Nutrition risk among an ethnically diverse sample of community-dwelling older adults

Orthopaedic Nurse Navigators and Total Joint Arthroplasty Preoperative Optimization: Obesity and Malnutrition-Part Four of the Movement Is Life Special ONJ Series

Obesity and malnutrition affect many patients with osteoarthritis and can predispose patients to worse outcomes after total joint arthroplasty (TJA). However, these modifiable risk factors can be addressed in preoperative optimization programs driven by nurse navigators. Our aim is to provide resources and recommendations for nurse navigators when addressing obesity and malnutrition among TJA patients. In addition to discussions with nurse navigators regarding obesity and malnutrition, a literature review was conducted to assess the current practice standards for management. Nurse navigators often had difficulty implementing long-term interventions, but interventions in the literature included medical and bariatric treatments for obesity and more targeted assessment of nutrition status. These findings are incorporated into our recommendations for nurse navigators. Addressing obesity and malnutrition in preoperative optimization can contribute to improved outcomes, as has been demonstrated in current practice and in the literature.

Malnutrition-related mortality trends in older adults in the United States from 1999 to 2020

BACKGROUND

Malnutrition mortality in older adults is underrepresented in scientific literature. This obscures any recent changes and hinders needed social change. This study aims to assess malnutrition mortality trends in older adults (≥ 65 years old) from 1999 to 2020 in the United States (U.S.).

METHODS

Mortality data from the Centers for Disease Control and Prevention's (CDC) Wide-Ranging Online Data for Epidemiology Research (WONDER) database were extracted. The ICD-10 Codes E40 - E46 were used to identify malnutrition deaths. Crude mortality rates (CMR) and age-adjusted mortality rates (AAMR) were extracted by gender, age, race, census region, and urban-rural classification. Joinpoint regression analysis was used to calculate annual percentage changes (APC) of AAMR by the permutation test and the parametric method was used to calculate 95% confidence intervals. Average Annual Percentage Changes (AAPC) were calculated as the weighted average of APCs.

RESULTS

Between 1999 and 2020, 93,244 older adults died from malnutrition. Malnutrition AAMR increased from 10.7 per 100,000 in 1999 to 25.0 per 100,000 in 2020. The mortality trend declined from 1999 to 2006 (APC = -8.8; 95% CI: -10.0, -7.5), plateaued till 2013, then began to rise from 2013 to 2020 with an APC of 22.4 (95% CI: 21.3, 23.5) and an overall AAPC of 3.9 (95% CI: 3.1, 4.7). Persons ≥ 85 years of age, females, Non-Hispanic Whites, residents of the West region of the U.S., and urban areas had the highest AAPCs in their respective groups.

CONCLUSION

Despite some initial decrements in malnutrition mortality among older adults in the U.S., the uptrend from 2013 to 2020 nullified all established progress. The end result is that malnutrition mortality rates represent a historical high. The burden of the mortality uptrends disproportionately affected certain demographics, namely persons ≥ 85 years of age, females, Non-Hispanic Whites, those living in the West region of the U.S., and urban areas. Effective interventions are strongly needed. Such interventions should aim to ensure food security and early detection and remedy of malnutrition among older adults through stronger government-funded programs and social support systems, increased funding for nursing homes, and more cohesive patient-centered medical care.

Effectiveness of Theory-Based Physical Activity and Nutrition Interventions in Aging Latino Adults: A Scoping Review

In the United States (US), Latino individuals older than 50 years face health disparities compared to their White counterparts. Considering the rising life expectancy and the projected increase of older Latino adults in the US, this scoping review aimed to determine the effectiveness of theory-based and culturally relevant strategies that promote healthy aging in Latinos. Web of Science and PubMed databases were searched between December 2022 and February 2023 for peer-reviewed articles assessing healthy aging interventions tailored to community-dwelling aging Latino adults. We included nine studies describing the effects of seven interventions on physical activity- or nutrition-related outcomes. Although not always statistically significant, interventions had a beneficial impact on well-being indicators. The most commonly used behavioral theories were Social Cognitive Theory and Attribution Theory. Latino cultural elements in these studies included partnering with community organizations that serve Latinos (such as Catholic churches), delivery of in-person bilingual group sessions by trusted community members (such as promotoras or Latino dance instructors), and incorporating values such as family and religion into the health curriculum, among others. Future strategies that promote healthy aging in Latino adults should proactively culturally adapt the theoretical foundations and the design, recruitment, and implementation processes to ensure their relevance and effectiveness.

'I eat to not die': Diet and exercise experiences of older adults living alone

INTRODUCTION

Living alone is a critical health risk factor among older adults. Regular exercise and a balanced diet are important for maintaining an independent and healthy life. However, it can be more difficult for older adults living alone to maintain healthy exercise and dietary habits due to their lack of social support. This study aimed to explore the life changes that accompany living alone and their needs, focussing on exercise and diet.

METHODS

This was a qualitative descriptive study. Purposeful sampling was conducted to recruit community-dwelling older adults living alone. Thematic analyses were applied to analyse the qualitative data collected from semistructured interviews.

RESULTS

Fifteen subjects, including 5 men and 10 women, participated in the interviews. The median age was 77 years, ranging from 66 to 88, and the median duration of living alone was 16 years, ranging from 3 to 35. Six main themes were developed, namely unavoidable difficulties of living alone: lack of someone to depend on and loneliness, just eating 'to not die', exercise that is good for health but hard to do consistently, conflict between maintaining independence and dependence on others, coping with available resources, and resources needed for regular exercise and a balanced diet.

CONCLUSION

Living alone leads to poor dietary habits, such as skipping meals or insufficient food intake. Food security should be ensured through the reinforcement of social support, financial assistance and the operation of public cafeterias. In addition, an individually tailored group exercise programme that can meet the need for social interaction and improve self-efficacy would help older adults living alone maintain regular exercise habits.

Identification and engagement of naturally occurring retirement communities to support healthy aging in Canada: A set of methods for replication

Background

Naturally occurring retirement communities (NORCs), unplanned communities with a high proportion of older adult residents, offer a model to support older adults to age well in place. The aim of this paper is to provide a comprehensive description of the methods used to identify and engage NORCs appropriate for the development of supportive service programming in Canada.

Methods

Three steps were used to identify and select NORCs in which to develop supportive service programming including: 1) identification of potential NORCs using Canadian Census Dissemination Areas, the Ontario Marginalization Index and Google Maps, 2) engagement of property owner/manager to determine the availability of common space for communal programming and willingness of the owner to support programming and, 3) engagement of older adult residents within the NORC to co-design programming.

Results

Four cities in the south-east, south-central, and south-west of Ontario, Canada were identified to develop NORCs with supportive service programming. Using the methods described, six NORCs were identified, landlords and older adult residents were engaged, and programs initiated between April 2018 and March 2019. The sites included two private high-rise apartments, a city-owned low-rise subsidized apartment complex, two multi-building private high-rise complexes and a mobile home community. An average of 35 (min 20, max 78) older adult members were engaged in an average of 20.5 unique activity sessions at each site per month. On average, social (54%) and physical activities (30%) were more common than nutritional (10%) and knowledge-sharing (8%).

Conclusions

The increased prevalence of unplanned, geographically-bound NORCs creates an opportunity for governments, social and health service providers and policy makers to support healthy aging in their communities. Our experience with the creation of six new NORCs with supportive service programming provides a tested set of methods that can be applied in other communities.

Malnutrition Increases Hospital Length of Stay and Mortality among Adult Inpatients with COVID-19

Background: Malnutrition has been linked to adverse health economic outcomes. There is a paucity of data on malnutrition in patients admitted with COVID-19. Methods: This is a retrospective cohort study consisting of 4311 COVID-19 adult (18 years and older) inpatients at 5 Johns Hopkins-affiliated hospitals between 1 March and 3 December 2020. Malnourishment was identified using the malnutrition universal screening tool (MUST), then confirmed by registered dietitians. Statistics were conducted with SAS v9.4 (Cary, NC, USA) software to examine the effect of malnutrition on mortality and hospital length of stay among COVID-19 inpatient encounters, while accounting for possible covariates in regression analysis predicting mortality or the log-transformed length of stay. Results: COVID-19 patients who were older, male, or had lower BMIs had a higher likelihood of mortality. Patients with malnutrition were 76% more likely to have mortality (p < 0.001) and to have a 105% longer hospital length of stay (p < 0.001). Overall, 12.9% (555/4311) of adult COVID-19 patients were diagnosed with malnutrition and were associated with an 87.9% increase in hospital length of stay (p < 0.001). Conclusions: In a cohort of COVID-19 adult inpatients, malnutrition was associated with a higher likelihood of mortality and increased hospital length of stay.

Community-Dwelling Adults at Nutrition Risk: Characteristics in Relation to the Consumption of Oral Nutritional Supplements

Purpose: Nutrition risk and utilization rate of simple but effective interventions such as oral nutritional supplementation (ONS) in community settings in the United States, particularly among older adults, has received little emphasis. We conducted a cross-sectional study of community-dwelling adults ≥55 years of age and living independently to assess their risk of poor nutrition and characteristics in relation to ONS consumption. Methods: Demographic characteristics, activities of daily living (ADL), and health care resource utilization in the past 6 months were also collected via telephone survey. Nutrition risk was assessed with the abridged Patient-Generated Subjective Global Assessment (abPG-SGA) and the DETERMINE Checklist. A logistic regression model tested possible predictors of ONS use. Results: Of 1001 participants surveyed, 996 provided data on ONS use and 11% (n = 114) reported consuming ONS during the past 6 months. ONS users were more likely to be at high nutrition risk than nonusers based on both abPG-SGA (43% vs 24%, P < .001) and DETERMINE Checklist (68% vs 48%, P < .001) scores. ONS users reported less functional independence based on ADL scores (86% vs 92%, P = .03), taking ≥3 medications/day (77% vs 53%, P < .001), and utilizing more health care services. Higher nutrition risk (per abPG-SGA), lower body mass index, hospitalization in the past 6 months, and ≥3 medications/day were each independently associated with ONS use (P < .05). Conclusions: Although one in four, urban community-dwelling adults (≥55 years of age) were classified as at high nutrition risk in our study, only 11% reported consuming ONS—a simple and effective nutrition intervention. Efforts to improve identification of nutrition risk and implement ONS interventions could benefit nutritionally vulnerable, community-dwelling adults.

Nutrition Care for Poorly Nourished Outpatients Reduces Resource Use and Lowers Costs

Background and Objectives:

Over 25% of United States (US) community-dwelling, older adults are at nutritional risk. Health and cost burdens of poor nutrition can be lowered by nutrition programs for hospital inpatients, but few studies have looked at the impact on outpatients. The objective of our study was to assess outcomes of a nutrition focused quality improvement program (QIP) on healthcare resource use and costs in poorly nourished outpatients.

Methods:

This pre-post QIP study was implemented at 3 US healthcare system clinics. Included patients (n = 600) were ≥45 years old, had ≥2 chronic conditions, and were enrolled over a 15-month interval. For comparison, historical (n = 600) and concurrent control (n = 600) groups were used. Assessment of poor nutritional status was performed during each patient’s baseline visit. Healthcare resource use (hospitalizations, emergency department visits, and outpatient clinic visits), medication use, and costs were determined for a 90-day interval.

Results:

QIP patients (mean age 61.6 years) were predominantly female (62.5%) and overweight/obese (81.7%). The proportion of QIP outpatients presenting for healthcare services was significantly reduced compared to both historical and concurrent controls—relative risk reduction (RRR) versus historical (11.6%, P < .001) and versus concurrent (8.9%, P = .003). Of those who presented, RRR for healthcare resource use by QIP was significant in comparison with historical (12.9%, P = .022) but not concurrent controls. No significant differences were observed for medication usage. Lower resource use among QIP patients yielded total cost savings of $290 923 or per-patient savings of $485.

Conclusions:

Nutrition QIPs in outpatient clinics are feasible and can reduce healthcare resource use and cut costs. Such findings underscore benefits of nutritional interventions for community-dwelling outpatients with poor nutritional status.

Predicting Malnutrition Risk with Data from Routinely Measured Clinical Biochemical Diagnostic Tests in Free-Living Older Populations

Malnutrition (undernutrition) in older adults is often not diagnosed before its adverse consequences have occurred, despite the existence of established screening tools. As a potential method of early detection, we examined whether readily available and routinely measured clinical biochemical diagnostic test data could predict poor nutritional status. We combined 2008-2017 data of 1518 free-living individuals ≥50 years from the United Kingdom National Diet and Nutrition Survey (NDNS) and used logistic regression to determine associations between routine biochemical diagnostic test data, micronutrient deficiency biomarkers, and established malnutrition indicators (components of screening tools) in a three-step validation process. A prediction model was created to determine how effectively routine biochemical diagnostic tests and established malnutrition indicators predicted poor nutritional status (defined by ≥1 micronutrient deficiency in blood of vitamins B6, B12 and C; selenium; or zinc). Significant predictors of poor nutritional status were low concentrations of total cholesterol, haemoglobin, HbA1c, ferritin and vitamin D status, and high concentrations of C-reactive protein; except for HbA1c, these were also associated with established malnutrition indicators. Additional validation was provided by the significant association of established malnutrition indicators (low protein, fruit/vegetable and fluid intake) with biochemically defined poor nutritional status. The prediction model (including biochemical tests, established malnutrition indicators and covariates) showed an AUC of 0.79 (95% CI: 0.76-0.81), sensitivity of 66.0% and specificity of 78.1%. Clinical routine biochemical diagnostic test data have the potential to facilitate early detection of malnutrition risk in free-living older populations. However, further validation in different settings and against established malnutrition screening tools is warranted.

Older adults with obesity have higher risks of some micronutrient inadequacies and lower overall dietary quality compared to peers with a healthy weight, National Health and Nutrition Examination Surveys (NHANES), 2011-2014

OBJECTIVE

To evaluate total usual intakes and biomarkers of micronutrients, overall dietary quality and related health characteristics of US older adults who were overweight or obese compared with a healthy weight.

DESIGN

Cross-sectional study.

SETTING

Two 24-h dietary recalls, nutritional biomarkers and objective and subjective health characteristic data were analysed from the National Health and Nutrition Examination Survey 2011-2014. We used the National Cancer Institute method to estimate distributions of total usual intakes from foods and dietary supplements for eleven micronutrients of potential concern and the Healthy Eating Index (HEI)-2015 score.

PARTICIPANTS

Older adults aged ≥60 years (n 2969) were categorised by sex and body weight status, using standard BMI categories. Underweight individuals (n 47) were excluded due to small sample size.

RESULTS

A greater percentage of obese older adults compared with their healthy-weight counterparts was at risk of inadequate Mg (both sexes), Ca, vitamin B6 and vitamin D (women only) intakes. The proportion of those with serum 25-hydroxyvitamin D < 40 nmol/l was higher in obese (12 %) than in healthy-weight older women (6 %). Mean overall HEI-2015 scores were 8·6 (men) and 7·1 (women) points lower in obese than in healthy-weight older adults. In addition, compared with healthy-weight counterparts, obese older adults were more likely to self-report fair/poor health, use ≥ 5 medications and have limitations in activities of daily living and cardio-metabolic risk factors; and obese older women were more likely to be food-insecure and have depression.

CONCLUSIONS

Our findings suggest that obesity may coexist with micronutrient inadequacy in older adults, especially among women.

Budget Impact Analysis of a Home-Based Nutrition Program for Adults at Risk for Malnutrition

BACKGROUND

Hospital-based, nutrition-focused interventions have significantly lowered the cost-associated burden of poor nutrition through a reduction in healthcare resource utilization (HCRU). However, for patients at risk for poor nutrition who receive nutritional care at home, limited evidence exists on the economic impact of nutrition-focused interventions.

OBJECTIVE

To estimate the 30-day cost-savings associated with an at-home nutrition-focused quality improvement program in the postacute care setting for patients at risk for poor nutrition from the perspective of a hospital system.

METHODS

We compared the HCRU of 1546 patients enrolled in a quality improvement program during 1 year versus 7413 patients in a pre-program historical cohort who received care during the 1 year before the quality improvement program implementation. The analysis included the number of 30-day hospitalizations, emergency department and outpatient visits for both cohorts, and the associated costs. The main analysis included the fixed and variable costs for the program, and the costs of oral nutritional supplement and delivery. The costs for hospitalization, emergency department, and outpatient visit costs were based on the 2013 Healthcare Cost and Utilization Project and Medical Expenditure Panel Survey.

RESULTS

Based on the 2013 survey, the baseline costs for hospitalization, emergency department, and outpatient visit costs were $18,296, $1312, and $535, respectively. Our health economic analysis about the 30-day overall HCRU has shown that the quality improvement program group resulted in a total cost-savings of $2,408,668 for the 1546 patients in the program and a net savings of $1558 per patient compared with the costs for the pre-quality improvement program historical cohort.

CONCLUSION

The use of a nutrition-focused quality improvement program led to significant 30-day cost-savings, by reducing HCRU for adults who received nutritional-based care at home. The improvements in HCRU highlight the importance of implementing nutrition-focused quality improvement programs for hospital systems that provide care for patients who are at risk for poor nutrition across a variety of care settings.

Racial Disparities in Nutritional Risk among Community-Dwelling Older Adults in Adult Day Health Care

Information regarding nutritional risk among users of American adult day health centers (ADHCs), 60% of whom are racial minorities, is scant. This study examined nutritional risk and associated factors in a diverse sample ADHC users aged 50+ using secondary cross-sectional analysis of data collected between 2013 and 2017. Risk was assessed using the DETERMINE checklist, and results were stratified by race. The majority of the sample (N = 188) was at moderate (45.2%) or high (38.5%) nutritional risk, with statistically significant racial differences. Blacks were at greater risk than any other group: 65% had high nutritional risk; 76.5% ate <5 servings of fruits, vegetables, or milk daily; 21% ate <2 meals daily, 48.5% reported involuntary weight loss/gain, and 41.2% had tooth loss/mouth pain. Older adults in ADHCs are at elevated risk of malnutrition, disproportionately so amongst blacks. Both routine nutrition screening and population-specific approaches are needed to attenuate risk.