Assessment of Dietary Intake in Three Cohorts of Advanced Age in Two Countries: Methodology Challenges

OBJECTIVES

Dietary intake information is key to understanding nutrition-related outcomes. Intake changes with age and some older people are at increased risk of malnutrition. Application, difficulties, and advantages of the 24-hour multiple pass recall (24hr-MPR) dietary assessment method in three cohorts of advanced age in the United Kingdom (UK) and New Zealand (NZ) is described.

PARTICIPANTS

The Newcastle 85+ study (UK) recruited a single year birth cohort of people aged 85 years during 2006-7. LiLACS NZ recruited a 10-year birth cohort of Māori (indigenous New Zealanders) aged 80-90 years and a single year birth cohort of non-Māori aged 85 years in 2010.

MEASUREMENTS

Two 24hr-MPR were conducted on non-consecutive days by trained assessors. Pictorial resources and language were adapted for the New Zealand and Māori contexts. Detailed methods are described.

RESULTS

In the Newcastle 85+ study, 805 (93%) participants consented to the 24-MPR, 95% of whom completed two 24hr-MPR; in LiLACS NZ, 218 (82%) consented and 203 (76%) Māori and 353 (90%) non-Māori completed two 24hr-MPR. Mean time to complete each 24hr-MPR was 22 minutes in the Newcastle 85+ study, and 45 minutes for Māori and 39 minutes for non-Māori in LiLACS NZ. Dietary assessment of participants residing in residential care and those requiring proxy respondents were successfully included in both studies. Most participants (83-94%) felt that data captured by the 24hr-MPR reflected their usual dietary intake.

CONCLUSIONS

Dietary assessment using 24hr-MPR was successful in capturing detailed dietary data including information on portion size and time of eating for over 1300 octogenarians in the UK and New Zealand (Māori and non- Māori). The 24hr-MPR is an acceptable method of dietary assessment in this age group.

Is the Utility of the GLIM Criteria Used to Diagnose Malnutrition Suitable for Bicultural Populations? Findings from Life and Living in Advanced Age Cohort Study in New Zealand (LiLACS NZ)

OBJECTIVES

To investigate associations between nutrition risk (determined by SCREEN-II) and malnutrition (diagnosed by the GLIM criteria) with five-year mortality in Māori and non-Māori of advanced age.

DESIGN

A longitudinal cohort study.

SETTING

Bay of Plenty and Lakes regions of New Zealand.

PARTICIPANTS

255 Māori; 400 non-Māori octogenarians.

MEASUREMENTS

All participants were screened for nutrition risk using the Seniors in the Community: Risk Evaluation for Eating and Nutrition (SCREEN-II). Those at high nutrition risk (SCREEN-II score <49) had the Global Leadership Initiative in Malnutrition (GLIM) criteria applied to diagnose malnutrition or not. Demographic, physical and health characteristics were obtained by trained research nurses using a standardised questionnaire. Five-year mortality was calculated from Government data. The association of nutrition risk (SCREEN-II) and a malnutrition diagnosis (GLIM) with five-year mortality was examined using logistic regression and cox proportional hazard models of increasing complexity.

RESULTS

56% of Māori and 46% of non-Māori participants had low SCREEN-II scores indicative of nutrition risk. The prevalence of GLIM diagnosed malnutrition was lower for both Māori and non-Māori (15% and 19% of all participants). Approximately one-third of participants (37% Māori and 32% non-Māori) died within the five-year follow-up period. The odds of death for both Māori and non-Māori was significantly lower with greater SCREEN II scores (better nutrition status), (OR (95% CI); 0.58 (0.38, 0.88), P < 0.05 and 0.53 (0.38, 0.75), P < 0.001, respectively). GLIM diagnosed malnutrition was not significantly associated with five-year mortality for Māori (OR (95% CI); 0.88 (0.41, 1.91), P >0.05) but was for non-Māori. This association remained significant after adjustment for other predictors of death (OR (95% CI); 0.50 (0.29, 0.86), P< 0.05). Reduced food intake was the only GLIM criterion predictive of five-year mortality for Māori (HR (95% CI); 10.77 (4.76, 24.38), P <0.001). For non-Māori, both aetiologic and phenotypic GLIM criteria were associated with five-year mortality.

CONCLUSION

Nutrition risk, but not malnutrition diagnosed by the GLIM criteria was significantly associated with mortality for Māori. Conversely, both nutrition risk and malnutrition were significantly associated with mortality for non-Māori. Appropriate phenotypic criteria for diverse populations are needed within the GLIM framework.

Letter to the Editor: Healthy for Life: An Innovative and Collaborative Approach to COVID 19 Lockdown in New Zealand

Recently Boreskie and colleagues published an editorial in the Journal of Frailty and Aging on Preventing Frailty Progression During the COVID-19 Pandemic (1). In it they proposed the SAVE programme (Socialization, Adequate nutrition, Vitamin D, Exercise) to prevent frailty. They concluded that creative thinking and concerted efforts would be needed to disseminate health recommendations to maintain the health of pre-frail and frail older adults in unprecedented times, such as those posed by the COVID-19 pandemic.

Reducing emergency presentations from long-term care: A before-and-after study of a multidisciplinary team intervention

INTRODUCTION

The complexity of care required by many older people living in long-term care (LTC) facilities poses challenges that can lead to potentially avoidable referrals to a hospital emergency department (ED). The Aged Residential Care Intervention Project (ARCHIP) ran an implementation study to evaluate a multidisciplinary team (MDT) intervention supporting LTC facility staff to decrease potentially avoidable ED presentations by residents.

METHODS

ARCHIP (conducted in 21 facilities [1,296 beds] with previously noted high ED referral rates) comprised clinical coaching for LTC facility staff by a gerontology nurse specialist (GNS) and an MDT (facility senior nurse, resident's general practitioner, GNS, geriatrician, pharmacist) review of selected high-risk residents' care-plans. A before-after repeated measures analysis was conducted for 9 months before and 9 months after intervention commencement (a 29-month period because of staggered facility enrolment). Modelling was adjusted for time trend, seasonality, facility size, and cluster effect.

RESULTS

ED admission rate ratio post- versus pre-intervention was 0.75 (95% C.I. 0.63, 0.89, p-value = 0.0008), a 25% reduction in ED presentations post-intervention. A sensitivity model used a shorter, staggered time period centred on intervention start (9 months pre-intervention and 9 months post-intervention) for each facility, and a four-level categorical intervention variable testing intervention effect over time. The sensitivity test showed a 24% reduction in ED presentations in months 1-3 post-intervention (p-value = 0.07), a 34% reduction in months 4-6 (p-value = 0.01), and a 32% reduction in ED presentations in months 7-9 (p-value = 0.03). However, when the higher ED referral rates for 3 months immediately pre-intervention were modelled, the impact of the intervention on ED presentation rates reverted almost to previous levels.

KEY CONCLUSIONS

A GNS-led MDT outreach intervention, targeted at selected conditions, decreases avoidable ED admissions of high-risk residents from selected facilities.

Health and Social Factors Associated with Nutrition Risk: Results from Life and Living in Advanced Age: A Cohort Study in New Zealand (LiLACS NZ)

OBJECTIVES

To establish the prevalence of high nutrition risk and associated health and social risk factors for New Zealand Māori and non-Māori in advanced age.

DESIGN

A cross sectional analysis of inception cohorts to LiLACS NZ.

SETTING

Bay of Plenty and Lakes region of the North Island, New Zealand.

PARTICIPANTS

255 Māori and 400 non- Māori octogenarians.

MEASUREMENTS

Nutrition risk was assessed using a validated questionnaire Seniors in the Community: Risk Evaluation for Eating and Nutrition (SCREEN II). Demographic, social, physical and health characteristics were established using an interviewer administered questionnaire. Health related quality of life (HRQOL) was assessed with the SF-12, depressive symptoms using the GDS-15.

RESULTS

Half (49%) of Māori and 38% of non-Māori participants were at high nutrition risk (SCREEN II score <49). Independent risk factors were for Māori younger age (p=0.04), lower education (p=0.03), living alone (p<0.001), depressive symptoms (p=0.01). For non- Māori high nutrition risk was associated with female gender (p=0.005), living alone (p=0.002), a lower physical health related quality of life (p=0.02) and depressive symptoms (p=0.002).

CONCLUSION

Traditional risk factors apply to both Māori and non-Māori whilst education as indicative of low socioeconomic status is an additional risk factor for Māori. High nutrition risk impacts health related quality of life for non-Māori. Interventions which socially facilitate eating are especially important for women and for Māori to maintain cultural practices and could be initiated by routine screening.

The BRIGHT Trial: what are the factors associated with nutrition risk?

OBJECTIVES

To determine the nutrition risk status and factors associated with nutrition risk among older adults enrolled in the Brief Risk Identification Geriatric Health Tool (BRIGHT Trial).

DESIGN

A cluster randomised controlled trial.

SETTING

Three main centres in New Zealand.

PARTICIPANTS

A total of 3,893 older adults were recruited from 60 general practices in three of the District Health Board (DHB) regions aged 75 years and older (or 65 years and older if Māori).

MEASUREMENTS

Nutrition risk was assessed using the Australian Nutrition Screening Initiative (ANSI). Validated questionnaires were used to establish quality of life (WHOQOL-BREF), physical function (the Nottingham Extended Activities of Daily Living) and depressive symptoms (15 item Geriatric Depression Scale). Demographic, standard of living and health data were established.

RESULTS

Sixty two percent of participants were identified to be at moderate or high nutrition risk. The mean ANSI score was 4.9 (range 0-21, maximum 29). Factors which independently predicted moderate or high nutrition risk were female gender, being Māori and other ethnicities versus European, not being married, taking multiple medications, having more depressive symptoms, cardiovascular disease and diabetes. Protective factors independently related to low nutrition risk were living with others, higher physical and social health related QOL and higher functional status. WHOQOL environmental and psychological factors were not associated with nutrition risk when other predictive factors were taken into account.

CONCLUSION

Nearly two thirds of participants were identified to be at higher nutrition risk. Women, living alone, taking multiple medications, with depressive symptoms, cardiovascular disease and ndiabetes were factors associated with higher nutrition risk. Those at low nutrition risk had a better functional status and physical and social health related QOL.

Validation of the nutrition screening tool 'Seniors in the Community: Risk Evaluation for Eating and Nutrition, version II' among octogenarians

OBJECTIVE

To determine the validity of the nutrition screening tool 'Seniors in the Community: Risk Evaluation for Eating and Nutrition, version II' (SCREEN II) among a purposive sample of octogenarians.

DESIGN

Cross-sectional validation study.

SETTING

Bay of Plenty, New Zealand.

PARTICIPANTS

Forty-five community-living residents aged 85-86 years. Equal proportions of participants were recruited at low, medium and high nutrition risk based on their SCREEN II score 12 months prior.

MEASUREMENTS

Nutrition risk was assessed using SCREEN II. Demographic and health data were established. Using established criterion a dietitian's nutrition risk rating assessment ranked participants from low risk (score of 1) to high risk (score of 10). The assessment included a medical history, anthropometric measures and dietary intake. Dietary intake was established from three 24 hour multiple pass recalls (MPR). A Spearman's correlation determined the association between the SCREEN II score and the dietitian's risk score. Receiver operating characteristic (ROC) curves were completed to determine the sensitivity and specificity of the cut-off point for high nutrition risk.

RESULTS

The SCREEN II score was significantly correlated with the dietitian's risk rating (rs = -0.76 (p<0.01). A newly defined cut-off point <49 was established for high nutrition risk derived from ROC curves and AUC (0.87, p < 0.01); sensitivity 90% and specificity 86%.

CONCLUSION

SCREEN II is a simple, easy to use, 14 item questionnaire and appears to be a valid tool for detection of nutrition risk people aged 85-86 years.

Proposal for a multiphase fall model based on real-world fall recordings with body-fixed sensors

Falls are by far the leading cause of fractures and accidents in the home environment. The current Cochrane reviews and other systematic reviews report on more than 200 intervention studies about fall prevention. A recent meta-analysis has summarized the most important risk factors of accidental falls. However, falls and fall-related injuries remain a major challenge. One novel approach to recognize, analyze, and work better toward preventing falls could be the differentiation of the fall event into separate phases. This might aid in reconsidering ways to design preventive efforts and diagnostic approaches. From a conceptual point of view, falls can be separated into a pre-fall phase, a falling phase, an impact phase, a resting phase, and a recovery phase. Patient and external observers are often unable to give detailed comments concerning these phases. With new technological developments, it is now at least partly possible to examine the phases of falls separately and to generate new hypotheses.The article describes the practicality and the limitations of this approach using body-fixed sensor technology. The features of the different phases are outlined with selected real-world fall signals.

How is the risk of undernutrition associated with cardiovascular disease among individuals of advanced age?

BACKGROUND

The oldest old (85+) are the fastest growing population segment in New Zealand. Cardiovascular disease (CVD) is the main cause of death and is associated with various risk factors including risk of undernutrition.

OBJECTIVES

To determine if there is an association between CVD and nutrition risk in advanced age.

SETTING

Three North Island locations (rural and urban areas) in New Zealand.

PARTICIPANTS

108 participants aged 85 years (75-79 for Maori).

MEASUREMENTS

Comprehensive health assessments were undertaken. Clinically manifest CVD was pre-defined and ascertained from interviews and hospitalisation records. Nutrition risk was assessed using a validated questionnaire-Seniors in the Community: Risk evaluation for eating and nutrition, Version II (SCREEN II).

RESULTS

72 participants (67%) had CVD (49% men); 52% of participants had a SCREEN II score < 50. Those with CVD had lower HDL level [median(IQR)] [1.4(0.7) vs. 1.6(0.6)] (p=0.041), and higher waist circumference [97.5(19.1) vs. 89.3(20.6)] (p=0.043) compared to those without CVD. Those with CVD were at no greater nutrition risk than those without CVD (SCREEN II score: [49(7) vs. 51(10)] (p=0.365). Using logistic regression controlling for confounders, SCREEN II scores trended towards an inverse association with CVD (p=0.10).

CONCLUSION

Two thirds of the study participants had CVD and half were at risk of undernutrition. Nutrition risk was mildly associated with CVD. This study provides further evidence that those in advanced age are at risk of undernutrition. Further research is needed to establish how the causes and consequences of CVD are related to nutrition risk.

The prepare pilot RCT of home-based progressive resistance exercises for venous leg ulcers

OBJECTIVE

To establish the feasibility of conducting a home-based progressive resistance exercise programme to improve calf muscle pump function in community-based patients with venous leg ulcers.

METHOD

Participants were randomised to receive a 12-week progressive resistance exercise programme using heel raises in addition to compression. The control was usual care in addition to compression. Randomisation was stratified by ulcer duration and ulcer size. Air plethysmography was used to determine changes in calf muscle pump function from baseline. Changes in ulcer parameters were measured using the SilhouetteMobile device.

RESULTS

Forty participants were randomised. There were significantly greater improvements in ejection fraction of the calf muscle in the exercise group compared with the control (usual care) group (mean difference 18.5%, 95% CI 0.03 to 36.6%, p<0.05). Other parameters improved in the exercise group but the mean differences were not significant. Adherence with prescribed exercises was 81% and there was no significant difference in the numbers reporting adverse events. There were also no significant differences in ulcer healing parameters (change in area, percentage change in area, number healed at 12 weeks, time to healing).

CONCLUSION

A community-based randomised trial of progressive resistance exercise is feasible. The prescribed exercises appeared to increase ejection fraction, but the effect of exercise on ulcer healing requires further investigation.

Effect of the addition of a "help" question to two screening questions on specificity for diagnosis of depression in general practice: diagnostic validity study

OBJECTIVE

To determine the validity of two written screening questions for depression with the addition of a question inquiring if help is needed.

DESIGN

Cross sectional validation study.

SETTING

19 general practitioners in six clinics in New Zealand.

PARTICIPANTS

1025 consecutive patients receiving no psychotropic drugs.

MAIN OUTCOME MEASURES

Sensitivity, specificity, and likelihood ratios of the two screening questions, the help question, combinations of the screening and help questions, and diagnosis by general practitioners.

RESULTS

The help question alone had a sensitivity of 75% (95% confidence interval 60% to 85%) and a specificity of 94% (93% to 96%). The positive likelihood ratio for the help question was 13.0 (9.5 to 17.8) and the negative likelihood ratio was 0.27 (0.17 to 0.44). The likelihood ratio for patients wanting help today was 17.5 (11.8 to 31.9). The general practitioner diagnosis had a sensitivity of 79% (65% to 88%) and a specificity of 94% (92% to 95%).

CONCLUSION

Adding a question inquiring if help is needed to the two screening questions for depression improves the specificity of a general practitioner diagnosis of depression.

Do delayed prescriptions reduce the use of antibiotics for the common cold? A single-blind controlled trial

OBJECTIVE

To test the use of a delayed prescription compared with instructions to take antibiotics immediately in patients presenting to family physicians with upper respiratory tract infections (common colds).

STUDY DESIGN

Randomized controlled single-blind study.

POPULATION

Subjects were 129 patients presenting with the common cold who requested antibiotics or whose physicians thought they wanted them. All patients were in a family practice in Auckland, New Zealand, consisting of 15 physicians (9 male, 6 female) who had completed medical school between 1973 and 1992.

OUTCOMES MEASURED

Outcomes were antibiotic use (taking at least 1 dose of the antibiotic), symptom scores, and responses to the satisfaction questions asked at the end of the study.

RESULTS

Patients in the delayed-prescription group were less likely to use antibiotics (48%, 95% CI, 35%-60%) than were those instructed to take antibiotics immediately (89%, 95% CI, 76%-94%). Daily body temperature was higher in the immediate-prescription group. The lack of difference in the symptom score between the 2 groups suggests that there is no danger in delaying antibiotic prescriptions for the common cold.

CONCLUSIONS

Delayed prescriptions are a safe and effective means of reducing antibiotic consumption in patients with the common cold. Clarification of patient expectations for antibiotics may result in a lower prescription rate. When the patient demands a prescription, delaying its delivery has the potential to provide gentle education.

Falls: a comparison of trends in community, hospital and mortality data in older Australians

BACKGROUND AND AIMS

Falls are major contributors to disability, morbidity and death for older people. Frequently, falls-related data for each of these areas is viewed in isolation. The aim of this study was to establish trends in incidence of falls-related events including: community reporting of falls and falls-related injuries, hospitalizations as a result of accidental falls, and mortality related to accidental falls for older people in two states of Australia (Victoria and South Australia).

METHODS

We analysed data sets for falls hospitalizations and mortality rates for the period 1988 to 1997, and from two longitudinal population-based proportional samples during the same time period.

RESULTS

Age-standardised falls mortality rates have steadily declined in Victoria, and remained unchanged between 1988 and 1997 in South Australia. In both states, age-standardised falls hospitalization rates have increased significantly (in Victoria, RR=1.32, 95% CI: 1.30-1.34; and South Australia, RR=1.05, 95% CI: 1.03-1.06). In both states, there was a clear age-related effect, with those in the 85-year and older age group having a falls-related mortality rate approximately 40 times that of those aged 65-69 years, and a hospitalization rate 9 times that of those in the 65-69 age group. The community studies indicated that falls rates remain high among older Australians, and that injurious falls occurred in 10% in the first wave of data collection in each of these studies.

CONCLUSIONS

The results highlight that various indicators related to falls trends taken in isolation may yield differing conclusions. For a true reflection of the effectiveness of falls prevention programs, falls-related mortality, hospitalization and community data need to be integrated. Increased focus on falls prevention activity in Australia during the 1990's has not reduced the magnitude of this major public health problem.

Evidence databases, the Internet, and general practitioners: the New Zealand story

AIM

To determine self-reported access to and use of the Internet and the Cochrane Library by general practitioners (GPs) in New Zealand.

METHODS

A national cross sectional postal and fax survey of randomly selected GPs.

RESULTS

A total of 381 of 459 eligible GPs returned completed questionnaires (83%). The mean age of this sample was 45.7 years (SD 8.6) and average years in general practice was 15.7 years (SD 8.8 years). 74% (277) were male and 77% (289) in full-time practice. Internet access was present in 40% (95% CI 36-46%) of practices and 76% (72-81%) of GP's homes. The majority, 56% (51-61%), of GPs had used the Internet with regard to a patient. Younger GPs (<35 years old OR = 2.69, 95% CI 1.10-6.60) and male GPs (OR 1.72, 95% CI 1.02-2.90) were significantly more likely to report use of the Internet with respect to patients. 42% (95% CI 37-47%) of GPs were aware of the Cochrane Library but only 15% (11-19%) had used it. Those in group practice were more likely to be aware of the Cochrane database (adjusted OR 1.85, CI 1.09-3.12).

CONCLUSIONS

Internet use is prevalent among GPs. Solo practitioners, older GPs and female GPs are least likely to avail themselves of this resource. Although half of GPs knew about Cochrane, a minority used it. Access and use of evidence databases can be improved in New Zealand. Strategies to assist those least likely already to use Cochrane may help our collective efforts towards evidence based practice.

Care for older persons. Are divisional programs meeting needs?

BACKGROUND

A national forum on healthy ageing was convened for divisions of general practice in November 1998.

OBJECTIVE

Views of delegates were sought regarding divisional programs for older people related to the following areas: working in collaboration; integration; the context of the older person; ageism; and structural barriers. These areas were felt to influence success of current prospects for future programs for older people.

DISCUSSION

Further communication, collaboration and integration appears essential to realise the potential that general practice offers to programs for older people. Issues from the forum are discussed in relation to relevant National General Practice Strategy Review and the changes introduced into the Medical Benefits Schedule in November 1999. Consideration of these themes will aid future divisional programs for older people.

The psychosocial health status of carers of persons with dementia: a comparison with the chronically ill

This project aimed to determine overall psychosocial health (measured using the psychosocial dimension of the Functional Limitations Profile) and factors which influence this in a group of carers of those with dementia and to compare their psychosocial health with that of older people attending general practitioners (GPs); arthritis support groups and a pain clinic (out-patients) and a group of community dwellers undergoing renal dialysis. The carer group showed a significant decrease in recreation and pastimes and social interactions compared to older GP attenders. The carers showed similar restrictions in social interactions and recreation to those with chronic arthritis, but the latter were more impaired in the domains of emotional behaviour and sleep and rest. The older people attending a pain clinic did not differ in the areas of alertness and social interactions compared to the carer group. The dialysis group demonstrated the greatest dysfunction overall. These results suggest that the psychosocial health of carers of those with dementia is impaired, the profile of which differs from those suffering with chronic diseases. Social and recreation activities appear most affected in the carers. Commensurate with studies exploring the health status of those suffering from diseases, the measurement of the psychosocial health status of carers should also be considered in the scope of assessment and intervention.

Case finding in the elderly: a postal questionnaire

AIMS

To evaluate a postal questionnaire designed to identify elderly persons in need of geriatric evaluation and intervention in the community.

METHODS

A sample of elderly persons, over 75 years, was randomly selected from the age-sex register of four general practices in the Auckland area. All respondents filled out postal questionnaires and a blinded assessment was made in their own homes using validated geriatric assessment tools (the reference test). Objective evaluations were compared to self report questionnaire results and sensitivity, specificity, positive and negative predictive values were calculated.

RESULTS

Sixty-four persons aged 75-93 were evaluated. Thirty-nine subjects (61%) answered the questionnaire in a way which indicated they had one or more unmet needs. Reference test evaluations showed that 23 persons (36%) had problems in one or more areas. Sensitivity for the questionnaire was 0.78 (18/23 correctly identified) and specificity was 0.49. Positive and negative predictive values were 46% and 80% respectively.

CONCLUSIONS

A postal questionnaire may be a useful adjunct to health surveillance of the elderly in general practice in New Zealand.