Which characteristics of nursing home residents influence differences in malnutrition prevalence? An international comparison of The Netherlands, Germany and Austria

The relation between resident-related factors and care problems in nursing homes: a multi-level analysis

BACKGROUND

Care problems such as decubitus and fall incidents are prevalent in nursing homes. Yet, research regarding explanatory factors on these care problems is scarce. The aim of this study is twofold: (1) to identify the degree to which a diverse set of resident-related factors (e.g., care dependency levels) are associated with the sum of six care problems (pressure ulcers, incontinence, malnutrition, falls, freedom restriction, and pain), and (2) to investigate which resident-related factors are associated with each of these six care problems individually.

METHODS

Data were collected (2016-2023) using the International Prevalence Measurements of Care Quality (LPZ). Factors such as age, number of diagnoses, and length of stay were included. While respecting nested data within eight organizations, the associations between thirteen resident-related factors and the six care problems were determined using multilevel analyses.

RESULTS

A total of 3043 residents were included (mean age 81.9; SD: 10.5). The most prevalent care problem was incontinence (n = 1834; 60.3%). Nurse proxy-rated confusion (r = 0.227; p < 0.001) and aggression (r = 0.285; p = 0.001) were associated strongest with the sum of the six care problems; and higher after correcting for the residents' care dependency levels (respectively r = 0.504; 0.584 - both p < 0.001). Pre-admission risk assessments for pressure ulcers (OR 7.03), malnutrition (OR 3.57), and falls (OR 3.93) were strongest associated with individual care problems such as pressure ulcers, and falls.

CONCLUSIONS

This study shows the association between several resident-related factors and care problems such as gender, years since admission, and care dependency level. Factors such as proxy-rated aggression and confusion were strongest associated with the presence of care problems, while pre-admission risk assessments were strongest associated with several individual care problems. The findings underscore the importance of prioritizing early pre-assessments, as they empower care professionals to take into account resident-specific factors and their influence on the emergence of care problems.

Nutrition among nursing home residents: results from the NutriCare study

Background

Older adults living in nursing homes (NHs) are considered a vulnerable population in terms of nutrition. The aim of the present study was to explore the usual intake of energy, macronutrients, and specific food groups, along with offers in the NH menus on a nationally representative sample of Slovenian NH residents and compare dietary patterns with the established recommendations.

Methods

The study was conducted as part of a cross-sectional NutriCare study on 317 residents (65-101 years) from 20 Slovenian NHs in 9 health regions. Relatively independent residents were selected using quota sampling by sex and age. Data collection involved interviews and anthropometric measurements. Usual dietary intake was assessed by a multiple-source method from two 24-h dietary recalls and food frequency questionnaires. Adherence of dietary intake to the recommendations and dietary composition of NH menus were assessed. The Mini Nutritional Assessment (MNA) was used to explore nutritional status.

Results

Notable variability in energy and macronutrient intakes was observed with some participants showing intakes below and others above the recommended values. A high prevalence of BMI > 30 kg/m2 was observed in 39% of participants, indicating potential discrepancies between total energy intake and expenditure. The usual intake of fat was 36% of total energy intake (TEI). The intake of foods of animal origin exceeded dietary guidelines. Intake of carbohydrates (46% TEI in men and 47% TEI in women) as well as dietary fibre (20 g/day for both sexes) was below recommendations. A scarce intake of fruits, vegetables, and cereals was observed. In total, 40% of men and 35% of women had usual daily protein intakes lower than 1 g/kg of body weight. The protein content of breakfast and dinner could be improved. NH residents consumed little food from outside NH. The usual nutrient and food group intakes of residents reflected the NH menu offers.

Conclusion

The study results on the usual intake of energy, macronutrients, specific food groups, and offers in the NH menus indicate the potential for optimisation. According to the World Health Organisation, the prevalence of BMI > 30 kg/m2 is notable and warrants attention. Careful meal planning and regular monitoring of the nutritional status of NH residents should be considered.

The perceptions of food service staff in a nursing home on an upcoming transition towards a healthy and sustainable food environment: a qualitative study

BACKGROUND

Healthy and sustainable food environments are urgently needed, also in nursing and residential care homes. Malnutrition in care homes is becoming an increasing problem as populations worldwide are ageing and many older people do not consume sufficient protein, fibre, fruit, and vegetables. Nursing homes also often experience a lot of food waste. A transition in the food environment like a nursing home, involves the participation of facility management and food service staff members. This study aims to map out their perceived barriers and facilitators for this transition.

METHODS

A qualitative study using semi-structured interviews was conducted with food service staff members (n = 16), comprising of kitchen staff (n = 4), wait staff (n = 10), and facility management (n = 2) of two nursing homes in the Netherlands. Thematic analysis was used to derive content and meaning from transcribed interviews.

RESULTS

Four main themes were identified. Theme 1: 'Communication, transparency and accountability in the chain', highlighting the lack of effective communication flows and a fragmented overview of the food service chain as a whole. Theme 2: 'Understanding, knowledge and ability of the concepts healthy and sustainable', revealing the gap in staff's understanding of these abstract concepts, despite perceiving themselves as having sufficient knowledge and ability. Theme 3: 'The pampering service mind-set', highlighting the contradiction in the staff's shared goal of proving the highest quality of life for residents while also pampering them in ways that may not align with promoting healthy and sustainable food choices. Theme 4: 'Transition is important but hard to realize', describing the barriers such as existing routines and a lack of resources as challenges to implementing changes in the food service.

CONCLUSIONS

Facilitators to transitioning nursing homes towards a healthy and sustainable food environment as perceived by staff members included transparent communication, accountability in the food supply chain, staff's perceived ability and shared goal, while barriers included lack of understanding of the concepts healthy and sustainable, the current pampering mindset, and top-down decision-making. These findings provide valuable insights for nursing homes seeking to transition towards a healthier and more sustainable food environment.

Magnitude of undernutrition and its association with dietary diversity among older persons in Ethiopia: a systematic review and meta-analysis, 2023

Undernutrition in elders remains under-detected, under-treated, and under-resourced and leads to further weight loss, increased infections, and delay in recovery from illness as well as increased hospital admissions and length of stay. The reports of the findings were fragmented and inconsistent in Ethiopia. Therefore, the main objective of this meta-analysis was to estimate the pooled prevalence of undernutrition and its association with dietary diversity among older persons in Ethiopia. Online databases (Medline, PubMed, Scopus, and Science Direct), Google, Google Scholar, and other grey literature were used to search articles until the date of publication. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline was followed. The random effect model was used to estimate the pooled prevalence; whereas subgroup analysis and meta-regression were performed to identify the probable source of heterogeneity using Stata version 14.0 software. Out of 522 studies accessed, 14 met our criteria and were included in the study. A total of 7218 older people (aged above 60 years old) were included in the study. The pooled proportion of undernutrition among older persons in Ethiopia was 20⋅6 % (95 % CI 17⋅3, 23⋅8). Elders who consumed low dietary diversity scores were strongly associated with undernutrition among older persons. Therefore, promoting appropriate intervention strategies for elders to improve dietary diversity practices and nutritional status is crucial.

Nutritional status and associated factors of older persons in sub-Saharan Africa: a scoping review

BACKGROUND

The older person population is rapidly increasing globally, including sub-Saharan Africa (SSA). Concurrently, malnutrition is also increasing among older persons in SSA, with a dearth of empirical evidence on nutritional status and associated factors among the older persons in the region to inform effective interventions to promote healthy ageing.

AIM/OBJECTIVE

This review assessed the nutritional status and associated factors among older persons in SSA.

METHOD

PubMed, Google Scholar, and Cochrane Library electronic databases were searched for published articles from 2010 to 2021 using keywords and Boolean logic. Also, we carried out a free web-based search to retrieve other relevant evidence that assesses the older persons' nutritional status. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow chart was used to appraise the research articles that responded to the study's research questions.

FINDINGS

Twenty studies met the inclusion criteria, from which data were extracted as findings. The malnutrition prevalence was between 6 to 54% among older persons in SSA. We found that the prevalence of malnutrition vary and could be as high as 28.4% in a low socio-economic status area. Of these studies, twelve (12) provided data on undernutrition with prevalence ranging from 2.9 to 41%;10 provided data on overweight (8.1-54.1%) and 5 on obesity (2.7-44.7%). Seventeen of the studies evaluated factors associated with malnutrition; 4 studies revealed the association between socioeconomic status and malnutrition, 7 studies reported a significant association between dietary habits and malnutrition. Four studies showed an association between educational status and malnutrition. Disease conditions associated with malnutrition were reported in four of the studies.

CONCLUSION

This review shows that malnutrition is a problem among older persons in SSA coupled with many risk factors which should be given critical attention. We recommend nutrition education for older persons as well as the development of nutrition interventions for this vulnerable group.

The Association between Malnutrition and Physical Performance in Older Adults: A Systematic Review and Meta-Analysis of Observational Studies

In recent years the focus of healthcare and nutritional science in older adults has shifted from mortality towards physical performance and quality of life. The aim of this review was to summarize observational studies on physical performance in malnourished (MN) or at risk of malnutrition (RMN) older adults compared with well-nourished (WN) older adults. Eligible studies had to report on nutritional status and objectively measured physical performance in older adults (≥60 y). MN or RMN groups had to be compared with a WN group, measured with a validated nutrition screener. Ovid Medline and Web of Science were searched until 13 November, 2020. Study quality was scored using a modified Newcastle-Ottawa Scale (NOS). Results were analyzed by meta-analysis when possible, or narratively reviewed otherwise. Forty-five studies (16,911 participants in total) were included from studies in outpatient clinics (n = 6), nursing homes (n = 3), community-dwelling older adults (n = 20), hospitalized patients (n = 15), or a combination (n = 1). Studies used 11 different screeners of malnutrition, and 8 types of physical performance measures. Meta-analysis showed that compared with MN, WN groups had better hand grip strength (mean difference [MD] = 4.92 kg; 95% CI: 3.43, 6.41; P < 0.001; n = 23), faster gait speed (MD = 0.16 m/s; 95% CI: 0.05, 0.27; P = 0.0033; n = 7), performed faster on timed-up-and-go (MD = -5.94 s; 95% CI: -8.98, -2.89; P < 0.001; n = 8), and scored 1.2 more short physical performance battery points (95% CI: 1.32, 2.73; P < 0.001; n = 6). Results were less pronounced when compared with RMN. Narratively, all studies showed an association for knee extension strength, 6-min walking test, and multicomponent tests, except for the chair stand test. Study limitations include no studies scoring "good" on NOS, lack of confounder adjustment, and high heterogeneity. Overall, evidence from cross-sectional studies indicate an association between malnutrition and worse physical performance in older adults. This study is registered in PROSPERO as CRD42020192893.

Reasons for and against Nutritional Interventions. An Exploration in the Nursing Home Setting

Malnutrition (MN) is widespread in nursing homes. Sometimes, but not always, nutritional interventions (NIs) are made, and the reasons for or against NIs are unknown. The aim of this cross-sectional study was to describe these reasons for residents with and without MN according to nurses’ subjective judgement and according to objective signs of MN. The nutritional status of 246 nursing home residents was subjectively judged by nurses (MN, at risk of MN, no MN) and objectively assessed by body mass index (BMI), weight loss (WL), and low food intake. NIs (enriched meals and/or oral nutritional supplements) were recorded using a standardized questionnaire, and nurses’ main reasons for (not) giving NIs were obtained in an open question. Of the residents, 11.0% were subjectively malnourished, and 25.6% were at risk of MN; 32.9% were malnourished according to objective criteria. Overall, 29.7% of the residents received NIs, 70.4% of those with MN as assessed by the nurses, 53.0% of those with objective MN, and 11.0% and 18.0% of non-malnourished residents, respectively. Reasons for NIs most often stated were low intake (47.9%), WL (23.3%), and low BMI (13.7%). Reasons against NIs mostly mentioned were adequate BMI (32.9%) and sufficient intake (24.3%). The lack of NIs for residents with MN was partially—but not always—explained by valid reasons. As residents without MN frequently received NIs, criteria for both MN rating and providing NIs, require closer scrutiny.

Malnutrition Is Associated With Impaired Functional Status in Older People Receiving Home Care Nursing Service

Objective: This study aimed to explore the magnitude and significance of associations among nutritional status, functional status, comorbidities, age, and gender in older adults receiving assistance from the in-home nursing care service.

Method: In this cross-sectional study, 210 home-dwelling persons 65 years or older who received in-home nursing care service were evaluated. Demographic variables, nutritional status, comorbidities, and the dependency levels of activities of daily living were analyzed. To assess the correlation among the factors that influence nutritional status, a theoretical model was developed and adjusted using the path analysis model.

Results: The primary finding is that functional status is directly associated with nutritional status (β = 0.32; p < 0.001) and severity of comorbidities is indirectly associated with nutritional status (β = −0.07; p < 0.017).

Conclusion: The elicited outcomes in this study reinforce the concept that nutritional status is linked with functional status in older adults receiving in-home care nursing service.

Malnutrition Prevalence Rates among Dutch Nursing Home Residents: What Has Changed over One Decade? A Comparison of the Years 2009, 2013 and 2018

OBJECTIVES

To assess changes in prevalence of malnutrition and its associated factors among people living in Dutch nursing homes in 2009, 2013 and 2018.

DESIGN

Secondary data analysis of the International Prevalence Measurement of Care Quality (LPZ) study.

SETTING

Dutch nursing homes.

PARTICIPANTS

Residents living at a psychogeriatric or somatic ward in Dutch nursing homes in 2009, 2013 or 2018.

MEASUREMENTS

weight and height, unintentional weight loss over the last month and last six months, age, sex, length of stay up to the measurement day, care dependency, and the presence of various diseases (dementia, diabetes mellitus, stroke, diseases of the respiratory system, respiratory diseases and pressure ulcers).

RESULTS

In total, 14,317 residents were included in this study with a mean age of 82.2, 70.9 female and 66.8% was living on a psychogeriatric ward. Results of this study show relative stability in background characteristics of the nursing home population over the last decade. In the total sample, 16.7% was malnourished and these percentages were 16.6% in 2009, 17.5% in 2013 and 16.3% in 2018. Multiple binary logistic regression analyses revealed having a pressure ulcer, female sex and living on a psychogeriatric department to be positively associated and having diabetes mellitus to be negatively associated with malnutrition throughout the years. These associations were strong and similar across years.

CONCLUSION

Even though much attention has been paid to prevent malnutrition in Dutch nursing homes over the last decades, results show a relatively stable malnutrition prevalence rate of around 16%. This leads to the question if nursing staff is able to sufficiently recognize residents with (a risk of) malnutrition, and if they are aware of interventions they could perform to decrease this rate.

Needs and availability of medical specialists' and allied health professionals' visits in German nursing homes: a cross-sectional study of nursing home staff

BACKGROUND

The medical care for nursing home residents is estimated to be partly inadequate in Germany. The aim of this study is to investigate the needs and utilization of general practitioners (GPs), medical specialists and allied health professionals.

METHODS

A survey was sent to a nationwide random sample of 1069 nursing homes in Germany in January 2019. Nursing staff managers were asked about medical care. Regular nursing home visits by medical specialists and allied health professionals were defined as at least one contact per year to at least one nursing home resident.

RESULTS

A total of 486 persons responded (45.5%). On average, nursing homes have contact to 8.6 (interquartile range: 4-10) different GPs. Almost 70% of respondents agreed that residents' medical care should be coordinated by GPs. However, only 46.0% stated that specialist treatment should require GP referral. A high need was seen for care from physiotherapists (91.0%), neurologists or psychiatrists (89.3%), dentists (73.7%), and urologists (71.3%). Regarding the actual utilization of medical specialists and health professionals, most nursing homes have regular contact to physiotherapists (97.1%), psychiatrists or neurologists (90.4%), speech therapists (85.0%), and dentists (84.8%). Remarkable discrepancies between need and utilization were found for urologists and ophthalmologists.

CONCLUSION

There is large variance in the number of GPs per nursing home, and needs for medical specialists, especially urologists and ophthalmologists, seem unmet. Interprofessional collaboration between GPs, medical specialists and allied health professionals should be improved, and GPs should play a more coordinating role.

Medical Nutrition Terminology and Regulations in the United States and Europe-A Scoping Review: Report of the ISPOR Nutrition Economics Special Interest Group

BACKGROUND

The term medical nutrition (MN) refers to nutritional products used under medical supervision to manage disease- or condition-related dietary needs. Standardized MN definitions, aligned with regulatory definitions, are needed to facilitate outcomes research and economic evaluation of interventions with MN.

OBJECTIVES

Ascertain how MN terms are defined, relevant regulations are applied, and to what extent MN is valued.

METHODS

ISPOR's Nutrition Economics Special Interest Group conducted a scoping review of scientific literature on European and US MN terminology and regulations, published between January 2000 and August 2015, and pertinent professional and regulatory Web sites. Data were extracted, reviewed, and reconciled using two-person teams in a two-step process. The literature search was updated before manuscript completion.

RESULTS

Of the initial 1687 literature abstracts and 222 Web sites identified, 459 records were included in the analysis, of which 308 used MN terms and 100 provided definitions. More than 13 primary disease groups as per International Classification of Disease, Revision 10 categories were included. The most frequently mentioned and defined terms were enteral nutrition and malnutrition. Less than 5% of the records referenced any MN regulation. The health economic impact of MN was rarely and insufficiently (n = 19 [4.1%]) assessed, although an increase in economic analyses was observed.

CONCLUSIONS

MN terminology is not consistently defined, relevant European and US regulations are rarely cited, and economic evaluations are infrequently conducted. We recommend adopting consensus MN terms and definitions, for example, the European Society for Clinical Nutrition and Metabolism consensus guideline 2017, as a foundation for developing reliable and standardized medical nutrition economic methodologies.

Prevalence of malnutrition using harmonized definitions in older adults from different settings - A MaNuEL study

BACKGROUND & AIMS

Malnutrition is widespread among older people and related to poor outcome. Reported prevalences vary widely, also because of different diagnostic criteria used. This study aimed to describe prevalences in several populations of older persons in different settings using harmonized definitions.

METHODS

Available studies within the Joint Programming Initiative (JPI) Knowledge Hub 'Malnutrition in the Elderly' (MaNuEL) were used to calculate and compare prevalences of malnutrition indicators: low BMI (<20 kg/m²; age-specific BMI <20 if age 65-<70 and <22 kg/m² if age ≥70 years), previous weight loss (WL), moderate and severe decrease in food intake, and combined BMI <20 kg/m² and/or WL in participants aged ≥65 years.

RESULTS

Fifteen samples with in total 5956 participants (59.3% women) were included: 7 consisting of community-dwelling persons, 2 studies in geriatric day hospitals, 3 studies in hospitalized patients and 3 in nursing homes. Mean age of participants ranged between 67 and 87 years. Up to 4.2% of community-dwelling persons had a BMI <20 kg/m², 1.6 and 9% of geriatric day hospital patients, 4.5-9.4% of hospital patients and 3.8-18.2% of nursing home residents. Using age-specific cut-offs doubled these prevalences. WL was reported in 2.3-10.5% of community-dwelling persons, 6% and 12.6% of geriatric day hospital patients, 5-14% of hospitalized patients and 4.5-7.7% of nursing home residents. Severe decrease in food intake was recorded in up to 9.6% of community-dwelling persons, 1.5% and 12% of geriatric day hospital patients, 3.4-34.2% of hospitalized patients and 1.5-8.2% of nursing home residents. The criteria age-specific BMI and WL showed opposing prevalences across all settings. Compared to women, low BMI and moderate decrease in food intake showed low prevalences in men but similar prevalences were observed for weight loss and severe decrease in food intake. In half of the study samples, participants in a younger age group had a higher prevalence of WL compared to those of an older age group. Prevalence of BMI <20 kg/m² and WL at the same time did not exceed 2.6% in all samples. The highest prevalences were observed based on combined definitions when only one of the three criteria had to be present.

CONCLUSIONS

Prevalences for different criteria vary between and within the settings which might be explained by varying functional status. The criteria used strongly affect prevalence and it may be preferable to look at each criterion separately as each may indicate a nutritional problem.

Adaptation transculturelle en français du Edinburgh Feeding Evaluation in Dementia (EdFED) Scale : un questionnaire pour évaluer les difficultés à s'alimenter de personnes âgées présentant des troubles cognitifs en centre d'hébergement

ABSTRACTThe Edinburgh Feeding Evaluation in Dementia (EdFED) Scale was designed to identify feeding difficulties for people with moderate to severe dementia. Its Canadian-French cross-cultural adaptation was carried out, as part of an experimental study, whose secondary objective was to document its construct validity. A back-translation method was followed. The EdFED-f was used during a meal with 26 elderly residents who had cognitive disorders. There was a significant correlation between EdFED-f scores and energy intakes calculated using a visual estimation of plate wash method (r=-0,50, p=0,009). EdFED-f scores also showed a significant difference according to the percentage of food consumed at meals (p=0,015). These results support the validity of the EdFED-f to assess feeding difficulties among elderly French-speaking Canadians living in residential and long-term care centers.

Nutrition knowledge, dietary patterns and anthropometric indices of older persons in four peri-urban communities in Ga West municipality, Ghana

BACKGROUND

Older adults are vulnerable to malnutrition due to sociologic, physiologic and anatomical effects of ageing.

OBJECTIVE

To investigate the influence of nutrition knowledge and dietary patterns on nutritional status of community-dwelling ambulatory older adults.

METHODS

This cross-sectional survey involved 120 elderly aged 60-70 years purposively selected from four peri-urban communities in Ga West municipality, Ghana. Nutrition knowledge was assessed using a structured questionnaire and dietary intakes obtained using a standardized food frequency questionnaire. BMI from weight/height measurements was proxy for nutritional status. Data was analyzed descriptively in SPSS. Associations were tested using correlation analyses (-1

RESULTS

28% had adequate knowledge on geriatric nutrition. Dietary patterns were mostly fair (40%) or poor (53%). Bloating (25%), constipation (18%), appetite loss (12%) and chewing difficulties (11%) affected intakes. Underweight was 10% while 21.7% were overweight or obese (16.6%). Positive insignificant corrections existed between knowledge and nutritional status (r=0.261) and with diet quality (r=0.415). However, strong significant (p=0.027) positive correlation (r=0.699) existed between diet quality and nutritional status.

CONCLUSION

Nutrition knowledge was adequate but dietary intake was poor and a quarter were malnourished. The associations reaffirm that supporting the elderly to make healthy dietary choices and ensuring household food security is crucial to preventing malnutrition.

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Key Words

• Dietary knowledge
• body mass index
• elderly
• food diversity
• geriatric nutrition

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MESH Headings

• Aged/statistics & numerical data
• Anthropometry
• Cross-Sectional Studies
• Diet/statistics & numerical data
• Female
• Ghana
• Health Knowledge, Attitudes, Practice
• Humans
• Male
• Middle Aged
• Nutritional Status
• Urban Population/statistics & numerical data

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Affiliation(s)

Faith Agbozo Department of Family and Community Health, School of Public Health, University of Health and Allied Sciences, Ho, Ghana
Joyce Amardi-Mfoafo Department of Family and Consumer Sciences, College of Agriculture and Consumer Sciences, University of Ghana, Legon, Accra
Helen Dwase Department of Family and Consumer Sciences, College of Agriculture and Consumer Sciences, University of Ghana, Legon, Accra
Basma Ellahi Faculty of Health and Social Care, University of Chester, Chester, CH1 4BJ, UK

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Assessment of nutritional status in the elderly: a proposed function-driven model

Background

There is no accepted or standardized definition of ‘malnutrition’. Hence, there is also no definition of what constitutes an adequate nutritional status. In elderly people, assessment of nutritional status is complex and is complicated by multi-morbidity and disabilities combined with nutrition-related problems, such as dysphagia, decreased appetite, fatigue, and muscle weakness.

Objective

We propose a nutritional status model that presents nutritional status from a comprehensive functional perspective. This model visualizes the complexity of the nutritional status in elderly people.

Design and results

The presented model could be interpreted as the nutritional status is conditional to a person’s optimal function or situation. Another way of looking at it might be that a person’s nutritional status affects his or her optimal situation. The proposed model includes four domains: (1) physical function and capacity; (2) health and somatic disorders; (3) food and nutrition; and (4) cognitive, affective, and sensory function. Each domain has a major impact on nutritional status, which in turn has a major impact on the outcome of each domain.

Conclusions

Nutritional status is a multifaceted concept and there exist several knowledge gaps in the diagnosis, prevention, and optimization of treatment of inadequate nutritional status in elderly people. The nutritional status model may be useful in nutritional assessment research, as well as in the clinical setting.

Process, structural, and outcome quality indicators of nutritional care in nursing homes: a systematic review

Background

The quality of nursing homes (NHs) has attracted a lot of interest in recent years and is one of the most challenging issues for policy-makers. Nutritional care should be considered an important variable to be measured from the perspective of quality management. The aim of this systematic review is to describe the use of structural, process, and outcome indicators of nutritional care in NHs and the relationship among them.

Methods

The literature search was carried out in Pubmed, Embase, Scopus, and Web of Science. A temporal filter was applied in order to select papers published in the last 10 years. All types of studies were included, with the exception of reviews, conference proceedings, editorials, and letters to the editor. Papers published in languages other than English, Italian, and Spanish were excluded.

Results

From the database search, 1063 potentially relevant studies were obtained. Of these, 19 full-text articles were considered eligible for the final synthesis. Most of the studies adopted an observational cross-sectional design. They generally assessed the quality of nutritional care using several indicators, usually including a mixture of many different structural, process, and outcome indicators. Only one of the 19 studies described the quality of care by comparing the results with the threshold values. Nine papers assessed the relationship between indicators and six of them described some significant associations—in the NHs that have a policy related to nutritional risk assessment or a suitable scale to weigh the residents, the prevalence or risk of malnutrition is lower. Finally, only four papers of these nine included risk adjustment. This could limit the comparability of the results.

Conclusion

Our findings show that a consensus must be reached for defining a set of indicators and standards to improve quality in NHs. Establishing the relationship between structural, process, and outcome indicators is a challenge. There are grounds for investigating this theme by means of prospective longitudinal studies that take the risk adjustment into account.

Dairy food supplementation may reduce malnutrition risk in institutionalised elderly

Malnutrition in institutionalised elderly increases morbidity and care costs. Meat and dairy foods are high-quality protein sources so adequate intakes may reduce malnutrition risk. We aimed to determine whether inadequate intakes of meat and dairy foods contribute to malnutrition in institutionalised elderly. This cross-sectional study involved 215 elderly residents (70·2 % females, mean age 85·8 years) from twenty-one aged-care facilities in Melbourne, Australia. Dietary intake was assessed using observed plate waste. Food groups and serving sizes were based on the Australian Guide to Healthy Eating. Nutrient content was analysed using a computerised nutrient analysis software (Xyris). Malnutrition risk was assessed using the Mini Nutrition Assessment (MNA) tool; a score between 24 and 30 indicates normal nutritional status. Data were analysed using robust regression. Mean MNA score was 21·6 (sd 2·7). In total, 68 % of residents were malnourished or at risk of malnutrition (MNA score≤23·5). Protein intake was 87 (sd 28) % of the Australian recommended dietary intake (RDI). Consumption averaged 1 serving each of dairy foods and meat daily. Number of dairy and meat servings related to proportion of protein RDI (both P<0·001), with the former contributing 13 % and the latter 12 % to protein RDI. Number of dairy servings (P<0·001), but not meat servings increased MNA score; each dairy serving was associated with a 1 point increase in MNA score so based on current intakes, on average if residents consumed the recommend four dairy servings (addition of 3 points to MNA score) they would achieve normal nutrition status (>24 points). Provision of meat and dairy foods did not meet recommended levels. On the basis of current dietary intakes in aged-care residents, increasing consumption of dairy foods to the recommended four servings daily ensures protein adequacy and may reduce malnutrition risk in institutionalised elderly, and so reduce risk of comorbidities and costs associated with malnutrition.

Who receives oral nutritional supplements in nursing homes? Results from the nutritionDay project

BACKGROUND & AIMS

Oral nutritional supplements (ONS) can be helpful for nursing home (NH) residents to prevent or treat malnutrition. Presently little is known about the use of ONS in NHs and the factors associated with its use. Thus, the aim of this analysis was to describe the use of ONS in NHs participating in the nutritionDay project and to determine characteristics of NH residents receiving ONS.

METHODS

Data from nutritionDay (nD), a cross-sectional multicenter study with standardized questionnaires on resident and NH level were analyzed. NH residents participating between 2007 and 2014 aged 65 years or older were included. Unit characteristics (2 variables), general residents' characteristics (18), residents' nutritional status (3) and residents' nutrition (4) were of interest as potential predictors of the use of ONS (no vs yes). Univariate binary logistic regression (LR) analyses were performed for all variables, and significant predictors (p < 0.05) subsequently included in a multivariate analysis (backwards LR).

RESULTS

13.9% of 23,689 NH residents received ONS. Univariate analysis identified all variables as predictors. After multivariate analysis 19 variables remained in the model (Nagelkerke's R² = 0.319). Odds ratios (OR [95% Confidence Interval]) of receiving ONS were highest in residents receiving supplementary parenteral nutrition (29.05 [14.85-56.81]; however only 1.1% of all participants) and fortified diet (11.91 [8.52-16.64]; 5.7%). The odds ratio of receiving ONS was 3.26 ([2.86-3.71]; 18.3%) for residents being classified as at risk of malnutrition and 4.56 ([3.86-5.40]; 10.0%) for malnourished residents according to NH staff. Low BMI and weight loss in the last year increased the odds of receiving ONS by 2.34 ([1.93-2.84]; 16.0%) and 1.38 ([1.23-1.54]; 32.8%), respectively. Furthermore, increasing age, cognitive and functional impairment, low food intake on nD, neurological disease and cancer were associated with an increased likelihood of the use of ONS. In NH units with a nutritional expert (67.1%) and units performing a nutritional assessment at least once a month (71.6%), the odds of receiving ONS were also significantly increased (1.89 [1.71-2.10] and 1.17 [1.06-1.29]).

CONCLUSION

In NHs who participated in the nutritionDay, ONS are used for residents with poor nutritional and functional status and often in combination with other nutritional interventions. Future studies need to clarify the role of NH staff in the prescription and distribution of ONS and focus on the reasons for and adequacy of the use of ONS in NHs.

Indicators of oral nutritional supplements prescription in nursing home residents: A cross-sectional study

BACKGROUND & AIMS

Identifying factors associated with oral nutritional supplement (ONS) prescription in nursing homes (NH) may help to treat malnutrition in this very old and vulnerable population.

OBJECTIVES

The aim of the study was to investigate if resident-related and NH-related characteristics were associated with ONS prescription.

DESIGN

Cross-sectional study using medical and demographic data from 6275 NH residents and data on the structure and organization (e.g., presence of a dietitian, organization of the meal) of 175 NHs in southwestern France. The main outcome measure was ONS prescription (dichotomous variable: yes/no).

RESULTS

ONS were prescribed for 7.8% (n = 489) of NH residents. In a multivariate binary logistic regression, resident-related factors associated with the prescription of ONS were age, clinical markers of undernutrition (body mass index and weight loss), disability in activities of daily living, pain, pressure sores, and hospitalization in the last 12 months. NH-related factors associated with ONS prescription were: presence of a dietitian (Odds Ratio (OR): 1.46, 95% Confidence Interval: 1.18-1.88), NH coordinating physician with specific training in geriatrics (OR: 2.58, 95% CI: 1.48-4.49), organization of evening snack (OR: 1.63, 95% CI: 1.28-2.07), number of general practitioners per NH bed (OR: 0.49, 95% CI: 0.38-0.64 intermediate tertile; OR:0.77, 95% CI:0.59-1.06 highest tertile. Reference category: lowest tertile) and number of drug prescriptions (OR: 0.97, 95% CI: 0.94-0.99).

CONCLUSIONS

Both resident's characteristics and NH characteristics were associated with ONS prescription independently of each other. Our results showed that NH organizational aspects are associated with ONS prescribing, suggesting that modifiable aspects may contribute to achieve optimal nutritional status in the NH setting.

Malnutrition in the nursing home

PURPOSE OF REVIEW

Malnutrition in the nursing home is increasingly recognized as a major international research priority, given the expanding geriatric populations, serious consequences, and challenges conducting research in nursing homes. This review examines the recent literature and suggests implications for research and practice.

RECENT FINDINGS

Across the recent studies, approximately 20% of nursing home residents had some form of malnutrition. However, malnutrition definitions were variable and prevalence ranged from 1.5 to 66.5%. Depression, cognitive impairment, functional impairment, and swallowing difficulty were consistently associated with malnutrition. Mortality was the major consequence of malnutrition among nursing home residents, whereas higher BMIs had lower risks of mortality. Beneficial interventions to reduce malnutrition in the nursing home included dietary supplements, greater resident role in food choice, and staff training programs.

SUMMARY

To truly tackle the issue of malnutrition in the nursing home setting, a consistent definition is needed. We strongly recommend that an expert consensus panel identify a standard set of measures to more accurately compare the prevalence across countries. Given the mortality consequences of malnutrition and the paucity of intervention studies, research on interventions for malnutrition in the nursing home needs to be a higher priority for facilities, researchers, and funding agencies.