Prospective audits of quality of PEM recognition and nutritional support in critically ill elderly patients

Chronic wounds in persons living with dementia: An integrative review

BACKGROUND

Persons living with dementia (PLWD) are at risk for chronic wounds; however, they are rarely included in research.

OBJECTIVES

To inform practice and research directions, the aim of this integrative review was to identify and synthesise previous knowledge about the characteristics of chronic wounds in PLWD, in terms of chronic wound types, prevalence, setting and interventions.

DESIGN

A literature search was conducted for publications in English using PubMed, Web of Science and CINAHL. The minimum information required for inclusion was how many PLWD enrolled in the study had wounds.

METHODS

This integrative review followed the Whittemore and Knafl methodology. Data extraction and synthesis were guided by a directed content analysis, with a coding structure based on an initial review of the literature.

RESULTS

Thirty-six articles met the inclusion criteria. The majority were missing characteristics of PLWD including severity of dementia and race/ethnicity/nationality, and none mentioned skin tone. Most focused on pressure injuries in the nursing home and acute care setting. Few included information on interventions. Only one discussed challenges of wound care for a PLWD exhibiting aggression.

CONCLUSION

There is a gap in the literature regarding PLWD and chronic wounds other than pressure injuries that are common in older adults (e.g. diabetic foot ulcers, venous leg ulcers). Research is warranted among those PLWD who live alone and those who receive wound care from family caregivers to understand experiences. Knowledge can inform the development of future novel interventions for wound healing. Future research is needed regarding chronic wounds in those who exhibit behavioural and psychological symptoms of dementia.

RELEVANCE TO CLINICAL PRACTICE

Nurses that care for chronic wounds in PLWD can contribute their knowledge to include information in guidelines on best care practices and contribute their perspective to research teams for future research.

The implications of nutrition services within the health care system on the quality of life and longevity, in developed countries: a re-analysis of 38 studies

BACKGROUND

The United Nations' Global Population Pyramid is undertaking a shift from pyramid to cube. The concomitant decline in fertility and mortality rates produces a higher portion of older people, and, thus, an increased number of deaths due to cancer and cardiovascular disease (CVD). Limited studies have investigated the effect of health care services on longevity. In this work, findings from studies throughout the world are presented and re-analysed in order to evaluate the effect of health care services on population's health status.

METHODS

Studies that have assessed the associations of nutritional and other health care services (i.e., physicians supply, technical support, inter-collaboration) on longevity and health status were retrieved (searches in PubMed, EMBASE, Scopus, up to January 2010), and summarized here.

RESULTS

Few studies, mostly located in the US and the UK, have evaluated the role of health care services on population's health status. The majority of the studies reported a beneficial association between the frequency of physicians and mortality, while some other studies reported weak or no associations between physician's supply and longevity. Also nutritional services (screening) seem to promote better clinical outcome.

CONCLUSION

Although very few data are available, it seems that there is a positive correlation between the quality and quantity of health care services and longevity. Strong primary health care seems to be effective on the population's health outcome. Active health policy and enhancement of health and nutritional services within the health care system may contribute to improved population's health and their overall quality of life.

How to improve nutritional support in geriatric institutions

Nutritional problems are frequent in nursing homes including undernutrition, obesity, and diabetes mellitus, mainly related to disability and behavior troubles. Adequate nutritional care relies both on the quality of menus for regular and modified diet (texture-modified and enriched food) and on the staff knowledge of nutritional problems, particularly undernutrition. Self-assessment of professional practices for all staff categories that are involved in this area can be used to increase training of staff and quality of nutritional care.

A review of the evidence for the impact of improving nutritional care on nutritional and clinical outcomes and cost

BACKGROUND

The association between malnutrition and poor clinical outcome is well-established, yet most research has focussed on the role of artificial nutritional support in its management. More recently, emphasis has been placed on the provision of adequate nutritional care, including nutritional screening and the routine provision of food and drink. The aim of this literature review is to establish the evidence for the efficacy of interventions that might result in improvements in nutritional and clinical outcomes and costs.

METHODS

A structured literature review was conducted investigating the role of nutritional care interventions in adults, and their effects on nutritional and clinical outcomes and costs, in all healthcare settings. Ten databases were searched electronically using keywords relating to nutritional care, patient outcomes and healthcare costs. High quality trials were included where available.

RESULTS

Two hundred and ninety-seven papers were identified and reviewed. Of these, only two randomised, controlled trials and six other trials were identified that addressed the major issues. A further 99 addressed some aspects of the provision of nutritional care, although very few formally evaluated nutritional or clinical outcomes and costs.

CONCLUSIONS

This review reveals a serious lack of evidence to support interventions designed to improve nutritional care, in particular with reference to their effects on nutritional and clinical outcomes and costs. The review suggests that screening alone may be insufficient to achieve beneficial effects and thus more research is required to determine the most cost-effective interventions in each part of the nutritional care pathway, in a variety of healthcare settings and across all age ranges, to impact upon nutritional and clinical outcomes.

Effects of Helicobacter pylori infection on gut appetite peptide (leptin, ghrelin) expression in elderly inpatients

The aim of the study was to investigate the relationship between gastritis and leptin and ghrelin in elderly patients. Patients older than 75 years undergoing an endoscopy were included. We reported data on nutritional status and Helicobacter pylori infection diagnosis (serology, 13C-urea breath test, culture, histology, and polymerase chain reaction on gastric biopsies). Gastric messenger RNA expression of leptin and ghrelin were quantified by real-time polymerase chain reaction. Sixty-two patients were included (84.7 +/- 5.2 years). H. pylori infection was associated with decreased gastric expression of leptin (p = .021), ghrelin (p =.002), and plasma ghrelin levels (p = .018). Atrophy was associated with decreased gastric leptin (p = .007) and ghrelin (p = .02). H. pylori infection correlated negatively with patient energy intake (r = -0.36; p = .001) and body mass index (r = -0.34; p = .018). The negative association between ghrelin and H. pylori infection may be related to a higher prevalence of atrophy and raises the possibility that H. pylori may be contributing to undernutrition in some older people.

Prevention and Treatment of Pressure Ulcers

Pressure ulcers are complex chronic wounds for which no gold standard for prevention or treatment has yet been established. Several attempts at developing guidelines has been undertaken by different organizations. Pressure ulcers are devastating comorbidities for patients and difficult to prevent or manage. Whether or not pressure ulcers are preventable remains controversial. The strategy for prevention includes recognizing the risk, decreasing the effects of pressure, assessing nutritional status, avoiding excessive bed rest and prolonged sitting, and preserving the integrity of the skin. The principles of treatment of pressure ulcers include assessing severity, reducing pressure, friction and shear forces, optimizing local wound care, removing necrotic debris, managing bacterial contamination, and correcting nutritional deficits.

Delirium symptoms and low dietary intake in older inpatients are independent predictors of institutionalization: a 1-year prospective population-based study

OBJECTIVE

To assess the effects of delirium on the institutionalization rate, taking into account geriatric syndromes and nutritional status.

METHODS

This population-based study took place in an acute care unit and included participants older than 75 years, arriving from home and later discharged. Confusion Assessment Method (CAM) symptoms were recorded by the nurses within 24 hours after admission and every 3 days. Delirium was defined using the CAM algorithm, and subsyndromal delirium responded to symptoms not fulfilling the CAM algorithm. These delirium categories were either present at admission (prevalent) or occurred during the hospital stay (incident). Participants were classified as having a low dietary intake when energy intake was at any time lower than 600 kcal/d. Age, sex, known cognitive impairment, weight, functional dependency, and laboratory testing as well as diagnoses were also recorded. Step-by-step backward logistic regression was used to identify predictors of institutionalization.

RESULTS

Among 427 patients, 310 (72.6%) were discharged and were compared with 117 (27.4%) participants admitted to an institution. Female sex (odds ratio [OR]: OR 2.15, 95% confidence interval [CI]: CI 1.22-3.78), prevalent delirium (OR 3.19, 95% CI 1.33-7.64), subsyndromal delirium (OR 2.72, 95% CI 1.48-5.01), incident subsyndromal delirium (OR 4.27, 95% CI 2.17-8.39), low dietary intake (OR 2.50, 95% CI 1.35-4.63), and a fall (OR 2.16, 95% CI 1.22-3.84) or a diagnosis of stroke (OR 2.03, 95% CI 1.04-3.94) were independent predictors of institutionalization.

CONCLUSIONS

Symptoms of delirium and severe nutritional impairment led patients to geriatric institutions. Therefore, these institutions need to implement policies that address both of these issues.

Lean body mass in preschool aged urban children in India: gender difference

OBJECTIVE

To estimate lean body mass (LBM) in preschool aged boys and girls in India and explore gender difference.

DESIGN

Crossectional.

SETTING

Immunization clinic of a charitable Government General Hospital in Kolkata, India.

SUBJECTS

Two-hundred and forty-five children (147 boys and 98 girls) aged 1-5 y from among the urban poor were admitted in the study between July 1999 and December 2000. Children with acute or chronic illness or congenital malformation were excluded.

METHOD

Length/height to the nearest 0.1 cm, weight to the nearest 10 g and total body resistance using multifrequency bioelectrical (Xitron 4000B) impedance analyzer (BIA) at 50 kHz were measured. Their nutritional status was compared with National Center for Health Statistics (NCHS) median data and lean body mass (LBM) was calculated using anthropometry and BIA equations. The groups were compared using analysis of variance and multiple linear regression.

RESULTS

Girls were more stunted (P<0.001) and underweight (P<0.047), while the degree of wasting was similar. Mean LBM percentage was higher in boys compared with girls by anthropometry (P<0.001) and BIA (P<0.005), which persisted after adjusting for age. With increasing age, LBM percentage declined in girls (P<0.02) in contrast to reference girls, in whom it increased. In boys LBM percentage increased with age as is in reference boys.

CONCLUSIONS

In addition to the girls being more stunted and underweight, LBM% decreased in girls with increasing age but steadily increased in boys, suggesting hidden deprivation of female children.

Is a 24-h cyclic closed enteral feeding system microbiologically safe in geriatric patients?

BACKGROUND AND AIMS

The microbiological quality of a 1-l closed enteral feeding system (CS) was prospectively monitored under clinical conditions simulating cyclic feeding over a 24-h period in geriatric patients.

METHOD

The set was connected after diet sampling (T0). After 5-h feeding, the set was disconnected and a sample taken (T5). Diet was sampled after 12 h before (T12A) and after a 10 ml diet-flush of the set (T12B), after 24-h (T24) and in the pouch (P24). Concentrations of micro-organisms were considered significant when above 10(4) colony-forming units per millilitre.

RESULTS

Twenty-one CS were examined. T0 samples were all sterile; 10 out of 21 T5 were contaminated. The microbiological content of the diet was lower in T12B, compared to T12A (P=0.002). None of the P24 samples was contaminated; 19 were sterile and two contained low levels of micro-organisms that had been previously found in the sets.

CONCLUSION

The CS was sterile before connecting to the patient. Retrograde contamination of the set was observed without contamination of the pouch after 24-h hanging time. Performing a diet-flush decreased the rate of diet contamination at the distal extremity of the set. Thus, cyclic enteral nutrition using the same pouch during a 24-h period seems to be safe in geriatric patients.

[Annual incidence and risk factors for nosocomial bacterial infections in an acute care geriatric unit]

PURPOSE

Elderly inpatients are particularly exposed to the risk of nosocomial infections, thus the study of their risk factors and consequences is of interest.

METHODS

Among 1,565 subjects referred to a short-term geriatric unit, patients hospitalised for a year for an acute event and unable to move themselves were followed up for the occurrence of nosocomial infections.

RESULTS

Among these 402 immobilised patients (age: 86.3 +/- 7.6 years), 102 nosocomial infections occurred in 91 patients (22.6%), whereas the estimation of the incidence in the total hospitalised population (1,565 subjects, age: 85.1 +/- 6.2 years) was 9.4% (95% confidence interval [CI] 8.3-11.2). Forty-seven point seven percent of nosocomial infections were urinary tract nosocomial infections, 27.5% were lower respiratory nosocomial infections, 9.2% were cutaneous nosocomial infections, 7.3% were septicaemia and 8.2% were of unknown origin. The relative risk (RR) of NI linked to functional dependency for mobility was 5.5 (95% CI: 3.93-7.7, P < 0.001). Other risk factors were: for all nosocomial infections: cancer diagnosis (RR 1.1, 95% CI: 1.1-1.2, P = 0.01); and respectively for urinary tract NI: bladder indwelling (RR 4.8, 95% CI: 2.9-7.7, P < 0.001), pulmonary NI: swallowing disorders (RR 5.4, 95% CI: 2.8-10.5, P < 0.001); and septicaemia: venous catheter (RR 5.4, 95% CI: 1.3-23.3, P = 0.002). NI were associated with an increased length of stay (22.1 +/- 11.7 days in infected patients vs 16.3 +/- 9.5 days in immobilised non-infected subjects, P < 0.001). The mean length of stay for the 1,565 subjects was 10.3 +/- 7.6 days. Death was attributed to nosocomial infections in 13 subjects. In conclusion, functional dependency for mobility, bladder indwelling, venous catheter, swallowing disorders and diagnosis of cancer were risk factors for nosocomial infections in hospitalised elderly subjects in an acutecare setting.

Issues and dilemmas in the prevention and treatment of pressure ulcers: a review

Considerable dogma and rhetoric, rather than evidence-based results, have accompanied recommendations for the prevention and treatment of pressure ulcers. Therapy for pressure ulcers is generally empiric, based on anecdotal experience, or borrowed from the treatment of patients with acute wounds. The treatment of pressure ulcers is problematic because of multiple comorbidities of patients, the chronic duration of pressure ulcers, and often by the physician's relative unfamiliarity with treatment options. Issues and dilemmas in the prevention of pressure ulcers center around risk assessment, means of pressure relief, and nutritional support. Similar issues in the treatment of pressure ulcers include implementing pressure relief, nutritional support, local wound care, the best method of debridement, diagnosing infection, the use of topical growth factors, and surgical treatment. The accumulating data for the prevention and management of pressure ulcers permits an outline of clinical strategies.

Functional and metabolic early changes in calf muscle occurring during nutritional repletion in malnourished elderly patients

BACKGROUND

Metabolic alterations in skeletal muscle associated with malnutrition and the potential reversibility of such alterations during refeeding are not fully understood.

OBJECTIVE

We characterized early changes in muscle during refeeding in malnourished, hospitalized elderly subjects.

DESIGN

Muscle function, metabolism, and mass were evaluated in 24 clinically stable patients (11 were malnourished) by using isokinetic plantar flexor torque measurements and nuclear magnetic resonance (NMR) imaging for medial gastrocnemius mass assessment and 31P and 13C NMR spectroscopy for inorganic phosphate (Pi), phosphocreatine, and glycogen quantitation.

RESULTS

Malnourished subjects had lower muscle mass (P < 0.02) and tended to have lower strength than did control subjects. In malnourished subjects, muscle strength increased after refeeding (P < 0.01) whereas muscle mass was unchanged. The ratio of Pi to ATP was lower in malnourished than in control subjects (P < 0.001) and increased during refeeding (P < 0.01). The mean ratio of phosphocreatine to ATP was lower in malnourished than in control subjects (P < 0.01) and increased to control values after refeeding. Muscle glycogen showed a scattered distribution for malnourished subjects; the mean value did not differ significantly from that of control subjects, either at baseline or after refeeding.

CONCLUSIONS

The lower ratio of phosphocreatine to ATP in malnourished subjects could have resulted from either lower total muscle creatine or reduced oxidative capacities. High or normal glycogen associated with a low Pi-to-ATP ratio in malnourished subjects suggested preferential use of lipid over carbohydrate for energy supply, which is known to reduce muscle performance. The data suggest that normalization of muscle metabolite content after refeeding improves muscle strength in malnourished subjects.

The role of nutrition in prevention and healing of pressure ulcers

Among the many risk factors for pressure ulcers, malnutrition is potentially reversible. This article examines the relationship of malnutrition to the prevention and healing of pressure ulcers. Evidence for nutrition in preventing and healing pressure ulcers is presented. Specific nutrients, including some amino acids, vitamins, and minerals, have been evaluated for their effects on wound healing.