Effects of dietary supplement on functional condition and clinical outcome measured with a modified Norton scale

The influence of patients' nutritional risk, nutritional status, and energy density in MEDPass versus conventional administration of oral nutritional supplements - A secondary analysis of a randomized controlled trial

OBJECTIVES

The clinical influence of nutritional risk, nutritional status, and energy density of oral nutritional supplements (ONS) in MEDPass versus conventional administration of ONS is currently unknown. The aim of this analysis was to examine whether these variables have an impact on clinical outcomes.

METHODS

Secondary analysis of the intention to treat dataset of the randomized controlled MEDPass Trial in geriatric and medical inpatients. Patients in the intervention group received 4 × 50 ml ONS during the medication rounds (MEDPass mode), while those in the control group received ONS in a non-standardized manner. The examined endpoints included energy and protein coverage, ONS intake, handgrip strength (HGS), weight, appetite nausea and 30-day mortality. Three subgroup analyses for NRS 2002 total score (3, 4 or 5-7 points), NRS 2002 impaired nutritional status score (0, 1, 2 or 3 points) and energy density of the ONS (1.5 kcal/mL or 2 kcal/mL) were performed using linear and logistic regression with interaction and mixed effect models.

RESULTS

The data of 202 patients (103 women and 99 men) at nutritional risk (NRS total 2002 score ≥3), mean (SD) age 82.2 (6.5) years were included. There was no significant difference between the groups in the primary endpoint energy coverage in all three subgroup analyses. There were also no significant differences between the groups in the secondary endpoints of protein coverage, ONS intake, HGS, weight, appetite, nausea, and 30-day mortality.

CONCLUSION

The MEDPass mode of ONS administration was not superior to the conventional mode of administration in this study. ONS with high energy density (≥2 kcal/mL) should be offered since current evidence shows a tendency towards improved appetite, increased ONS and increased energy intake.

Absence of oral nutritional support in low food intake inpatients is associated with an increased risk of hospital-acquired pressure injury

BACKGROUND & AIMS

Hospital-acquired pressure injury (HAPI) incidence is a common burden in hospitals. Decreased food intake leading to malnutrition compromises body tissues involved in pressure injury occurrence. However, most tools for predicting pressure injuries do not include daily food intake monitoring nor consider further nutritional interventions. This study aimed to investigate clinical practices for food intake monitoring and its association with predicting HAPI risk, together with Norton Scale use, and whether the initiation or absence of oral nutritional supplements (ONS), separately from other nutritional interventions, was associated with HAPI incidence in low food intake inpatients, who consumed less than 50% of requirements.

METHODS

This observational cohort study covered a one-year period (08/2018-07/2019). Demographic and clinical data were extracted from computerized files of patients hospitalized ≥7 days, aged ≥60 years, and who ate orally. Patients receiving enteral or parenteral nutrition were excluded. Differences were studied between groups without and with HAPI grade ≥2. Subgroups divided by Norton Scale and intake, Norton Scale and albumin levels, food intake and initiation (or not) of any nutritional intervention versus ONS only, were examined for the consistency of association with HAPI.

RESULTS

Of the 5155 admissions during the study period, 895 patients fulfilled the inclusion criteria: 48% female, mean age 77.6 ± 9.1 years, 11% with MUST score ≥2. Nutritional intake was reported in 76% of patients, of them 22% had low food intake, and 9% of the study group developed HAPI grade ≥2. Regarding HAPI incidence, no differences were found between groups divided by MUST scores. Independent risk factors significantly associated with HAPI were Norton <14, albumin levels <3 g/dl, and low food intake. Not providing ONS in low food intake patients had an adjusted 3.49-fold (95%CI 1.57-7.75) increase in HAPI risk (6-fold for non-adjusted relative risk).

CONCLUSION

Failure to initiate ONS as part of nutritional support in low food intake patients is associated with high HAPI risk in these patients. Consequently, monitoring of daily food intake for identifying low intake patients should be integrated into routinely used tools such as the Norton Scale, and adherence to nutritional protocols should be addressed.

Dietary advice with or without oral nutritional supplements for disease-related malnutrition in adults

BACKGROUND

Disease-related malnutrition has been reported in 10% to 55% of people in hospital and the community and is associated with significant health and social-care costs. Dietary advice (DA) encouraging consumption of energy- and nutrient-rich foods rather than oral nutritional supplements (ONS) may be an initial treatment.

OBJECTIVES

To examine evidence that DA with/without ONS in adults with disease-related malnutrition improves survival, weight, anthropometry and quality of life (QoL).

SEARCH METHODS

We identified relevant publications from comprehensive electronic database searches and handsearching. Last search: 01 March 2021.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of DA with/without ONS in adults with disease-related malnutrition in any healthcare setting compared with no advice, ONS or DA alone.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study eligibility, risk of bias, extracted data and graded evidence.

MAIN RESULTS

We included 94, mostly parallel, RCTs (102 comparisons; 10,284 adults) across many conditions possibly explaining the high heterogeneity.  Participants were mostly older people in hospital, residential care and the community, with limited reporting on their sex. Studies lasted from one month to 6.5 years.  DA versus no advice - 24 RCTs (3523 participants) Most outcomes had low-certainty evidence. There may be little or no effect on mortality after three months, RR 0.87 (95% confidence interval (CI) 0.26 to 2.96), or at later time points. We had no three-month data, but advice may make little or no difference to hospitalisations, or days in hospital after four to six months and up to 12 months. A similar effect was seen for complications at up to three months, MD 0.00 (95% CI -0.32 to 0.32) and between four and six months. Advice may improve weight after three months, MD 0.97 kg (95% CI 0.06 to 1.87) continuing at four to six months and up to 12 months; and may result in a greater gain in fat-free mass (FFM) after 12 months, but not earlier. It may also improve global QoL at up to three months, MD 3.30 (95% CI 1.47 to 5.13), but not later. DA versus ONS - 12 RCTs (852 participants) All outcomes had low-certainty evidence. There may be little or no effect on mortality after three months, RR 0.66 (95% CI 0.34 to 1.26), or at later time points. Either intervention may make little or no difference to hospitalisations at three months, RR 0.36 (95% CI 0.04 to 3.24), but ONS may reduce hospitalisations up to six months. There was little or no difference between groups in weight change at three months, MD -0.14 kg (95% CI -2.01 to 1.74), or between four to six months. Advice (one study) may lead to better global QoL scores but only after 12 months. No study reported days in hospital, complications or FFM. DA versus DA plus ONS - 22 RCTs (1286 participants) Most outcomes had low-certainty evidence. There may be little or no effect on mortality after three months, RR 0.92 (95% CI 0.47 to 1.80) or at later time points. At three months advice may lead to fewer hospitalisations, RR 1.70 (95% CI 1.04 to 2.77), but not at up to six months. There may be little or no effect on length of hospital stay at up to three months, MD -1.07 (95% CI -4.10 to 1.97). At three months DA plus ONS may lead to fewer complications, RR 0.75 (95% CI o.56 to 0.99); greater weight gain, MD 1.15 kg (95% CI 0.42 to 1.87); and better global QoL scores, MD 0.33 (95% CI 0.09 to 0.57), but this was not seen at other time points. There was no effect on FFM at three months. DA plus ONS if required versus no advice or ONS - 31 RCTs (3308 participants) Evidence was moderate- to low-certainty. There may be little or no effect on mortality at three months, RR 0.82 (95% CI 0.58 to 1.16) or at later time points. Similarly, little or no effect on hospitalisations at three months, RR 0.83 (95% CI 0.59 to 1.15), at four to six months and up to 12 months; on days in hospital at three months, MD -0.12 (95% CI -2.48 to 2.25) or for complications at any time point. At three months, advice plus ONS probably improve weight, MD 1.25 kg (95% CI 0.73 to 1.76) and may improve FFM, 0.82 (95% CI 0.35 to 1.29), but these effects were not seen later. There may be little or no effect of either intervention on global QoL scores at three months, but advice plus ONS may improve scores at up to 12 months. DA plus ONS versus no advice or ONS - 13 RCTs (1315 participants) Evidence was low- to very low-certainty. There may be little or no effect on mortality after three months, RR 0.91 (95% CI 0.55 to 1.52) or at later time points. No study reported hospitalisations and there may be little or no effect on days in hospital after three months, MD -1.81 (95% CI -3.65 to 0.04) or six months. Advice plus ONS may lead to fewer complications up to three months, MD 0.42 (95% CI 0.20 to 0.89) (one study). Interventions may make little or no difference to weight at three months, MD 1.08 kg (95% CI -0.17 to 2.33); however, advice plus ONS may improve weight at four to six months and up to 12 months. Interventions may make little or no difference in FFM or global QoL scores at any time point.

AUTHORS' CONCLUSIONS

We found no evidence of an effect of any intervention on mortality. There may be weight gain with DA and with DA plus ONS in the short term, but the benefits of DA when compared with ONS are uncertain. The size and direction of effect and the length of intervention and follow-up required for benefits to emerge were inconsistent for all other outcomes.  There were too few data for many outcomes to allow meaningful conclusions. Studies focusing on both patient-centred and healthcare outcomes are needed to address the questions in this review.

Nutritional risk is a predictor for long-term mortality: 5-Year follow-up of the EFFORT trial

BACKGROUND AND AIMS

The nutritional risk screening (NRS 2002) is a validated screening tool for malnutrition. This study aims to investigate the prognostic value of the NRS 2002 and its individual components regarding long-term mortality and adverse outcomes in a well-characterized cohort of medical inpatients.

METHODS

We performed a 5-year follow-up investigation of patients included in the investigator-initiated, prospective, randomized controlled multicenter EFFORT trial that evaluated the effects of individualized nutritional intervention vs. standard hospital food. We used multivariable cox regression analyses adjusted for randomisation arm, study centre, comorbidities and main admission diagnosis to investigate associations between NRS 2002 total scores at time of hospital admission and several long-term outcomes.

RESULTS

We had confirmed mortality data over the mean follow-up time of 3.2 years in 1874 from the initial cohort of 2028 EFFORT patients. Mortality showed a step-wise increase in patients with NRS 3 (289/565 [51.2%]) and NRS 4 (355/717 [49.6%]) to 59.5% (353/593) in patient with NRS≥5 corresponding to an adjusted Hazard Ratio (HR) of 1.28 (95%CI 1.15 to 1.42, p ≤ 0.001) for mortality after one year and 1.13 (95%CI 1.05 to 1.23, p = 0.002) for the overall time period. All individual components of NRS including disease severity, food intake, weight loss and BMI provided prognostic information regarding long-term mortality risk.

CONCLUSION

Nutritional risk mirrored by a NRS 2002 total score is a strong and independent predictor of long-term mortality and morbidity in polymorbid medical inpatients particularly in patients with high nutritional risk with an NRS ≥5 points.

Nutrition support in hospitalised adults at nutritional risk

BACKGROUND

The prevalence of disease-related malnutrition in Western European hospitals is estimated to be about 30%. There is no consensus whether poor nutritional status causes poorer clinical outcome or if it is merely associated with it. The intention with all forms of nutrition support is to increase uptake of essential nutrients and improve clinical outcome. Previous reviews have shown conflicting results with regard to the effects of nutrition support.

OBJECTIVES

To assess the benefits and harms of nutrition support versus no intervention, treatment as usual, or placebo in hospitalised adults at nutritional risk.

SEARCH METHODS

We searched Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE (Ovid SP), Embase (Ovid SP), LILACS (BIREME), and Science Citation Index Expanded (Web of Science). We also searched the World Health Organization International Clinical Trials Registry Platform (www.who.int/ictrp); ClinicalTrials.gov; Turning Research Into Practice (TRIP); Google Scholar; and BIOSIS, as well as relevant bibliographies of review articles and personal files. All searches are current to February 2016.

SELECTION CRITERIA

We include randomised clinical trials, irrespective of publication type, publication date, and language, comparing nutrition support versus control in hospitalised adults at nutritional risk. We exclude trials assessing non-standard nutrition support.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane and the Cochrane Hepato-Biliary Group. We used trial domains to assess the risks of systematic error (bias). We conducted Trial Sequential Analyses to control for the risks of random errors. We considered a P value of 0.025 or less as statistically significant. We used GRADE methodology. Our primary outcomes were all-cause mortality, serious adverse events, and health-related quality of life.

MAIN RESULTS

We included 244 randomised clinical trials with 28,619 participants that met our inclusion criteria. We considered all trials to be at high risk of bias. Two trials accounted for one-third of all included participants. The included participants were heterogenous with regard to disease (20 different medical specialties). The experimental interventions were parenteral nutrition (86 trials); enteral nutrition (tube-feeding) (80 trials); oral nutrition support (55 trials); mixed experimental intervention (12 trials); general nutrition support (9 trials); and fortified food (2 trials). The control interventions were treatment as usual (122 trials); no intervention (107 trials); and placebo (15 trials). In 204/244 trials, the intervention lasted three days or more.We found no evidence of a difference between nutrition support and control for short-term mortality (end of intervention). The absolute risk was 8.3% across the control groups compared with 7.8% (7.1% to 8.5%) in the intervention groups, based on the risk ratio (RR) of 0.94 (95% confidence interval (CI) 0.86 to 1.03, P = 0.16, 21,758 participants, 114 trials, low quality of evidence). We found no evidence of a difference between nutrition support and control for long-term mortality (maximum follow-up). The absolute risk was 13.2% in the control group compared with 12.2% (11.6% to 13%) following nutritional interventions based on a RR of 0.93 (95% CI 0.88 to 0.99, P = 0.03, 23,170 participants, 127 trials, low quality of evidence). Trial Sequential Analysis showed we only had enough information to assess a risk ratio reduction of approximately 10% or more. A risk ratio reduction of 10% or more could be rejected.We found no evidence of a difference between nutrition support and control for short-term serious adverse events. The absolute risk was 9.9% in the control groups versus 9.2% (8.5% to 10%), with nutrition based on the RR of 0.93 (95% CI 0.86 to 1.01, P = 0.07, 22,087 participants, 123 trials, low quality of evidence). At long-term follow-up, the reduction in the risk of serious adverse events was 1.5%, from 15.2% in control groups to 13.8% (12.9% to 14.7%) following nutritional support (RR 0.91, 95% CI 0.85 to 0.97, P = 0.004, 23,413 participants, 137 trials, low quality of evidence). However, the Trial Sequential Analysis showed we only had enough information to assess a risk ratio reduction of approximately 10% or more. A risk ratio reduction of 10% or more could be rejected.Trial Sequential Analysis of enteral nutrition alone showed that enteral nutrition might reduce serious adverse events at maximum follow-up in people with different diseases. We could find no beneficial effect of oral nutrition support or parenteral nutrition support on all-cause mortality and serious adverse events in any subgroup.Only 16 trials assessed health-related quality of life. We performed a meta-analysis of two trials reporting EuroQoL utility score at long-term follow-up and found very low quality of evidence for effects of nutritional support on quality of life (mean difference (MD) -0.01, 95% CI -0.03 to 0.01; 3961 participants, two trials). Trial Sequential Analyses showed that we did not have enough information to confirm or reject clinically relevant intervention effects on quality of life.Nutrition support may increase weight at short-term follow-up (MD 1.32 kg, 95% CI 0.65 to 2.00, 5445 participants, 68 trials, very low quality of evidence).

AUTHORS' CONCLUSIONS

There is low-quality evidence for the effects of nutrition support on mortality and serious adverse events. Based on the results of our review, it does not appear to lead to a risk ratio reduction of approximately 10% or more in either all-cause mortality or serious adverse events at short-term and long-term follow-up.There is very low-quality evidence for an increase in weight with nutrition support at the end of treatment in hospitalised adults determined to be at nutritional risk. The effects of nutrition support on all remaining outcomes are unclear.Despite the clinically heterogenous population and the high risk of bias of all included trials, our analyses showed limited signs of statistical heterogeneity. Further trials may be warranted, assessing enteral nutrition (tube-feeding) for different patient groups. Future trials ought to be conducted with low risks of systematic errors and low risks of random errors, and they also ought to assess health-related quality of life.

Supportive interventions for enhancing dietary intake in malnourished or nutritionally at-risk adults

BACKGROUND

Supportive interventions such as serving meals in a dining room environment or the use of assistants to feed patients are frequently recommended for the management of nutritionally vulnerable groups. Such interventions are included in many policy and guideline documents and have implications for staff time but may incur additional costs, yet there appears to be a lack of evidence for their efficacy.

OBJECTIVES

To assess the effects of supportive interventions for enhancing dietary intake in malnourished or nutritionally at-risk adults.

SEARCH METHODS

We identified publications from comprehensive searches of the Cochrane Library, MEDLINE, Embase, AMED, British Nursing Index, CINAHL, SCOPUS, ISI Web of Science databases, scrutiny of the reference lists of included trials and related systematic reviews and handsearching the abstracts of relevant meetings. The date of the last search for all databases was 31 March 2013. Additional searches of CENTRAL, MEDLINE, ClinicalTrials.gov and WHO ICTRP were undertaken to September 2016. The date of the last search for these databases was 14 September 2016.

SELECTION CRITERIA

Randomised controlled trials of supportive interventions given with the aim of enhancing dietary intake in nutritionally vulnerable adults compared with usual care.

DATA COLLECTION AND ANALYSIS

Three review authors and for the final search, the editor, selected trials from titles and abstracts and independently assessed eligibility of selected trials. Two review authors independently extracted data and assessed risk of bias, as well as evaluating overall quality of the evidence utilising the GRADE instrument, and then agreed as they entered data into the review. The likelihood of clinical heterogeneity amongst trials was judged to be high as trials were in populations with widely different clinical backgrounds, conducted in different healthcare settings and despite some grouping of similar interventions, involved interventions that varied considerably. We were only able, therefore, to conduct meta-analyses for the outcome measures, 'all-cause mortality', 'hospitalisation' and 'nutritional status (weight change)'.

MAIN RESULTS

Forty-one trials (10,681 participants) met the inclusion criteria. Trials were grouped according to similar interventions (changes to organisation of nutritional care (N = 13; 3456 participants), changes to the feeding environment (N = 5; 351 participants), modification of meal profile or pattern (N = 12; 649 participants), additional supplementation of meals (N = 10; 6022 participants) and home meal delivery systems (N = 1; 203 participants). Follow-up ranged from 'duration of hospital stay' to 12 months.The overall quality of evidence was moderate to very low, with the majority of trials judged to be at an unclear risk of bias in several risk of bias domains. The risk ratio (RR) for all-cause mortality was 0.78 (95% confidence interval (CI) 0.66 to 0.92); P = 0.004; 12 trials; 6683 participants; moderate-quality evidence. This translates into 26 (95% CI 9 to 41) fewer cases of death per 1000 participants in favour of supportive interventions. The RR for number of participants with any medical complication ranged from 1.42 in favour of control compared with 0.59 in favour of supportive interventions (very low-quality evidence). Only five trials (4451 participants) investigated health-related quality of life showing no substantial differences between intervention and comparator groups. Information on patient satisfaction was unreliable. The effects of supportive interventions versus comparators on hospitalisation showed a mean difference (MD) of -0.5 days (95% CI -2.6 to 1.6); P = 0.65; 5 trials; 667 participants; very low-quality evidence. Only three of 41 included trials (4108 participants; very low-quality evidence) reported on adverse events, describing intolerance to the supplement (diarrhoea, vomiting; 5/34 participants) and discontinuation of oral nutritional supplements because of refusal or dislike of taste (567/2017 participants). Meta-analysis across 17 trials with adequate data on weight change revealed an overall improvement in weight in favour of supportive interventions versus control: MD 0.6 kg (95% CI 0.21 to 1.02); 2024 participants; moderate-quality evidence. A total of 27 trials investigated nutritional intake with a majority of trials not finding marked differences in energy intake between intervention and comparator groups. Only three trials (1152 participants) reported some data on economic costs but did not use accepted health economic methods (very low-quality evidence).

AUTHORS' CONCLUSIONS

There is evidence of moderate to very low quality to suggest that supportive interventions to improve nutritional care results in minimal weight gain. Most of the evidence for the lower risk of all-cause mortality for supportive interventions comes from hospital-based trials and more research is needed to confirm this effect. There is very low-quality evidence regarding adverse effects; therefore whilst some of these interventions are advocated at a national level clinicians should recognise the lack of clear evidence to support their role. This review highlights the importance of assessing patient-important outcomes in future research.

Screening for malnutrition among nursing home residents - a comparative analysis of the mini nutritional assessment, the nutritional risk screening, and the malnutrition universal screening tool

BACKGROUND

The European Society for Clinical Nutrition and Metabolism (ESPEN) has recommended the Mini Nutritional Assessment (MNA®), the Nutritional Risk Screening 2002 (NRS), and the Malnutrition Universal Screening Tool (MUST) for nutritional screening in various settings and age groups. While in recent years all three tools have been applied to nursing home residents, there is still no consensus on the most appropriate screening tool in this specific setting.

AIM

The present study aims at comparing the MNA, the NRS, and the MUST with regard to applicability, categorization of nutritional status, and predictive value in the nursing home setting.

METHOD

MNA, NRS, and MUST were performed on 200 residents from two municipal nursing homes in Nuremberg, Germany. Follow-up data on infection, hospitalization, and mortality were collected after six and again after twelve months.

RESULTS

Among 200 residents (mean age 85.5 ± 7.8 years) the MNA could be completed in 188 (94.0%) and the NRS and MUST in 198 (99.0%) residents. The prevalence of 'malnutrition' according to the MNA was 15.4%. The prevalence of 'risk of malnutrition' (NRS) and 'high risk of malnutrition' (MUST), respectively, was 8.6% for both tools. The individual categorization of nutritional status showed poor agreement between NRS and MUST on the one hand and MNA on the other. For all tools a significant association between nutritional status and mortality was demonstrated during follow-up as classification in 'malnourished', respectively 'high risk of malnutrition' or 'nutritional risk', was significantly associated with increased hazard ratios. However, the MNA showed the best predictive value for survival among well-nourished residents.

CONCLUSION

The evaluation of nutritional status in nursing home residents by MNA, NRS, and MUST shows significant differences. This observation may be of clinical relevance as nutritional intervention is usually based on screening results. As the items of the MNA reflect particularities of the nursing home population, this tool currently appears to be the most suitable one in this setting.

Dietary advice with or without oral nutritional supplements for disease-related malnutrition in adults

BACKGROUND

Disease-related malnutrition has been reported in 10% to 55% of people in hospital and the community. Dietary advice encouraging the use of energy- and nutrient-rich foods rather than oral nutritional supplements has been suggested as the initial approach for managing disease-related malnutrition.

OBJECTIVES

To examine evidence that dietary advice in adults with disease-related malnutrition improves survival, weight and anthropometry; to estimate the size of any additional effect of nutritional supplements combined with dietary advice and to compare the effects of dietary advice with oral nutritional supplements.

SEARCH STRATEGY

Relevant publications were identified from comprehensive electronic database searches and handsearching.Last search: 14 February 2010.

SELECTION CRITERIA

Randomised controlled trials of dietary advice with or without oral nutritional supplements in people with disease-related malnutrition in any health-care setting compared with no advice, oral nutritional supplements or dietary advice given alone.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial eligibility, risk of bias and extracted data.

MAIN RESULTS

Forty-five studies (3186 participants) met the inclusion criteria; (dietary advice compared with: no advice (1053 participants); with oral nutritional supplements (332 participants); with dietary advice and oral nutritional supplements (731 participants); and dietary advice plus oral nutritional supplements compared with no additional intervention (1070 participants). Follow-up ranged from 18 days to 24 months. No comparison showed a significant difference between groups for mortality or morbidity. There was a significant change in weight found between groups when comparing dietary advice to no advice for interventions lasting greater than 12 months, mean difference 3.75 kg (95% confidence interval 0.97 to 6.53), and when all studies were combined, mean difference 1.47 kg (95% confidence interval 0.32 to 2.61) although there was significant heterogeneity in the combined analysis (I(2) = 90%). Similar improvements in weight were found for the comparison of dietary advice with nutritional supplements if required versus no advice, mean difference 2.20 kg (95% confidence interval 1.16 to 3.25). Dietary advice compared with no advice was also associated with significantly improved mid-arm muscle circumference when all studies were combined, but with moderate heterogeneity, mean difference 0.81 mm (95% confidence interval 0.31 to 1.31). Dietary advice given with nutritional supplements compared with dietary advice alone resulted in improvements in: mid-arm muscle circumference, mean difference -0.89 mm (95% confidence interval -1.35 to -0.43); triceps skinfold thickness, mean difference -1.22 mm (95% confidence interval -2.34 to -0.09); and grip strength, mean difference -1.67 kg (95% confidence interval -2.96 to -0.37), although the effects on triceps skinfold thickness and grip strength were heterogeneous. Dietary advice with supplements if required resulted in a significant increase in triceps skinfold thickness compared with no advice, mean difference 0.40 mm (95% confidence interval 0.10 to 0.70), although these results are from a single trial with only 29 participants.

AUTHORS' CONCLUSIONS

Evidence of variable quality suggests that dietary advice with or without oral nutritional supplements may improve weight, body composition and grip strength. We found no evidence of benefit of dietary advice or oral nutritional supplements given alone or in combination on survival. Studies addressing the impact of nutritional interventions on nutritional, functional and patient-centred outcomes are needed.

Predicting the value of the Mini Nutritional Assessment (MNA) as an indicator of functional ability in older Iranian adults (Kahrizak elderly study)

OBJECTIVE

We aimed to investigate the appropriateness of the Mini Nutritional Assessment (MNA) in predicting functional ability in older adults.

DESIGN

Cross-sectional study.

SETTING

Participants were recruited from the Kahrizak Charity Foundation (KCF).

MEASUREMENTS

Nutritional and ability status were examined using the MNA and the Barthel Index (BI). Participants were divided according to MNA (≤ 23.5 and > 23.5).

RESULTS

Two hundred and thirty-five ≥ 60-year-old subjects were studied. The MNA and BI were positively correlated (r = 0.199; P = 0.001). The optimal cut-off point for BI with the highest sensitivity and specificity derived from the ROC curve was approximately 91.5 for males and 83.5 for females. The BI was significantly associated with MNA (odds ratio (OR): 1.89; 95% CI: 1.17-3.05, P = 0.009), mobility (OR: 6.39; 95% CI: 3.43-11.89, P < 0.001), consuming ≥ 2 servings of fruit and vegetables (OR: 2.27; 95% CI: 1.09-4.72, P = 0.02) and self-view of nutritional status (OR: 4.15; 95%CI: 1.26-13.63, P = 0.01). The sensitivity (62.9% in males; 68.2% in females) and specificity (51.4% in males and 52.9% in females) of these cut-off points justifies the appropriateness of the MNA for determining functional ability.

CONCLUSION

The MNA is potentially able to verify functional status among the elderly (as BI ≥ 91.5 with those of < 91.5 in males and ≥ 83.5 with those of < 83.5 in females) of KCF. It is suggested that this relationship should be further studied in a larger prospective population-based study.

Protein and energy supplementation in elderly people at risk from malnutrition

BACKGROUND

Evidence for the effectiveness of nutritional supplements containing protein and energy, often prescribed for older people, is limited. Malnutrition is more common in this age group and deterioration of nutritional status can occur during illness. It is important to establish whether supplementing the diet is an effective way of improving outcomes for older people at risk from malnutrition.

OBJECTIVES

This review examined trials for improvement in nutritional status and clinical outcomes when extra protein and energy were provided, usually as commercial 'sip-feeds'.

SEARCH STRATEGY

We searched The Cochrane Library, MEDLINE, EMBASE, Healthstar, CINAHL, BIOSIS, CAB abstracts. We also hand searched nutrition journals and reference lists and contacted 'sip-feed' manufacturers.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials of oral protein and energy supplementation in older people, with the exception of groups recovering from cancer treatment or in critical care.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trials prior to inclusion and independently extracted data and assessed trial quality. Authors of trials were contacted for further information as necessary.

MAIN RESULTS

Sixty-two trials with 10,187 randomised participants have been included in the review. Maximum duration of intervention was 18 months. Most included trials had poor study quality. The pooled weighted mean difference (WMD) for percentage weight change showed a benefit of supplementation of 2.2% (95% confidence interval (CI) 1.8 to 2.5) from 42 trials. There was no significant reduction in mortality in the supplemented compared with control groups (relative risk (RR) 0.92, CI 0.81 to 1.04) from 42 trials. Mortality results were statistically significant when limited to trials in which participants (N = 2461) were defined as undernourished (RR 0.79, 95% CI 0.64 to 0.97).The risk of complications was reduced in 24 trials (RR 0.86, 95% CI 0.75 to 0.99). Few trials were able to suggest any functional benefit from supplementation. The WMD for length of stay from 12 trials also showed no statistically significant effect (-0.8 days, 95% CI -2.8 to 1.3). Adverse effects included nausea or diarrhoea.

AUTHORS' CONCLUSIONS

Supplementation produces a small but consistent weight gain in older people. Mortality may be reduced in older people who are undernourished. There may also be a beneficial effect on complications which needs to be confirmed. However, this updated review found no evidence of improvement in functional benefit or reduction in length of hospital stay with supplements. Additional data from large-scale multi-centre trials are still required.

Dietary advice for illness-related malnutrition in adults

BACKGROUND

Illness-related malnutrition has been reported in 10% to 55% of ill people in hospital and the community in areas of food sufficiency. Dietary advice encouraging the use of energy- and nutrient-rich foods rather than oral nutritional supplements has been suggested for managing illness-related malnutrition.

OBJECTIVES

To examine evidence that dietary advice to improve nutritional intake in adults with illness-related malnutrition improves survival, weight and anthropometry; to estimate the size of any additional effect of nutritional supplements given in combination with dietary advice.

SEARCH STRATEGY

Relevant publications were identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. Additional studies were sought by contacting dietitians, clinicians and the manufacturers of nutritional supplements. Last search: September 2007

SELECTION CRITERIA

Randomised controlled trials of dietary advice in people with illness-related malnutrition compared with:(1) no advice;(2) oral nutritional supplements; and(3) dietary advice plus oral nutritional supplements.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial eligibility, methodological quality and extracted data.

MAIN RESULTS

Thirty-six studies (37 comparisons) met the inclusion criteria with 2714 randomised participants. Twelve trials (comparing dietary advice plus supplements if required with no advice) identified during searching are included as a separate comparison. Follow up ranged from 18 days to 24 months. No comparison showed a significant difference in mortality. There are several significant results for change in weight and other nutritional indices favouring nutritional intervention, but the precise contributions of the different strategies have yet to be determined. It is uncertain whether nutritional supplements and dietary advice produce the same effects. There was insufficient evidence to draw conclusions about clinical outcomes and cost. Few data were available for other outcomes.

AUTHORS' CONCLUSIONS

This review highlights the lack of evidence for the provision of dietary advice in managing illness-related malnutrition. Dietary advice plus nutritional supplements may be more effective than dietary advice alone or no advice in enhancing short-term weight gain, but whether this is sustainable, or whether survival and morbidity are improved remains uncertain. A large adequately-powered randomised controlled trial is needed comparing the efficacy of different therapies to increase dietary intake in people with illness-related malnutrition and examining the impact of this on clinical function and survival.

Dietary advice for illness-related malnutrition in adults

BACKGROUND

Illness-related malnutrition has been reported in 10% to 55% of ill people in hospital and the community in areas of food sufficiency. Dietary advice encouraging the use of energy- and nutrient-rich foods rather than oral nutritional supplements has been suggested for managing illness-related malnutrition.

OBJECTIVES

To examine evidence that dietary advice to improve nutritional intake in adults with illness-related malnutrition improves survival, weight and anthropometry; to estimate the size of any additional effect of nutritional supplements given in combination with dietary advice.

SEARCH STRATEGY

Relevant publications were identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. Additional studies were sought by contacting dietitians, clinicians and the manufacturers of nutritional supplements. Last search: October 2006

SELECTION CRITERIA

Randomised controlled trials of dietary advice in people with illness-related malnutrition compared with:(1) no advice;(2) oral nutritional supplements; and(3) dietary advice plus oral nutritional supplements.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial eligibility, methodological quality and extracted data.

MAIN RESULTS

Thirty-five studies (37 comparisons) met the inclusion criteria with 2648 randomised participants. Twelve trials (comparing dietary advice plus supplements if required with no advice) identified during searching are included as a separate comparison. Follow up ranged from 18 days to 24 months. No comparison showed a significant difference in mortality. Significant improvements in weight at three months were found for groups receiving dietary advice plus nutritional supplements compared with dietary advice alone, WMD 1.68 kg (95% CI 0.14 to 3.21) or no additional advice, WMD 1.97 (95% CI 0.07 to 3.86). There were significant improvements in grip strength and mid-arm muscle circumference in the advice plus supplement groups compared with dietary advice alone. It is uncertain whether nutritional supplements and dietary advice produce the same effects. No significant differences were found between groups for clinical outcomes. Few data were available for other outcomes.

AUTHORS' CONCLUSIONS

This review highlights the lack of evidence for the provision of dietary advice in managing illness-related malnutrition. Dietary advice plus nutritional supplements may be more effective than dietary advice alone or no advice in enhancing short-term weight gain, but whether this is sustainable, or whether survival and morbidity are improved remains uncertain. A large adequately-powered randomised controlled trial is needed comparing the efficacy of different therapies to increase dietary intake in people with illness-related malnutrition and examining the impact of this on clinical function and survival.

ESPEN Guidelines on Enteral Nutrition: Geriatrics

Nutritional intake is often compromised in elderly, multimorbid patients. Enteral nutrition (EN) by means of oral nutritional supplements (ONS) and tube feeding (TF) offers the possibility to increase or to insure nutrient intake in case of insufficient oral food intake. The present guideline is intended to give evidence-based recommendations for the use of ONS and TF in geriatric patients. It was developed by an interdisciplinary expert group in accordance with officially accepted standards and is based on all relevant publications since 1985. The guideline was discussed and accepted in a consensus conference. EN by means of ONS is recommended for geriatric patients at nutritional risk, in case of multimorbidity and frailty, and following orthopaedic-surgical procedures. In elderly people at risk of undernutrition ONS improve nutritional status and reduce mortality. After orthopaedic-surgery ONS reduce unfavourable outcome. TF is clearly indicated in patients with neurologic dysphagia. In contrast, TF is not indicated in final disease states, including final dementia, and in order to facilitate patient care. Altogether, it is strongly recommended not to wait until severe undernutrition has developed, but to start EN therapy early, as soon as a nutritional risk becomes apparent.

Living with chronic obstructive pulmonary disease: Part I. Struggling with meal-related situations: experiences among persons with COPD

Reduced nutritional intake with low and decreased body weight can be a component of normal ageing. There is, however, also a greater risk for reduced nutritional intake within certain diagnoses, especially for chronic diseases. Malnutrition in chronic obstructive pulmonary disease (COPD) is caused by many factors. The relationship between COPD and low values of body mass index (BMI) is a known independent risk for mortality. For optimal support and care with special focus on nutritional status and interventions, caregivers need more knowledge about the meal-related situations (i.e. shopping for food, cooking and eating) of COPD patients. The aim of this study was to describe experiences of meal-related situations as viewed from the individual's perspective. The sample included eight women and five men with COPD recruited from five primary health clinics. The participants' average age was 68.9 years, with values of forced expiratory volume in 1 second (FEV(1) percentage) ranging from 18 to 69 and BMI values from 15 to 40. A descriptive design with qualitative interviews and self-reported diaries were used and the data were later analysed using content analysis. Findings showed consistency between informants' COPD, nutritional status and descriptions of experiences in meal-related situations. Findings were disease-specific but were also found to be general- and age-related. Respondents described physical influences and positive and negative feelings in their meal-related situations. Feelings of dependence, level of activity, transport of food, having company or being alone, appetite, hunger and need of time were also mentioned. Most research reports reduced nutritional status from a medical perspective. To our knowledge, no study has reported the positive and negative feelings that arise when eating in persons with COPD. Malnutrition for persons with COPD is not only caused by eating difficulties: eating is an integral part of social situations as shown in this study.

Nutritional status, well-being and functional ability in frail elderly service flat residents

OBJECTIVE

To investigate nutritional status and its relationship to cognition, well-being, functional ability and energy intake in frail elderly service flat residents.

DESIGN

Cross-sectional and prospective study.

SETTING

Two municipal service flat complexes.

SUBJECTS

A total of 80 residents (median age 85.5 (79-90) y) with regular home care assistance participated. A subgroup of 35 residents took part in a re-examination 1 y later.

METHODS

Mini Nutritional Assessment (MNA), Short Portable Mental Status Questionnaire, Barthel Index and Health Index were used for the evaluation of nutritional, cognitive and ADL function and well-being, respectively.

RESULTS

In all, 30% of the frail and chronically ill service flat residents were assessed as malnourished and 59% were at risk of malnutrition. The malnourished residents had worse cognitive conditions (P<0.001) and well-being (P<0.05), lower functional ability (P<0.01) and they had a greater need for daily assistance (P<0.05) than the other residents. The median night fast period was 14.0 (12.5-15.0) h. Five subjects classified as malnourished at baseline had lost a median of -9.6 kg (range -11.0 to +7.3 kg) (P<0.05) in body weight at the 1-y follow-up, which contrasted significantly from the weight stability in residents classified as at risk for malnutrition or well-nourished.

CONCLUSION

Out of 10 residents, nine were assessed to have impending nutritional problems that related to impaired well-being, cognition, and functional ability. Malnourished residents had a significant weight loss over one year. Studies are needed to determine whether weight loss and nutrition-related dysfunction in service flat residents are preventable or treatable.

Protein and energy supplementation in elderly people at risk from malnutrition

BACKGROUND

Evidence for the effectiveness of nutritional supplements containing protein and energy, which are often prescribed for older people, is limited. Furthermore malnutrition is more common in this age group and deterioration of nutritional status can occur during illness. It is important to establish whether supplementing the diet is an effective way of improving outcomes for older people at risk from malnutrition.

OBJECTIVES

This review examined the evidence from trials for improvement in nutritional status and clinical outcomes when extra protein and energy were provided, usually in the form of commercial 'sip-feeds'.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Healthstar, CINAHL, BIOSIS, CAB abstracts. We also hand searched nutrition journals and reference lists and contacted 'sip-feed' manufacturers. Date of most recent search: March 2004.

SELECTION CRITERIA

Randomised controlled trials and quasi-randomised controlled trials of oral protein and energy supplementation in older people with the exception of groups recovering from cancer treatment or in critical care.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trials prior to inclusion and independently extracted data and assessed trial quality. Authors of trials were contacted for further information as necessary.

MAIN RESULTS

Forty-nine trials with 4790 randomised participants have been included in the review. Most included trials had poor study quality. The pooled weighted mean difference [WMD] for percentage weight change showed a benefit of supplementation of 2.3% (95% confidence interval (CI) 1.9 to 2.7) from 34 trials. There was a reduced mortality in the supplemented compared with control groups (relative risk (RR) 0.74, CI 0.59 to 0.92) from 32 trials. The risk of complications from 14 trials showed no significant difference (RR 0.95, 95% CI 0.81 to 1.11). Few trials were able to suggest any functional benefit from supplementation. The pooled weighted mean difference (WMD) for length of stay from 10 trials also showed no statistically significant effect (WMD -1.98 days, 95% CI -5.20 to 1.24).

AUTHORS' CONCLUSIONS

Supplementation produces a small but consistent weight gain in older people. There may also be a beneficial effect on mortality. However, there was no evidence of improvement in clinical outcome, functional benefit or reduction in length of hospital stay with supplements. Additional data from large-scale multi-centre trials are still required.

Estimation of energy intake in clinical practice: a comparison between a food record protocol and a precoded food record book

The aim of this study was to compare energy intake estimated from a clinical food record protocol (CFRP) with that from a precoded food record book (PFRB) as reference method. Food and fluid consumption were recorded in 10 older patients using a CFRP in parallel with a PFRB during a 6-day period. The results showed that there were no significant differences in mean energy intake estimated from the CFRP as compared with that estimated from the PFRB. The correlation coefficient between the calculated daily energy intake from the CFRP and PFRB was 0.96. The differences in energy intake (kcal/day) between the CFRP and PFRB, plotted against their mean value for 10 patients, showed that results were within the limits of agreement (mean +/- 2SD) for nine patients. The differences in each day's energy intake between the two methods plotted against their mean value showed that 97% of the estimated daily energy intake was within the limits of agreement. The weighted kappa between the two methods was 0.76. The CFRP would seem to be acceptable for the estimation of mean energy intake in the hospital setting.

Eating difficulties, assisted eating and nutritional status in elderly (> or = 65 years) patients in hospital rehabilitation

This study describes frequencies and associations between eating difficulties, assisted eating and nutritional status in 520 elderly patients in hospital rehabilitation. Eating difficulties were observed during a meal and nutritional status was assessed with Subjective Global Assessment form. Eighty-two percent of patients had one or more eating difficulties, 36% had assisted eating and 46% malnutrition. Three components of eating were focused upon ingestion, deglutition, and energy (eating and intake). Deglutition and ingestion difficulties and low energy were associated with assisted eating, and low energy associated with malnutrition. Underestimation of low energy puts patients at risk of having or developing malnutrition.

Reliability and validity of the nutritional form for the elderly (NUFFE)

AIM

The aim of this study was to test the reliability and validity of the Nutritional Form for the Elderly (NUFFE).

BACKGROUND

The prevalence of undernutrition among older people in nursing homes and hospitals reaches high levels. Assessment of older patients' nutritional status is an important task for nurses in clinical care. To use a simple nutritional assessment instrument for older people is one approach for nurses. Examples of such instruments are the well validated Mini Nutritional Assessment (MNA) and the newly developed NUFFE.

METHODS

A total of 114 consecutively chosen, newly admitted older patients in an elder care rehabilitation ward in western Sweden were interviewed using the NUFFE and MNA. Arm and calf circumferences, body mass index (BMI), and presence of pressure sores and skin ulcers were noted as part of the MNA on admission. Weight was monitored and BMI calculated on discharge. Serum albumin levels on admission and discharge were used if these were available in the records. Reliability of the NUFFE was measured as homogeneity. Criterion related validity, concurrent validity, construct validity, and predictive validity were assessed with different statistical methods. The regional research ethics committee approved the study.

RESULTS

The results showed that the NUFFE is a fairly reliable and valid instrument for identifying actual and potential undernutrition among older patients.

CONCLUSION

The NUFFE is a simple tool for nurses to use to assess older patients with the aim of detecting undernourished individuals and those at risk for undernutrition. When doing a nutritional assessment with the NUFFE, the BMI ought also to be calculated. The assessment could also be combined with food intake recording for a period of time.

Can individualised nutritional support improve healing in therapy-resistant leg ulcers?

OBJECTIVE

This study investigated whether an individually designed programme of nutritional support can improve healing in otherwise therapy-resistant venous leg ulcers.

METHOD

Six primary health-care patients, aged between 79 and 93 years, with venous ulcers that had been open for one year or more (range: 1.5-8 years) were recruited into the study. The patients were asked to follow an individualised diet plan which included the use of liquid dietary supplements. Ulcer area, anthropometric and biochemical variables, and energy and nutrient intake were assessed before intervention and then regularly for nine months.

RESULTS

At nine months ulcer healing had occurred in two patients, of whom one had had ulcers on both legs. In a third patient the ulceration on one leg had healed and that on the other leg had almost healed. In a fourth patient, the ulcer area reduced by approximately 90%.

CONCLUSION

The use of nutritional support might have assisted the wound healing in these patients. Although the relationship between nutritional supplementation and wound healing is not well defined, an appropriate nutritional plan is recommended if undernourishment is suspected and leg ulcers are not healing.

Treatment of protein-energy malnutrition in chronic nonmalignant disorders

Protein-energy malnutrition (PEM) is common in connection with chronic disease and is associated with increased morbidity and mortality. Because the risk of PEM is related to the degree of illness, the causal connections between malnutrition and a poorer prognosis are complex. It cannot automatically be inferred that nutritional support will improve the clinical course of patients with wasting disorders. We reviewed studies of the treatment of PEM in cases of chronic obstructive pulmonary disease, chronic heart failure, stroke, dementia, rehabilitation after hip fracture, chronic renal failure, rheumatoid arthritis, and multiple disorders in the elderly. Several methodologic problems are associated with nutrition treatment studies in chronically ill patients. These problems include no generally accepted definition of PEM, uncertain patient compliance with supplementation, and a wide range of outcome variables. Avail-able treatment studies indicate that dietary supplements, either alone or in combination with hormonal treatment, may have positive effects when given to patients with manifest PEM or to patients at risk of developing PEM. In chronic obstructive pulmonary disease, nutritional treatment may improve respiratory function. Nutritional therapy of elderly women after hip fractures may speed up the rehabilitation process. When administered to elderly patients with multiple disorders, diet therapy may improve functional capacity. The data regarding nutritional treatment of the conditions mentioned above is still inconclusive. There is still a great need for randomized controlled long-term studies of the effects of defined nutritional intervention programs in chronically ill and frail elderly with a focus on determining clinically relevant outcomes.

Individually adjusted meals for older people with protein-energy malnutrition: a single-case study

The objective of this study was to investigate the effect of a 3-month intervention programme consisting of meals based on individual nutritional requirements in residents assessed as protein-energy malnourished on admission to a municipal care Institution. Using a single-case design, 11 malnourished residents were given individual care aimed at fulfilling their personal requirements for energy intake during a period of 12 weeks. The residents were selected from a sample of 261 newly admitted older adults of whom 87 were assessed to be malnourished on admission. Nutritional status, including anthropometric and biochemical variables and functional capacities were assessed before, during, and after the intervention. Energy intake was recorded every day. Body weight, and serum concentration of albumin and transthyretin were measured every other week. During a 3-month period, the mean value of energy intake reached the calculated energy requirement in 10 residents. Eight residents increased in weight, triceps skin-fold thickness, and transthyretin concentration. Nine residents increased in arm muscle circumference, and 10 showed increased serum albumin concentration and functional capacity. We conclude that nursing care based on individual nutritional requirements, resources, and desires improves nutritional status and functional capacity in a group of malnourished residents.

Protein-energy undernutrition in hospital in-patients

Impaired nutritional status has been frequently reported in surveys estimating its prevalence amongst patients in hospital. While there is no doubt that protein-energy undernutrition has serious implications for health, recovery from illness or surgery and hospital costs, lack of nationally or internationally accepted cut-off points and guidelines for most nutrition-related variables make nutritional assessment difficult and proper comparisons between studies impossible. In reviewing published work in which the prevalence of undernutrition has been assessed, it can be seen that each study defined undernutrition, or nutritional risk, using different methodology. This present review aims to highlight the problems which arise when deciphering these studies, and the resulting difficulty in determining the true prevalence of undernutrition and nutritional risk, amongst both general and specific groups of hospital in-patients. It is widely agreed that routine hospital practices can further adversely affect the nutritional status of sick patients in hospital. How this occurs, and the potential effects of impaired nutritional status on clinical outcome are examined. The methods currently available to assess nutritional status are evaluated in the knowledge that such assessments are difficult in clinical practice. The review concludes by proposing that if we want the medical and nursing professions to consider the nutritional status of hospital patients seriously, definitions of undernutrition and nutritional risk, and cut-off values for the nutritional variables measured must be agreed to allow evidence-based practice. Outcome measures which allow clear comparisons between groups and treatments must be used in studies assessing the effects of nutritional interventions.

[Oral nutrition therapy in malnutrition]

In the therapy of malnutrition in the elderly oral treatment should be preferred. It represents a particular challenge to relatives, caregivers and physicians. Because of the individual deficits in each patient a personal adapted plan has to be established. Treatment includes an optimized food supply, energy-rich and enriched meals, and liquid nutritional supplements but also special care during the meal and an inviting environment. The success is very much dependent on the intensity of care.

The identification and assessment of undernutrition in patients admitted to the age related health care unit of an acute Dublin general hospital

OBJECTIVES

To profile those over 65 yr admitted to an acute geriatric medical service. To identify and assess their undernutrition risk and quantify the nutritional intervention they received.

METHODS

Forty-nine consecutive admissions were recruited, 23 various parameters were assessed. A diagnosis of undernutrition was made according to a specifically designed flow chart.

RESULTS

Eighty-four per cent of recruits were at risk of undernutrition on admission and 80 per cent were moderately to severely at risk. There was deterioration from baseline nutritional status in 29 per cent of previously well nourished patients with hospitalization. In the undernourished group, an improvement and/or stasis from baseline was achieved in 75 per cent, with intervention.

CONCLUSIONS

The risk of undernutrition on admission to hospital and during treatment is an indicator of the need for nutrition services and nutritional screening for all acute medical services for older people.

Evaluating nurses' knowledge and patients energy intake after intervention

The aims of this study were to describe and assess nutritionally at-risk patients' energy intake and nurses' knowledge and opinions of patients' need of energy during their hospital stay, before and after training and education. The effects of the intervention were evaluated by using a questionnaire, answered by the nurses before and after the intervention, and indirectly by measuring the patients' nutritional outcome, using a nutritional assessment form. A total of 230 matched patients and 171 nurses (86 before the intervention and 85 after) participated in the study. After the education, results indicated that a greater number of patients received increased levels of energy intake, an increased average intake of energy, and more dietary supplements. Nurses' knowledge about the content of energy in a standard portion of food had increased, and they found it easier to assess patients' need of energy. After the education, more nurses had the opinion that well-educated nurses in nutrition make it easier to motivate patients to reach a sufficient intake of energy.

Nutritional intake and physical activity in leg ulcer patients

The aim of the study was to describe the nutritional intake, meal patterns, physical activity and need for help in nine women living in their own homes and being treated for venous leg ulcers. Food habits were identified by use of interviews and food diaries completed by the women during a period of seven days. The intake of energy and nutrients from 304 eating events during seven days was calculated and meal patterns were evaluated using a qualitative system for meal classification. Physical activity and the degree of need were identified with the help of interviews. The intakes of energy and key nutrients for wound healing, such as protein, vitamin C and zinc, were not optimal according to the Swedish nutrition recommendations, although food habits were well organized. Most of the women had hardly any physical activities and the need of help and support varied, from daily visits to visits every second week.

Nutritional support and functional status in undernourished geriatric patients during hospitalization and 6-month follow-up

The objective of this study, designed as a randomized controlled prospective intervention study, was to evaluate the effect of nutritional supplementation on functional status and need of care in undernourished geriatric patients during hospitalization, and up to 6 months after discharge. Participants consisted of 46 undernourished geriatric patients from a geriatric acute care hospital aged 75 years or older without malignant disease, or need for tube feeding or parenteral nutrition. Patients in the supplement group (SG, N = 20) were offered 400 mL (2100 kJ) daily of a liquid supplement during hospital stay and 200 mL (1050 kJ) per day for the following 6 months at home. Patients in the control group (CG, N = 26) had usual care without supplements. The main outcome measure was functional status based on the Barthel Activities of Daily Living score (ADL) at hospital admission, discharge and after 6 months, with higher scores indicating greater independence and a maximum score of 100 points. In supplemented patients with good acceptance (SG+, N = 11), a median improvement of 20 points was observed between admission and discharge, and a further improvement of 5 points at home. Median changes were 0 and -10 points in supplemented patients with poor acceptance (SG-, N = 9) and 5 and 2.5 points in CG, respectively. In SG+, the proportion of independent patients (> 65 points) increased continuously from 36% at admission to 63% at discharge, to 72% after 6 months, and was significantly higher compared to CG at discharge (63% vs 19%, p < 0.05) and after 6 months (72% vs 39%, p < 0.05). 64% of the patients in SG+ improved during hospitalization, compared to 23% in CG (p < 0.05). In the six months at home, 18% of SG+ improved; none of SG+ deteriorated in hospital or at home. In contrast, deterioration of the ADL score occurred in considerable proportions of SG- (22% in hospital, 22% at home) and CG (4% at hospital, 12% at home) patients. The proportion of patients who improved was smaller in SG- (44% at hospital, 22% at home) as well as in CG (23% at hospital, 35% at home), compared to SG+. In conclusion, a positive functional course was evident in supplemented patients with good acceptance during hospitalization, and further improvement was observed during the following 6 months at home. Nutritional support may contribute to reconvalescence and recovery of undernourished geriatric patients.

Alzheimer's disease, oral function and nutritional status

OBJECTIVES

To study differences in nutritional, dental status and oral function between institutionalised patients with Alzheimer's disease and cognitively healthy elderly people living in the community.

DESIGN

Comparison was made between two groups. Alzheimer's disease sufferers and healthy controls, using established criteria for anthropometric, mental and dental state.

SETTING

An institution and residential area in Stockholm, Sweden.

SUBJECTS

Forty patients with Alzheimer's disease living in a nursing home and 40 age- and gender-matched control subjects living independently.

INTERVENTION

Dental status and anthropometric variables.

RESULTS

Overnutrition was less frequent among the demented than the controls and more demented were undernourished. Dental status was similar in the two groups with few edentulous subjects but only 2 of 7 edentulous subjects with Alzheimer's disease wore dentures. Having natural teeth and many functional oral zones is important for food consistency choice, but not for nutritional status. In the Alzheimer group, the stage of dementia has a strong association to the ability to eat unaided and an association with dental status.

CONCLUSION

There are differences in nutritional status between Alzheimer's patients in institutions and cognitively healthy elderly living at home. The choice of food consistency is correlated to dental status but nutritional status is not shown to be influenced by dental status. However, the ability to eat unaided is strongly correlated to cognitive status.

Influence of dinner music on food intake and symptoms common in dementia

The influence of dinner music on food intake and symptoms common in dementia such as depressed mood, irritability and restlessness was studied. The study was carried out in a nursing-home ward in Sweden. Soothing music was played as dinner music for weeks, Swedish tunes form the 1920s and 1930s for two weeks and pop music for two weeks. Prior to these periods, there was one week without music, and at the end of the intervention there was a two-week control period. The effects of the intervention were assessed by psychological ratings and by weighing the food helpings. It was found that during all three music periods the patients ate more in total. The difference was particularly significant for the dessert. The staff were thought to be influenced by the music, as they served the patients more food, both main course and dessert, whenever music was played. The patients were less irritable, anxious and depressed during the music periods. The results of the study suggest that dinner music, particularly soothing music, can reduce irritability, fear-panic and depressed mood and can stimulate demented patients in a nursing-home ward into eating more.

Energy-enriched hospital food to improve energy intake in elderly patients

BACKGROUND

It was hypothesized that energy intake in hospitalized elderly patients could be improved by increasing the density of energy of the food and that the volume of food actually consumed, even with a higher energy content than the normal, would not change with servings of high energy-dense hospital food.

METHODS

Thirty-six elderly patients (52 to 96 years) of both sexes, long-term treated at two comparable wards, participated in this study. The patients were given 6 weeks of regular hospital food (RHF, 1670 kcal/d, 7.0 MJ) and 6 weeks of high-energy food (HE, 2520 kcal/d, 10.5 MJ). The volume of food was kept constant. A crossover study design was used. Food intake, energy intake, body weight, and modified functional condition (Norton scale) were measured.

RESULTS

Regardless of type of food (RHF or HE) and time of day (lunch or dinner), he food portion size (volume of food) intake was the same, approximately 80% of the portions consumed. HE led to a 40% increase in energy intake (from 25 +/- 1 during RHF to 35 +/- 2 kcal/kg/d, p < .0001), which resulted in a 3.4% increase in body weight (p < .001) after 3 weeks of HE. Only minimal changes in functional condition were found. The cost of HE was substantially lower (-85%) than any other mean available for improvement of energy intake.

CONCLUSIONS

A significant increase in energy intake can be achieved by higher energy density in regular hospital food and that HE does not cause a decrease in the volume of the food consumed. These findings suggest that it is the volume of food rather than the energy that limits voluntary energy intake of hospital food in elderly hospitalized patients.

The use of the Modified Norton Scale in nursing-home patients

Patients in three nursing-home wards in Sweden were in 1991 assessed by the Modified Norton Scale (MNS). Of the 71 patients, 38 (49%) were considered to be at risk of developing pressure sores. Six of the patients had a total of eight pressure sores. Five sores were assessed as stage II, two sores as stage III and one sore as stage IV. Only two of the six patients with pressure sores had any preventive equipment in their beds. The nursing and medical documentation of the existing pressure sores was not satisfactory. Individual programs for skin care and routine assessment with a pressure sore prediction instrument, such as the MNS, would serve the dual purpose of directing the relevant measures to the patient groups at the greatest risk and would aid in assessing the efficacy of pressure sore treatment strategies.