Patient, family and carer experiences of nutritional screening: a systematic review

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

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

Malnutrition, sarcopenia and cachexia: exploring prevalence, overlap, and perceptions in older adults with cancer

BACKGROUND

Older adults with cancer are a growing population requiring tailored care to achieve optimum treatment outcomes. Their care is complicated by under-recognised and under-treated wasting disorders: malnutrition, sarcopenia, and cachexia. We aimed to investigate the prevalence, overlap, and patients' views and experiences of malnutrition, sarcopenia, and cachexia, in older adults with cancer.

METHODS

Mixed-methods study with cross-sectional study and qualitative interviews. Interviews were thematically analysed through a phenomenological lens, with feedback loop analysis investigating relationships between themes and findings synthesised using modified critical interpretative synthesis.

FINDINGS

n = 30 were screened for malnutrition, sarcopenia, and cachexia, n = 8 completed semi-structured interviews. Eighteen (60.0%) were malnourished, 16 (53.3%) sarcopenic, and 17 (56.7%) cachexic. One or more condition was seen in 80%, and all three in 30%. In univariate analysis, Rockwood clinical frailty score (OR 2.94 [95% CI: 1.26-6.89, p = 0.013]) was associated with sarcopenia, reported percentage meal consumption (OR 2.28 [95% CI: 1.24-4.19, p = 0.008]), and visible wasting (OR 8.43 [95% CI: 1.9-37.3] p = 0.005) with malnutrition, and percentage monthly weight loss (OR 8.71 [95% CI: 1.87-40.60] p = 0.006) with cachexia. Screening tools identified established conditions rather than 'risk'. Nutritional and functional problems were often overlooked, overshadowed, and misunderstood by both patients and (in patients' perceptions) by clinicians; misattributed to ageing, cancer, or comorbidities. Patients viewed these conditions as both personal impossibilities, yet accepted inevitabilities.

CONCLUSION

Perceptions, identification, and management of these conditions needs to improve, and their importance recognised by clinicians and patients so those truly 'at risk' are identified whilst conditions are more remediable to interventions.

Families' perception of proposed nutrition screening on admission to pediatric hospitals: a qualitative analysis

Nutrition screening is the first step in most acute care pediatric nutrition care pathways. However, there is a lack of understanding of patient and families' perception of nutrition screening in pediatric populations. The objective of this study was to explore the potential perceptions, feelings, and opinions of families if pediatric nutrition screening were to be completed during hospital admission. Nine members of the Family Advisory Council at the Alberta Children's Hospital participated in a focus group to discuss questions around nutrition screening practices, malnutrition, and the pediatric nutrition screening tool. Transcripts were analyzed using MAXQDA and thematic analysis using the Braun and Clarke methodology. Two major themes emerged: screening may raise sensitive emotions and understanding the purpose of nutrition screening and the questions. Participants agreed discussions around growth and nutrition are vital to comprehensive medical care; however, the timing and approach of nutrition screening can lead to anxiety and feelings of judgement. A lack of understanding of the purpose of screening, next steps, and benefit to the individual patient could limit acceptance of nutrition screening. The findings of this study can inform training and education of healthcare professionals involved in nutrition screening.

Community-Based Nutrition Risk Screening in Older Adults (COMRISK): An Exploration of the Experience of Being Screened and Prevalence of Nutrition Risk in Alberta, Canada

The objectives of this feasibility study were to measure the prevalence of nutrition risk in community-dwelling older adults (CDOA, ages ≥ 65 years) and explore the perspectives of CDOA of the acceptability, value, and effectiveness of nutrition risk screening in primary care and community settings. Using the Seniors in the Community: Risk Evaluation for Eating and Nutrition (SCREEN)© eight-item tool (n = 276), results indicated that moderate and high nutrition risks affected 50 per cent and 8 per cent, respectively, of those screened. Interviewees (n = 16) agreed that screening is acceptable, important, and valuable (Theme One). Effectiveness was unclear, as only 3 of 16 respondents recalled being told their nutrition risk status. When articulating nutrition-related issues, a food security theme, expressed in the third person, was prominent (Theme Two). Screening for nutrition risk and receiving nutrition information in community-based settings are acceptable to CDOA and medically necessary, as evidenced by the high proportion of CDOA at moderate-high nutrition risk.

Dietitians' perceptions of identifying and managing malnutrition and frailty in the community: A mixed-methods study

AIM

This study aimed to explore dietitians' perceptions of their current practice for identifying and managing malnutrition/frailty in the community, to fill an evidence gap.

METHODS

This mixed-methods study involved an online survey distributed to dietitians practising in Australia and New Zealand, and semi-structured interviews with a subset of survey participants. The 34-item survey and interviews explored dietitians' practices for identifying/managing malnutrition and frailty, focusing on the community setting. Survey data were analysed descriptively and some simple association tests were conducted using statistical software. Interview data were analysed thematically.

RESULTS

Of the 186 survey respondents, 18 also participated in an interview. Screening and assessment for malnutrition varied in the community and occurred rarely for frailty. Dietitians reported practising person-centred care by involving clients/carers/family in setting goals and selecting nutrition interventions. Key barriers to providing nutrition care to community-dwelling adults included a lack of awareness/understanding of nutrition by clients and other health professionals (leading to them not participating in or valuing nutrition care), lack of time and resources in the community, and client access to foods/supplements. Enablers included engaging family members/carers and coordinating with other health professionals in nutrition care planning.

CONCLUSION

Reported practices for identifying malnutrition and frailty vary in the community, suggesting guidance may be needed for health professionals in this setting. Dietitians reported using person-centred care with malnourished and frail clients but encountered barriers in community settings. Engaging family members/carers and multidisciplinary colleagues may help overcome some of these barriers.

Enhancing nutrition screening in patients with kidney disease

Malnutrition is common in patients with kidney disease, and can exacerbate the individual and economic burden of the condition. The identification of malnutrition is essential to inform management interventions and improve patient outcomes, and nutrition screening can be considered the first stage in this process. The development of simple nutrition screening tools has assisted nurses in undertaking widespread, rapid assessments of patients' malnutrition risk. However, generic tools may not be appropriate or accurate in patients with kidney disease. This article explains some of the challenges of identifying malnutrition in this patient group and outlines some disease-specific tools that nurses can use to enhance nutrition screening.

'Between foods and medicines': A qualitative interview study of patient experiences of the meaning and usage of oral nutritional supplements

The aim of this study was to deepen the understanding of what oral nutritional supplements mean to patients and how this meaning connects to supplement usage, by exploring patient experiences of such supplements. Qualitative interviews were conducted in June 2019-March 2020 with ten patients with malnutrition or at nutritional risk, prescribed oral nutritional supplements by dietitians. Data were thematically analysed using systematic text condensation. Two final categories were identified: 'Oral nutritional supplements are a one-dimensional remedy' and 'Everyday oral nutritional supplement usage is regulated autonomously'. The patients described the meaning of oral nutritional supplements as nutrition. While the supplements could compensate for nutrients not eaten or be part of a helpful compensation strategy, they could not lessen the burden of altered eating. Supplement usage was described as dependent on the acceptance of taste and the priority given to nutrition in everyday life. Usage was greater when nutrients were perceived as needed, such as when striving for higher bodyweight or disease recovery. Usage was lower when a patient's own goals were not increased nutrient intake or bodyweight or when other activities were perceived as more important. Patient experiences indicated that oral nutritional supplements could serve as a remedy for malnutrition, but not for a situation of altered eating. Supplement usage was described as being regulated autonomously based on patient views on the importance of nutrition. Those views were diverse, highlighting the importance of supplement prescribers discussing treatment goals with each patient. A deeper understanding of the meaning of oral nutritional supplements and reasons for their usage from a patient perspective is crucial in order for healthcare to provide appropriate, effective nutrition therapy for malnutrition.

Identifying and Managing Malnutrition, Frailty and Sarcopenia in the Community: A Narrative Review

Malnutrition, frailty and sarcopenia are becoming increasingly prevalent among community-dwelling older adults; yet are often unidentified and untreated in community settings. There is an urgent need for community-based healthcare professionals (HCPs) from all disciplines, including medicine, nursing and allied health, to be aware of, and to be able to recognise and appropriately manage these conditions. This paper provides a comprehensive overview of malnutrition, frailty and sarcopenia in the community, including their definitions, prevalence, impacts and causes/risk factors; and guidance on how these conditions may be identified and managed by HCPs in the community. A detailed description of the care process, including screening and referral, assessment and diagnosis, intervention, and monitoring and evaluation, relevant to the community context, is also provided. Further research exploring the barriers/enablers to delivering high-quality nutrition care to older community-dwelling adults who are malnourished, frail or sarcopenic is recommended, to inform the development of specific guidance for HCPs in identifying and managing these conditions in the community.