Unidentified under-nutrition: dietary intake and anthropometric indices in a residential care home population

A systematic review and meta-analysis of the dietary fiber menu provision and consumption for older adults living in residential care facilities

BACKGROUND

Older adults living in residential care facilities are commonly given laxatives to treat constipation; however, these may not always provide full relief, and side effects include diarrhea. Dietary fiber effectively prevents constipation, and international guidelines recommend 25 g/d for optimal laxation. Older adults in residential care rely on the facility menu to provide their nutritional requirements, including adequate dietary fiber. Little is known about how much dietary fiber is provided and consumed.

OBJECTIVES

We aimed to determine the provision and consumption of dietary fiber for older adults living in residential care facilities.

METHODS

We systematically searched available literature for studies reporting the analysis of residential care menus and meals consumed by residents aged over 65 y. A meta-analysis was performed on the studies that provided the mean amount of dietary fiber provided and consumed by residents. A random effect model was applied due to the heterogeneity of study methodologies.

RESULTS

The literature search yielded 4406 publications, but only 28 studies were eligible for our meta-analysis. The study sample comprised 4817 residents. The mean amount of fiber provided to residents was 21.4 g/d [standard error (SE): 1.2; 95% confidence interval: 18.8, 24.2 g/d], the mean amount of fiber consumed by residents was 15.8 g/d (SE: 0.6; 95% confidence interval: 14.7, 16.9 g/d).

CONCLUSIONS

Older adults living in care facilities are provided with dietary fiber below the recommended guidelines. Compounding this is that residents consume much less than what is provided and do not meet the recommendations for dietary fiber consumption. There is scope to improve dietary fiber provision, promote consumption to residents to aid laxation, and potentially reduce laxative use and the unwanted side effects of diarrhea. This trial was registered at PROSPERO as CRD42023427265.

Dysphagia, texture modification, the elderly and micronutrient deficiency: a review

Dysphagia is an underlying symptom of many health issues affecting a person's ability to swallow. Being unable to swallow correctly may limit food intake and subsequently micronutrient status. The elderly may be the most at risk group of suffering dysphagia as well as most likely to be deficient in micronutrients. The use of texture-modified meals is a common approach to increasing dysphagia sufferer's food intake. The modification of food may affect the micronutrient content and currently there is a limited number of studies focusing on micronutrient content of texture-modified meals. This review considers the prevalence of dysphagia within the elderly UK community whilst assessing selected micronutrients. Vitamin B₁₂, C, D, folate, zinc and iron, which are suggested to be most likely deficient in the general elderly UK population, were reviewed. Each micronutrient is considered in terms of prevalence of deficiency, metabolic function, food source and processing stability to provide an overview with respect to elderly dysphagia sufferers.

Trace Mineral Intake and Deficiencies in Older Adults Living in the Community and Institutions: A Systematic Review

The global population is ageing with many older adults suffering from age-related malnutrition, including micronutrient deficiencies. Adequate nutrient intake is vital to enable older adults to continue living independently and delay their institutionalisation, as well as to prevent deterioration of health status in those living in institutions. This systematic review investigated the insufficiency of trace minerals in older adults living independently and in institutions. We examined 28 studies following a cross-sectional or cohort design, including 7203 older adults (≥60) living independently in 13 Western countries and 2036 living in institutions in seven Western countries. The estimated average requirement (EAR) cut-off point method was used to calculate percentage insufficiency for eight trace minerals using extracted mean and standard deviation values. Zinc deficiency was observed in 31% of community-based women and 49% of men. This was higher for those in institutional care (50% and 66%, respectively). Selenium intakes were similarly compromised with deficiency in 49% women and 37% men in the community and 44% women and 27% men in institutions. We additionally found significant proportions of both populations showing insufficiency for iron, iodine and copper. This paper identifies consistent nutritional insufficiency for selenium, zinc, iodine and copper in older adults.

A registry study of nursing assessments, interventions and evaluations according to nutrition for persons living in municipal residential care homes

AIM

The aim was to explore planned nursing interventions and evaluations of such interventions, in older people at risk for malnutrition living in municipal residential care homes.

DESIGNS

A registry study.

METHODS

The study was conducted using data from the Swedish national quality registry Senior Alert. Data on all persons assessed and registered in Senior Alert living in municipal residential care homes in a mid-sized town between January and December 2014 were subjected to statistical analysis.

RESULTS

In total, 677 nutritional risk assessments were performed among the participants (N = 587), who were between 65-109 years. A larger proportion of women were estimated as being at risk for malnutrition compared with men. The three most common prescribed nursing interventions were nutritional treatment, dietary support and weight control; however, interventions were not prescribed for all participants at risk for malnutrition. Lesser than 50% of the interventions were evaluated, with dietary support, pharmaceutical review and weight control the three most likely to be evaluated. Further, planned interventions for participants at risk of malnutrition were implemented more often for men than for women.

Low protein and micronutrient intakes in heterogeneous older population samples

BACKGROUND

Malnutrition is associated with comorbidities and functional decline among older people. Less is known about nutrient intakes across heterogeneous older populations.

OBJECTIVE

We examined nutritional status and nutrient intakes in different samples of older people representing broad spectrum of healthy and frail populations. We evaluated adequacy of their energy, protein and micronutrient intakes in comparison to recommendations.

DESIGN AND PARTICIPANTS

Cross-sectional study combined five datasets: home-dwelling older people participating in nutrition education and cooking classes (NC) [n=54], participants from Helsinki Businessmen Study [n=68], home-dwelling people with Alzheimer disease (AD) [n=99] and their spousal caregivers (n=97), participants from Porvoo Sarcopenia and Nutrition Trial (n=208), and residents of Helsinki assisted living facilities (ALF) [n=374]. Nutritional status was assessed using Mini Nutritional Assessment and nutrient intakes retrieved from 1 to 3 day food records.

RESULTS

Those suffering most from mobility limitation and cognitive decline had the poorest nutritional status (p<0.001; adjusted for age, sex, comorbidities). However, low intakes of energy, protein, and micronutrients were observed in high proportion in all groups, inadequate intakes of vitamins D, E, folate, and thiamine being most common. Protein intakes did not differ between the groups, but 77% of all participants had lower than recommended protein intake. In general, the NC group had highest micronutrient intakes and the ALF group the lowest. However, AD females had the lowest energy, protein, and vitamin C intakes.

CONCLUSIONS

Our study provides a detailed picture of risks related to nutrient intakes in various groups of older people. These findings could be used in planning tailored nutrition interventions.

Dietary intake of energy, nutrients and water in elderly people living at home or in nursing home

OBJECTIVES

There is a lack of detailed information on dietary intake in elderly people at an individual level, which is crucial for improvement of nutritional support. The aim of this study was to investigate the dietary intake in elderly people in two types of living situations.

DESIGN

Observational study, analysing prospective data.

SETTING

The dietary intake was studied in elderly people living at home or in nursing home, in different cities of Sweden.

PARTICIPANTS

A total of 264 elderly people (mean age 84) participated in the observational study.

MEASUREMENTS

Dietary intake was measured using weighed food records and food diaries, comparing females and males. The observed dietary intake was related to Recommended intake and Lower intake level.

RESULTS

All dietary intake and patient characteristic variables showed large individual differences (ranges). We found no significant differences (p>0.05) between those living at home and nursing home residents regarding the average intake of energy, protein and water when expressed as total intake per kg of body weight. A very low daily intake of energy (<20 kcal/kg body weight/day) was observed in 16% of the participants. For vitamin D and iron, 19% and 15%, respectively, had intakes below the Lower intake level. There was no correlation between intake of energy, protein or water and resident characteristics such as age, autonomy, morbidity, nutritional state or cognition.

CONCLUSIONS

The large individual differences (ranges) in energy, nutrients and water show that the use of mean values when analysing dietary intake data from elderly people is misleading. From a clinical perspective it is more important to consider the individual intake of energy, nutrients and water. Ageism is intrinsic in the realm of 'averageology'.

Dentition, nutritional status and adequacy of dietary intake among older residents in assisted living facilities

OBJECTIVE

We examined the relationships between dentition, nutritional status and dietary intakes of energy, protein and micronutrients among older people in assisted living facilities in Helsinki.

BACKGROUND

Poor dentition is associated with malnutrition. Less is known about how dentition is associated with detailed nutrient intakes in institutionalised older people.

MATERIALS AND METHODS

This cross-sectional study assessed 343 participants (mean age 83 years). Dentition was assessed by trained ward nurses and divided into edentulous participants without dentures (group 1), edentulous participants with removable dentures (group 2) and those with any natural teeth (group 3). Nutritional status was assessed by Mini Nutritional Assessment (MNA). The energy, protein and nutrient intakes were calculated from detailed 1-day food diaries and compared with the recommendations of the Finnish National Nutrition Council as a measure of dietary adequacy. Assessment included also participants' cognitive and functional status.

RESULTS

Of the participants, 8.2, 39.1 and 52.8% were in groups 1, 2 and 3, respectively. Altogether 22% were malnourished according to MNA. Group 1 had the poorest nutritional status. A large proportion of participants consumed less than the recommended amounts of energy, protein or micronutrients. Half of the participants consumed <60 g/day of protein. The intake of protein was significantly lower in group 1 than in other two groups.

CONCLUSION

Malnutrition and inadequate protein intake were very common and associated with dentition among older people with multiple disabilities in assisted living facilities. Assessment of dental status should be part of good nutritional care in long-term care.

‘You can’t be forcing food down ‘em’: Nursing home carers’ perceptions of residents’ dining needs

Malnutrition is a life-threatening condition among older people living in nursing care homes. This qualitative analysis of interview data from five care staff aimed to understand their perceptions of ‘caring for’ residents’ nutritional needs. Tensions in the delivery of care and institutionalisation and disempowerment were identified. Despite carers’ good intentions, they often failed to recognise the importance of the psychosocial aspects of mealtimes. Staff shortages, routine-driven, medically based working practices and residents’ resistance to institutionalisation emerged as barriers to quality caregiving. The findings indicate that the relational aspects of care are constrained by social, structural and ideological contexts.

Addressing the nutritional needs of older people in residential care homes

In the UK and Europe, malnutrition in older people is a significant and continuing problem. Malnutrition predisposes to disease, impedes recovery from illness, increases mortality and is costly to society. Despite the high number of older people potentially at risk, malnutrition in care homes has been under explored. There is concern that national guidelines regarding the nutritional care of older people in residential care homes are not always implemented. This qualitative study explored the factors that influence the nutritional care provided to residents in two different types of local authority residential care homes (providing personal care) in Wales. One home had communal dining rooms; the other had eight bedded units with their own kitchen and dining facilities. The sample of 45 participants, comprised 19 staff (managers, care and catering staff), 16 residents and 10 residents' relatives. Data were collected using semi-structured interviews, focus groups, observation and documentary review between August 2009 and January 2010. This paper focuses on how staff assessed and addressed residents' nutritional needs. In both care homes, staff strove to be responsive to residents' dietary preferences, provided person-centred care and worked in partnership with residents and their families to provide nutritious food in a homely environment. Neither home conducted nutritional screening to identify those at risk of malnutrition, contrary to national guidelines, but relied on ad hoc observation and monitoring. The staff's knowledge of special dietary needs was limited. A need for further training for care home staff regarding the importance of nutrition in maintaining health in older people, use of nutritional screening and special dietary needs was identified. Shared nutrition training between health and social care staff needs expansion and policy implications in terms of an enhanced regulatory focus on maintaining nutritional needs in care homes are proposed.

Prevalence and factors associated with feeding difficulty in institutionalized elderly with dementia in Taiwan

OBJECTIVES

The purpose of this study was to establish the prevalence rate of feeding difficulty and to understand the factors associated with it among people with dementia.

DESIGN

A cross-sectional design was used.

SETTING

Five nursing homes in Taiwan.

PARTICIPANTS

Ninety-three residents with dementia were enrolled.

MEASUREMENTS

Feeding difficulty was measured by The Edinburgh Feeding Evaluation in Dementia (EdFED) scale. Data included demographics, nutritional data, cognition, and independence were also collected.

RESULTS

Residents with EdFED scores above five had significantly longer duration of dementia (56.3±27.4 vs 42.2±22.8, P<0.05), greater dependence (26.2±20.8 vs 57.4±25.7, P<0.0001), lower BMI (21.5±3.8 vs 23.2±4.6, P<0.05), and greater cognitive impairment (8.4±2.6 vs 6.4±3.3, P<0.001) than those with EdFED scores under five. Using 5 points as the EdFED cutoff score, the prevalence rate of feeding difficulties was 60.2%. Using multiple regression to examine the predictors of feeding difficulty, 35.1% of the variance was explained, with ADL, cognition and number of medications being significant (beta = .46,.23 and .19, respectively), while non-significant factors were age, gender, duration of dementia and eating time.

CONCLUSION

The prevalence of feeding difficulty was high among Taiwanese elderly with dementia. Training nurses or nursing assistants to notice feeding problems in order to provide adequate assistance is important for preventing malnutrition among residents with dementia in Taiwan nursing homes.

Improving the dietary intake of frail older people

As a population subgroup, older people are more vulnerable to malnutrition especially those who are institutionalised. Recognition of deteriorating or poor nutritional status is key in reversing the effects of undernutrition and reinforces the value of regular weight checks and/or the use of screening tools. Commercially produced supplements are often the first option used to address undernutrition in both acute and community settings. They can be expensive and, although regularly prescribed, have undergone only limited evaluation of their effectiveness in community settings. An alternative but less researched approach to improve the nutritional status of undernourished people is food fortification. This approach may be particularly useful for older people, given their often small appetites. The ability to eat independently has been significantly related to decreased risk of undernutrition. Assisting people who have difficulty feeding themselves independently should become a designated duty and may be crucial in optimising nutritional status. Lack of nutrition knowledge has been identified as the greatest barrier to the provision of good nutritional care. Education and training of care staff are pivotal for the success of any intervention to address undernutrition. The development of undernutrition is a multi-factorial process and a package of approaches may be required to prevent or treat undernutrition. Nutrition must be at the forefront of care if national care standards are to be met.

Use of calcium, folate, and vitamin D₃-fortified milk for 6 months improves nutritional status but not bone mass or turnover, in a group of Australian aged care residents

In residential care, inadequate calcium and folate intakes and low serum vitamin D (25(OH)D) concentrations are common. We assessed whether daily provision of calcium, folate, and vitamin D₃-fortified milk for 6 months improved nutritional status (serum micronutrients), bone quality (heel ultrasound), bone turnover markers (parathyroid hormone, C-terminal collagen I telopeptide, terminal propeptide of type I procollagen), and/or muscle strength and mobility in a group of Australian aged care residents. One hundred and seven residents completed the study (mean (SD) age: 79.9 (10.1) years; body weight: 68.4 (15.4) kg). The median (inter-quartile range) volume of fortified milk consumed was 160 (149) ml/day. At the end of the study, the median daily vitamin D intake increased to 10.4 (8.7) μg (P < .001), which is 70% of the adequate intake (15 μg); and calcium density (mg/MJ) was higher over the study period compared with baseline (161 ± 5 mg/MJ vs. 142 ± 4 mg/MJ, P < .001). Serum 25(OH)D concentrations increased by 23 ± 2 nmol/L (83 (107)%, P < .001), yet remained in the insufficient range (mean 45 ± 2 nmol/L). Consumption of greater than the median intake of milk (160 ml/day) (n = 54, 50%) increased serum 25(OH)D levels into the adequate range (53 ± 2 nmol/L) and reduced serum parathyroid hormone by 24% (P = .045). There was no effect on bone quality, bone turnover markers, muscle strength, or mobility. Consumption of fortified milk increased dietary vitamin D intake and raised serum 25(OH)D concentrations, but not to the level thought to reduce fracture risk. If calcium-fortified milk also was used in cooking and milk drinks, this approach could allow residents to achieve a dietary calcium intake close to recommended levels. A vitamin D supplement would be recommended to ensure adequate vitamin D status for all residents.

Meals served in Danish nursing homes and to Meals-on-Wheels clients may not offer nutritionally adequate choices

Underweight is a significant problem among older Danish nursing home residents and home-care clients. The aim of this study was to evaluate the nutritional composition of the meals prepared for older adults in nursing homes and receiving Meals-on-Wheels deliveries, focusing on the menus most commonly served, including the standard menu (most commonly prepared), the energy and protein dense menu, and two types of texture modified menus (chopped and blended). Also, one portion of a homemade energy and protein dense drink was collected and analyzed. For each of the participating kitchens (N = 10), extra portions of different menus were made (3 days in a row). The meal samples (total n = 389) were analyzed for content of energy, protein, fat and carbohydrate. The findings were compared with recommendations regarding the foods to be served in Danish institutions. The nutrient content of the meals-on-wheels and nursing home meals, as well as that of the homemade energy and protein dense drink, varied considerably. The nursing home menus seldom or never fulfilled the recommendations. Our findings support the conclusion that meals served in Danish nursing homes and to meals-on-wheels clients do not consistently offer adequate nutritional intakes.

Malnutrition on the menu: nutritional status of institutionalised elderly Australians in low-level care

BACKGROUND

Most studies reporting malnutrition in the elderly relate to high-level care. However, one third of Australians in aged care reside in low-level care facilities. Data is limited on their nutritional status.

OBJECTIVE

To investigate the nutritional status of elderly in low-level care facilities.

DESIGN

A cross sectional study design.

SETTING

14 low-level aged care facilities in metropolitan Melbourne.

PARTICIPANTS

Convenience sample of 103 ambulatory elderly (86 +/- 6.6 years (mean +/- SD), 76% female, comprising 15% of the hostel population) able to perform daily functions of living.

MEASUREMENTS

Nutritional intake assessed by three-day weighed food records, and nutritional status by haematological and biochemical markers and body composition (dual energy X-ray absorptiometry).

RESULTS

FOOD served did not supply the estimated average requirements (EAR) for 5 of the 14 nutrients analysed. Compared with EAR, 34% of participants were protein malnourished and 62% had energy intake deficits. Micronutrient intake was low for calcium, magnesium, folate, zinc (for men) and dietary fibre. Vitamin D deficiency (serum 25OH Vitamin D < 50 nmol/L) was present in 58% of residents. More men than women had low haemoglobin (P < 0.000), low red blood cells (P < 0.000), and a raised white blood cell count (P = 0.004). Forty three percent of men and 21% women had sarcopenia, 28% of men and 44% women had excess body fat (> 28% and >40%, respectively) and 14% of men and 12 % of women were sarcopenic-obese. Only 12% showed no sign of undernutrition using seven different nutritional indicators. Around 65% had two or more indicators of undernutrition.

CONCLUSION

These findings highlight the need for the supply of more, better quality, nutrient dense food to residents and better detection of undernutrition in aged care facilities. Maintenance of nutritional status has the potential to reduce morbidity and delay the transition to high-level care.

Measuring body mass index (BMI) in nursing home residents: the usefulness of measurement of arm span

OBJECTIVE

To study whether arm span can be used as substitute for measurement of height in nursing home patients for calculating body mass index (BMI).

DESIGN

Explanatory observational study.

SETTING

Assessment of 35 nursing home residents admitted to long-term stay in a nursing home.

MAIN OUTCOME MEASURES

Correlation between measured height and arm span and of BMI based on both measures.

RESULTS

Measured height and arm span, and BMI calculated from either measure were significantly correlated, r(s)=0.75, p <0.001 and r(s)=0.89, p <0.001, respectively. The ratios of measured height and arm span and between BMIs based on height or arm span are close to 1, but the dispersion is rather large.

CONCLUSION

Arm span is a reliable substitute for measurement of height in nursing home patients. In persons with severe height reduction, arm-span-based BMI is probably more accurate than conventional height-based BMI.

Malnutrition in hospitals

Still common because screening tools are underused and poorly enforced