countries (p = 0.893). (4) Conclusions: High risk of malnutrition is common and concerning in hospitalized patients with COVID-19, suggesting that malnutrition screening and nutritional support during hospitalization are needed.

Oral nutritional interventions in frail older people who are malnourished or at risk of malnutrition: a systematic review

BACKGROUND

Malnutrition worsens the health of frail older adults. Current treatments for malnutrition may include prescribed oral nutritional supplements, which are multinutrient products containing macronutrients and micronutrients.

OBJECTIVE

To assess the effectiveness and cost-effectiveness of oral nutritional supplements (with or without other dietary interventions) in frail older people who are malnourished or at risk of malnutrition.

DATA SOURCES

MEDLINE, EMBASE, Cochrane Library, Scopus, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and grey literature were searched from inception to 13 September 2021.

REVIEW METHODS

A systematic review and meta-analysis was conducted to evaluate the effectiveness and cost-effectiveness of oral nutritional supplements in frail older people (aged ≥ 65 years) who are malnourished or at risk of malnutrition (defined as undernutrition as per National Institute for Health and Care Excellence guidelines). Meta-analysis and network meta-analysis were undertaken, where feasible, along with a narrative synthesis. A cost-effectiveness review was reported narratively. A de novo model was developed using effectiveness evidence identified in the systematic review to estimate the cost-effectiveness of oral nutritional supplements.

RESULTS

Eleven studies (n = 822 participants) were included in the effectiveness review, six of which were fully or partly funded by industry. Meta-analyses suggested positive effects of oral nutritional supplements compared with standard care for energy intake (kcal) (standardised mean difference 1.02, 95% confidence interval 0.15 to 1.88; very low quality evidence) and poor mobility (mean difference 0.03, p < 0.00001, 95% confidence interval 0.02 to 0.04; very low quality evidence) but no evidence of an effect for body weight (mean difference 1.31, 95% confidence interval -0.05 to 2.66; very low quality evidence) and body mass index (mean difference 0.54, 95% confidence interval -0.03 to 1.11; very low quality evidence). Pooled results for other outcomes were statistically non-significant. There was mixed narrative evidence regarding the effect of oral nutritional supplements on quality of life. Network meta-analysis could be conducted only for body weight and grip strength; there was evidence of an effect for oral nutritional supplements compared with standard care for body weight only. Study quality was mixed; the randomisation method was typically poorly reported. One economic evaluation, in a care home setting, was included. This was a well-conducted study showing that oral nutritional supplements could be cost-effective. Cost-effectiveness analysis suggested that oral nutritional supplements may only be cost-effective for people with lower body mass index (< 21 kg/m2) using cheaper oral nutritional supplements products that require minimal staff time to administer.

LIMITATIONS

The review scope was narrow in focus as few primary studies used frailty measures (or our proxy criteria). This resulted in only 11 included studies. The small evidence base and varied quality of evidence meant that it was not possible to determine accurate estimates of the effectiveness or cost-effectiveness of oral nutritional supplements. Furthermore, only English-language publications were considered.

CONCLUSIONS

Overall, the review found little evidence of oral nutritional supplements having significant effects on reducing malnutrition or its adverse outcomes in frail older adults.

FUTURE WORK

Future research should focus on independent, high-quality, adequately powered studies to investigate oral nutritional supplements alongside other nutritional interventions, with longer-term follow-up and detailed analysis of determinants, intervention components and cost-effectiveness.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42020170906.

FUNDING

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 51. See the NIHR Journals Library website for further project information.

Protein Intake and Oral Health in Older Adults-A Narrative Review

Oral health is vital to general health and well-being for all ages, and as with other chronic conditions, oral health problems increase with age. There is a bi-directional link between nutrition and oral health, in that nutrition affects the health of oral tissues and saliva, and the health of the mouth may affect the foods consumed. Evidence suggests that a healthy diet generally has a positive impact on oral health in older adults. Although studies examining the direct link between oral health and protein intake in older adults are limited, some have explored the relationship via malnutrition, which is also prevalent among older adults. Protein-energy malnutrition (PEM) may be associated with poor oral health, dental caries, enamel hypoplasia, and salivary gland atrophy. This narrative review presents the theoretical evidence on the impact of dietary protein and amino acid composition on oral health, and their combined impact on overall health in older adults.