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

Associations of malnutrition factors with dysphagia mediated by ADL among nursing home residents

OBJECTIVE

The potential link between malnutrition and dysphagia along with its underlying mechanisms remains unknown. This study aimed to investigate the association between malnutrition factors and dysphagia mediated by a decline in activities of daily living (ADL) among nursing home residents.

METHODS

This cross-sectional study used data from 705 nursing home residents. The primary factors were risk of malnutrition and dysphagia. A body mass index (BMI) of < 18.5 and insufficient energy and protein intakes were also collected as factors related to malnutrition. The causal mediation analysis was used with malnutrition factors as the exposure, dysphagia as the outcome, and ADL as the mediation factor.

RESULTS

In total, 391 residents (55.5%) were at risk of malnutrition and 451 residents (64.0%) had dysphagia. The average causal mediation effect (ACME) of risk of malnutrition on dysphagia was 0.07 (95% confidence interval, C, 0.07-0.08), and the ACME of BMI < 18.5 was 0.05 (95% CI 0.04-0.05, P < 0.001 for both). For insufficient nutritional intake, the ACME of low energy intake was 0.07 (95% CI 0.07-0.07), and the ACME of low protein intake was 0.03 (95% CI 0.02-0.04, P < 0.001 for both). The total effects of all these exposures on dysphagia were significant (P = 0.002 for low protein intake and P < 0.001 for the others).

CONCLUSION

Malnutrition factors were associated with dysphagia, mediated by a decline in ADL among nursing home residents. The results of this study suggest the importance of nutritional management along with approaches to ADL to prevent dysphagia.

Analysis of risk factors and development of predictive model for malnutrition in patients with traumatic brain injury

Malnutrition is a highly prevalent complication in patients with traumatic brain injury (TBI), and it is closely related to the prognosis of patients. Accurate identification of patients at high risk of malnutrition is essential. Therefore, we analyzed the risk factors of malnutrition in patients with TBI and developed a model to predict the risk of malnutrition. A retrospective collection of 345 patients with TBI, and they were divided into malnutrition and comparison groups according to the occurrence of malnutrition. Univariate correlation and multifactor logistic regression analyses were performed to determine patients' malnutrition risk factors. We used univariate and logistic regression (forward stepwise method) analyses to identify significant predictors associated with malnutrition in patients with TBI and developed a predictive model for malnutrition prediction. The model's discrimination, calibration, and clinical utility were evaluated using the receiver operating characteristic (ROC) curve, calibration plots, and decision curve analysis (DCA). A total of 216 patients (62.6%) developed malnutrition. Multifactorial logistic regression analysis showed that pulmonary infection, urinary tract infection, dysphagia, application of NGT, GCS score ≤ 8, and low ADL score were independent risk factors for malnutrition in patients with TBI (P < 0.05). The area under the curve of the model was 0.947. Calibration plots showed good discrimination of model calibration. DCA showed that the column line plot models were all clinically meaningful when nutritional interventions were performed over a considerable range of threshold probabilities (0-0.98). Malnutrition is widespread in patients with TBI, and the nomogram is a good predictor of whether patients develop malnutrition.

A Method for Assessing the Prevalence of Food Insecurity in Older Adults Based on Resource Constraints and Food-Related Physical Functioning Limitations

Background

Older adults with food-related physical functioning limitations often face food insecurity because of challenges that go beyond resource constraints. Difficulties with food acquisition at retailers, and food preparation and consumption are not captured by the United States Department of Agriculture's food security measure.

Objectives

The objective of this study was to develop a method to assess the overall prevalence of food insecurity regardless of underlying cause using validated measures that capture both food-related physical functioning limitations and resource-constraint food hardships. It also aims to examine the validity of this method in relation to sociodemographic characteristics, health, appetite, and dietary outcomes.

Methods

Using information from National Health and Nutrition Examination Surveys (2007-2018), 10,237 adults aged 60 y and older with complete food security and food-related physical functioning limitations data were included in the study. Comparisons of the cross-classification method and the standard food security methods are made and their relationships with depression, self-reported health, and healthy eating index 2015 are examined using multiple linear regression models.

Results

Using the cross-classification method, prevalence of low and very low food security because of resource constraints and food-related physical functioning limitations was found to be higher (13.6% and 7.3%, respectively) compared with food insecurity based solely on resource constraints (4.7% and 3.3%, respectively) or food-related physical functioning limitations (11.4% and 4.4%). Low and very low food security levels using the cross-classification method were associated with higher odds of depression and poor self-reported health, compared with the standard United States Department of Agriculture (USDA) resource-constrained food security measure.

Conclusions

The cross-classification method enables the identification of potentially food insecure older adults who might be classified otherwise if only each measure is used alone. This method serves as guidance for using both measures jointly to estimate food insecurity, regardless of its cause.

Determinants of Malnourishment in the Institutionalized Older Population: The FRAGILESS Study

BACKGROUND/OBJECTIVES

Malnutrition is a very common condition among older people and strongly affects their quality of life. The current literature relates the presence of nutritional deficiencies to several health-related factors that usually emerge at advanced stages of life. This study aimed to assess the associations between malnutrition and its determinants in a group of institutionalized older people via the Mini Nutritional Assessment-Short Form (MNA-SF) and the full MNA.

METHODS

The MNA-SF was compared with the full MNA to evaluate the nutritional status of 207 older people. A multinomial logistic regression analysis was performed.

RESULTS

The data revealed that institutionalized older people with cognitive impairment, frailty syndrome, dysphagia, a low BMI, a high duration of institutionalization, and a low educational level are more likely to be malnourished or at risk of malnutrition.

CONCLUSIONS

The results reveal that the MNA or MNA-SF may not identify common determinants of malnutrition or nutritional risk. The identified determinants depend on the test. Therefore, the data obtained determine the need to use adequate nutritional screening tools to control the presence of malnutrition. Nutritional screening is essential to decrease public costs, hospitalizations, rates of disability, dependence, morbidity, and even mortality among institutionalized older people.

Predictors of the Disability in Activities of Daily Living in Nursing Home Residents: A Descriptive Study

Background: Disability in activities of daily living (ADL) is a common problem among nursing home residents. The purpose of this research was to evaluate the geriatric syndromes that contribute to disability in nursing home residents.Method: The cross-sectional study included 124 older adults from two nursing homes. ADL disability was assessed with the Barthel Index. The sociodemographic characteristics and geriatric syndromes, including malnutrition, sarcopenia risk, frailty, immobility, urinary incontinence, cognitive impairment, and balance dysfunction were evaluated.Results: The 124 residents had a mean age of 80.12 ± 9.20 years and included 55.67% males. Age, malnutrition, sarcopenia risk, frailty, immobility, urinary incontinence, cognitive impairment, and balance dysfunction were all significantly correlated with the Barthel Index. However, only malnutrition, immobility, and urinary incontinence were found to account for 84.9% of the variance in disability of nursing home residents in regression analysis. These geriatric syndromes are the best predictors of ADL disability in all models (p < .05).Conclusion: This study found that malnutrition, immobility, and urinary incontinence considerably contributed to the disability profile of nursing home residents. Health professionals need to develop multi-dimensional care and prevention strategies, especially for geriatric syndromes such as malnutrition, immobility, and urinary incontinence.

Association between quadriceps muscle thickness or echo intensity, malnutrition, and activities of daily living in an integrated medical and long-term care facility: A cross-sectional study

BACKGROUND &AIMS

Malnutrition and physical function impairment are prevalent concerns in long-term care facilities. This study investigated the relationship between quadriceps muscle thickness (QMT) or echo intensity (QEI), nutritional status, and activities of daily living (ADL) in residents of an Integrated Facility for Medical and Long-term Care (IFMLC) in Japan.

METHODS

Using a cross-sectional design, 126 residents (86 women, median age 89 years) at an IFMLC were assessed. Malnutrition was diagnosed using the Global Leadership Initiative on Malnutrition (GLIM) criteria including disease burden/inflammation, while ADL status was evaluated using the Barthel Index (BI). QMT and QEI, indicative of muscle mass and intramuscular adipose tissue, were measured by ultrasound. Multivariate logistic and linear regression analyses were conducted to explore the association of QMT or QEI with malnutrition and ADL.

RESULTS

62 residents (49%) were in the lower QMT group and 63 residents (50%) were in the upper QEI group. The prevalence of severe malnutrition in the lower QMT group was significantly higher than that in the upper QMT group. Moreover, the lower QMT group had significantly lower BI points than the upper QMT group. The upper QEI group had significantly lower BI points than the lower QEI group. lower QMT was associated with severe malnutrition (odds ratio 3.170; 95% CI 1.238 to 8.725; P = 0.016). Furthermore, both lower QMT (B = -12.520; 95% CI -17.069 to -7.973; P < 0.001) and upper QEI (B = -7.598; 95% CI -12.565 to -2.631; P = 0.003) showed an independent correlation with lower BI scores.

CONCLUSION

This study found a relationship between lower QMT correlated with severe malnutrition and poor ADL, while higher QEI is associated with poor ADL.

Implementation of nutritional screening tools, nutritional assessment tools, and diagnostic criteria for malnutrition in convalescent rehabilitation wards: A nationwide survey

BACKGROUND & AIMS

The utilization of recommended nutritional assessment measures in rehabilitation settings remains unclear. This study explored methods for identifying nutritional disorders using data from a nationwide survey conducted in convalescent rehabilitation wards.

METHODS

This cross-sectional study analyzed the annual survey, including methods for identifying malnutrition, the risk of malnutrition, and overnutrition in Kaifukuki (convalescent) rehabilitation wards. Methods identifying malnutrition and risk of malnutrition were grouped into nutritional screening tools (NSTs), nutritional assessment tools (NATs), diagnostic criteria for malnutrition (DCM), and suboptimal methods (e.g., hypoalbuminemia). NSTs, NATs, and DCM were further categorized as "acceptable tools." The association between applying acceptable tools, hospital-based data (e.g., the number of beds), and ward-based data (e.g., assessor for nutritional status) was analyzed by logistic regression analysis with multiple imputations.

RESULTS

In total, 885 hospitals with Kaifukuki rehabilitation wards responded to the survey, and 754 hospitals were included in the analysis. Registered dietitians assessed the nutritional status in 88% of the hospitals, whereas other professionals (e.g., nurses) evaluated the nutritional status in the remainder. NSTs (e.g., Mini Nutritional Assessment Short-Form), NATs (e.g., Subjective Global Assessment), DCM (e.g., Global Leadership Initiative on Malnutrition criteria), and suboptimal tools were used in 13.1%, 5.4%, 4.8%, and 74.6% of cases, respectively. Most hospitals used acceptable measures (e.g., body mass index) for overnutrition (91.2%). Multiple logistic regression analysis showed that assessments by registered dietitians (adjusted odds ratio[OR]: 2.20.95% confidence interval[CI]: 1.09-4.45) and hospital-owned food services, a proxy for limited clinical practice time of dietitians, were associated with a low likelihood of implementing acceptable measures (adjusted OR: 0.64, 95%CI: 0.43-0.97).

CONCLUSIONS

Acceptable malnutrition measures, including the NSTs, NATs, and DCM, have not been widely applied in convalescent rehabilitation settings. The implementation of recommended tools for identifying malnutrition may be promoted when registered dietitians assess the patients' nutritional status.

Association between sarcopenia at discharge and functional outcomes 1 month and 6 months after discharge in patients in convalescent rehabilitation wards

AIM

This retrospective cohort study investigated the relationship between sarcopenia and Activities of Daily Living capacity after discharge from convalescent rehabilitation wards.

METHODS

We included consecutive patients discharged from three convalescent rehabilitation wards in a hospital in Japan between December 2018 and October 2020. Sarcopenia was diagnosed based on the criteria of the 2019 Asian Working Group for Sarcopenia, utilizing skeletal muscle mass index and handgrip strength. Statistical analyses were carried out separately for men and women. The primary outcome was a higher motor domain (motor Functional Independence Measure [mFIM]) and a higher cognitive domain (cognitive Functional Independence Measure [cFIM]) of the FIM score 1 month after discharge. The secondary outcomes were higher mFIM and cFIM scores 6 months after discharge, analyzed using binary logistic regression.

RESULTS

Among 305 participants (mean age 70.0 years, 148 men), 93 were identified as having sarcopenia. The prevalence of sarcopenia was 16% for outpatient rehabilitation services, 59% for home-visit rehabilitation services and 50% for older adult day care. Logistic regression analyses showed that sarcopenia at discharge was not an independent variable for mFIM at 1 month (odds ratio [OR] 20, 95% confidence interval [CI] 0.31-1300 for men, OR 0.51, 95% CI 0.11-2.4 for women) and cFIM (OR 0.63, 95% CI 0.10-3.8 for men, OR 5.3, 95% CI 0.81-34 for women). At 6 months, sarcopenia at discharge was not an independent variable for mFIM (OR 0.30, 95% CI 0.02-3.6 for men, OR 0.40, 95% CI 0.06-2.5 for women) and cFIM (OR 0.16, 95% CI 0.01-2.4 for men, OR 0.00, 95% CI 0.00-1.1 for women).

CONCLUSIONS

Sarcopenia at the time of discharge from convalescent rehabilitation wards does not independently predict FIM 1 month or 6 months after discharge. Geriatr Gerontol Int 2024; 24: 715-721.

Impact of Motivation for Eating Habits, Appetite and Food Satisfaction, and Food Consciousness on Food Intake and Weight Loss in Older Nursing Home Patients

BACKGROUND

This study analyzed data from the Long-term care Information system For Evidence (LIFE) database to examine the effects of motivation to eat, appetite and food satisfaction, and food consciousness on food intake and weight loss.

METHODS

Of the 748 nursing home residents enrolled in the LIFE database, 336 met the eligibility criteria for this cross-sectional study. Motivation to eat, appetite and food satisfaction, and food consciousness were rated on five-point Likert scales (e.g., good, fair, normal, not so good, and not good). We applied Spearman rank correlation coefficient and multiple regression analyses to analyze the relationships between these three items, daily energy and protein intake, and body weight loss over 6 months.

RESULTS

The mean participant age was 87.4±8.1 years and 259 (77%) were female. The required levels of care included-level 1, 1 (0%); level 2, 4 (1%); level 3, 107 (32%); level 4, 135 (40%); and level 5, 89 (27%). The mean daily energy intake was 28.2±7.8 kcal/kg. The mean daily protein intake was 1.1±0.3 g/kg. The mean weight loss over six months was 1.2±0.7 kg. We observed strong positive correlations among motivation to eat, appetite and food satisfaction, and food consciousness (r>0.8). These three items were significantly associated with higher daily energy intake but not with daily protein intake. Only appetite and food satisfaction were significantly associated with lower weight loss over six months.

CONCLUSION

The observed associations of appetite and food satisfaction suggest that these factors may be more important to assess than motivation to eat or food consciousness among older adult residents of long-term care facilities.

The Validity of Quadriceps Muscle Thickness as a Nutritional Risk Indicator in Patients with Stroke

This study aimed to investigate whether quadriceps muscle thickness (QMT) is useful for nutritional assessment in patients with stroke. This was a retrospective cohort study. Nutritional risk was assessed using the Geriatric Nutritional Risk Index (GNRI), with GNRI < 92 indicating a risk of malnutrition and GNRI ≥ 92 indicating normal conditions. Muscle mass was assessed using QMT and calf circumference (CC). The outcome was Functional Independence Measure (FIM) effectiveness. The cutoff values of QMT and CC for discriminating between high and low GNRI were determined using the receiver operating characteristic curve. The accuracy of the nutritional risk discrimination model was evaluated using the Matthews correlation coefficient (MCC). Multiple regression analysis was performed to assess the relationship between nutritional risk, as defined by QMT and CC, and FIM effectiveness. A total of 113 patients were included in the analysis. The cutoff values of QMT and CC for determining nutritional risk were 49.630 mm and 32.0 cm for men (MCC: 0.576; 0.553) and 41.185 mm and 31.0 cm for women (MCC: 0.611; 0.530). Multiple regression analysis showed that only nutritional risk defined by QMT was associated with FIM effectiveness. These findings indicate that QMT is valid for assessing nutritional risk in patients with stroke.

Impact of malnutrition on the quality of life in older patients with advanced heart failure: a cohort study

OBJECTIVES

The aim of this study was to assess the prevalence of malnutrition, the clinical characteristics associated with malnutrition and the impact of nutritional status on mortality, quality of life, self-care abilities, and activities of daily living in the older patients with advanced heart failure.

METHODS

A prospective multicentre cohort study including 260 community-dwelling elderly patients with advanced HF was conducted between June 2017 and December 2019. The study was carried out in 22 primary healthcare centres, three university hospitals, one acute-care hospital, and one geriatric rehabilitation unit in the city of Barcelona (Spain). Nutritional status was assessed at baseline using the Mini Nutritional Assessment questionnaire. Patient-reported outcome measures included quality of life (EQ-5D-3L), self-care behaviour (European Heart Failure Self-care Behaviour Scale) and impact on activities of daily living (Barthel Index).

RESULTS

Using the MNA-SF, 126 (48.5%) patients were identified as being at risk of malnutrition and 33 (12.7%) patients as having confirmed malnutrition. Compared to HF patients with normal nutritional status, patients with confirmed malnutrition were significantly older, with a lower BMI, and with reduced haemoglobin levels. During follow-up (median 14.9 months, Interquartile Range; 4.9-26.9), 133 (51.2%) of the included participants died, and mortality was significantly higher among patients identified as having malnutrition (p < 0.001). Better Barthel index and quality of life scores were inversely related to the risk of malnutrition, [Odds Ratio (OR) 0.97 (95% Confidence interval 0.96; 0.98) and OR 0.98 (95% Confidence interval, 0.96; 0.99)], respectively. Higher scores in the European Heart Failure Self-care Behaviour Scale, which implies worse self care, were related to higher malnutrition risk, OR 1.05 (95% Confidence interval, 1.02; 1.09. Adjusted multivariate logistic model found that malnutrition was significantly associated with poor quality of life, and adverse impacts on daily activities and self-care.

CONCLUSIONS

In community-dwelling older patients with advanced HF, malnutrition was associated with worse patient reported outcome measures related to poor quality of life, and adverse impacts on self-care and daily activities. Nutritional status must be systematically addressed by primary care nurses and family doctors to improve survival rates in these patients. It would be helpful the incorporation of expert professionals in nutrition in the primary health care centres.

Measures for Identifying Malnutrition in Geriatric Rehabilitation: A Scoping Review

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

Sarcopenic Dysphagia and Simplified Rehabilitation Nutrition Care Process: An Update

Sarcopenic dysphagia is characterized by weakness of swallowing-related muscles associated with whole-body sarcopenia. As the number of patients with sarcopenia increases with the aging of the world, the number of patients with sarcopenic dysphagia is also increasing. The prevalence of sarcopenic dysphagia is high in the institutionalized older people and in patients hospitalized for pneumonia with dysphagia in acute care hospitals. Prevention, early detection and intervention of sarcopenic dysphagia with rehabilitation nutrition are essential. The diagnosis of sarcopenic dysphagia is based on skeletal and swallowing muscle strength and muscle mass. A reliable and validated diagnostic algorithm for sarcopenic dysphagia is used. Sarcopenic dysphagia is associated with malnutrition, which leads to mortality and Activities of Daily Living (ADL) decline. The rehabilitation nutrition approach improves swallowing function, nutrition status, and ADL. A combination of aggressive nutrition therapy to improve nutrition status, dysphagia rehabilitation, physical therapy, and other interventions can be effective for sarcopenic dysphagia. The rehabilitation nutrition care process is used to assess and problem solve the patient's pathology, sarcopenia, and nutrition status. The simplified rehabilitation nutrition care process consists of a nutrition cycle and a rehabilitation cycle, each with five steps: assessment, diagnosis, goal setting, intervention, and monitoring. Nutrition professionals and teams implement the nutrition cycle. Rehabilitation professionals and teams implement the rehabilitation cycle. Both cycles should be done simultaneously. The nutrition diagnosis of undernutrition, overnutrition/obesity, sarcopenia, and goal setting of rehabilitation and body weight are implemented collaboratively.

A model for predicting physical function upon discharge of hospitalized older adults in Taiwan-a machine learning approach based on both electronic health records and comprehensive geriatric assessment

Background

Predicting physical function upon discharge among hospitalized older adults is important. This study has aimed to develop a prediction model of physical function upon discharge through use of a machine learning algorithm using electronic health records (EHRs) and comprehensive geriatrics assessments (CGAs) among hospitalized older adults in Taiwan.

Methods

Data was retrieved from the clinical database of a tertiary medical center in central Taiwan. Older adults admitted to the acute geriatric unit during the period from January 2012 to December 2018 were included for analysis, while those with missing data were excluded. From data of the EHRs and CGAs, a total of 52 clinical features were input for model building. We used 3 different machine learning algorithms, XGBoost, random forest and logistic regression.

Results

In total, 1,755 older adults were included in final analysis, with a mean age of 80.68 years. For linear models on physical function upon discharge, the accuracy of prediction was 87% for XGBoost, 85% for random forest, and 32% for logistic regression. For classification models on physical function upon discharge, the accuracy for random forest, logistic regression and XGBoost were 94, 92 and 92%, respectively. The auROC reached 98% for XGBoost and random forest, while logistic regression had an auROC of 97%. The top 3 features of importance were activity of daily living (ADL) at baseline, ADL during admission, and mini nutritional status (MNA) during admission.

Conclusion

The results showed that physical function upon discharge among hospitalized older adults can be predicted accurately during admission through use of a machine learning model with data taken from EHRs and CGAs.

Current Understanding of Sarcopenia and Malnutrition in Geriatric Rehabilitation

Malnutrition and sarcopenia are different but common conditions in older adults that share some underlying causes, including age-related physiological changes, decreased food intake, acute or chronic inflammation [...]

Effects of Undernutrition on Swallowing Function and Activities of Daily Living in Hospitalized Patients: Data from the Japanese Sarcopenic Dysphagia Database

This retrospective cohort study examined the effects of undernutrition on swallowing function and activities of daily living in hospitalized patients. Data from the Japanese Sarcopenic Dysphagia Database were used, and hospitalized patients aged ≥20 years with dysphagia were included in the analysis. Participants were assigned to the undernutrition or normal nutritional status group based on the Global Leadership Initiative on Malnutrition criteria. The primary outcome was the Food Intake Level Scale change, and the secondary outcome was the Barthel Index change. Among 440 residents, 281 (64%) were classified under the undernutrition group. The undernutrition group had a significantly higher Food Intake Level Scale score at baseline and Food Intake Level Scale change (p = 0.001) than the normal nutritional status group. Undernutrition was independently associated with the Food Intake Level Scale change (B = -0.633, 95% confidence interval = -1.099 to -0.167) and the Barthel Index change (B = -8.414, 95% confidence interval = -13.089 to -3.739). This was defined as the period from the date of admission to the hospital until discharge or 3 months later. Overall, our findings indicate that undernutrition is associated with reduced improvement in swallowing function and the ability to perform activities of daily living.