"Never the twain shall meet:" dual systems exacerbate malnutrition in older adults recently discharged from hospitals

Challenges in the Management of Geriatric Obesity in High Risk Populations

The global prevalence of obesity in the older adult population is growing, an increasing concern in both the developed and developing countries of the world. The study of geriatric obesity and its management is a relatively new area of research, especially pertaining to those with elevated health risks. This review characterizes the state of science for this “fat and frail” population and identifies the many gaps in knowledge where future study is urgently needed. In community dwelling older adults, opportunities to improve both body weight and nutritional status are hampered by inadequate programs to identify and treat obesity, but where support programs exist, there are proven benefits. Nutritional status of the hospitalized older adult should be optimized to overcome the stressors of chronic disease, acute illness, and/or surgery. The least restrictive diets tailored to individual preferences while meeting each patient’s nutritional needs will facilitate the energy required for mobility, respiratory sufficiency, immunocompentence, and wound healing. Complications of care due to obesity in the nursing home setting, especially in those with advanced physical and mental disabilities, are becoming more ubiquitous; in almost all of these situations, weight stability is advocated, as some evidence links weight loss with increased mortality. High quality interdisciplinary studies in a variety of settings are needed to identify standards of care and effective treatments for the most vulnerable obese older adults.

The effects of state-level expenditures for home- and community-based services on the risk of becoming a long-stay nursing home resident after hip fracture

SUMMARY

This study measures the effect of spending policies for long-term care services on the risk of becoming a long-stay nursing home resident after a hip fracture. Relative spending on community-based services may reduce the risk of long-term nursing home residence. Policies favoring alternative sources of care may provide opportunities for older adults to remain community-bound.

INTRODUCTION

This study aims to understand how long-term care policies affect outcomes by investigating the effect of state-level spending for home- and community-based services (HCBSs) on the likelihood of an individual's nursing home placement following hip fracture.

METHODS

This study uses data from the 5% sample of Medicare beneficiaries from 2005 to 2010 to identify incident hip fractures among dual-eligibility, community-dwelling adults aged at least 65 years. A multilevel generalized estimating equation (GEE) model estimated the association between an individual's risk of nursing home residence within 1 year and the percent of states' Medicaid long-term support service (LTSS) budget allocated to HCBS. Other covariates included expenditures for Title III services and individual demographic and health status characteristics.

RESULTS

States vary considerably in HCBS spending, ranging from 17.7 to 83.8% of the Medicaid LTSS budget in 2009. Hip fractures were observed from claims among 7778 beneficiaries; 34% were admitted to a nursing home and 25% died within 1 year. HCBS spending was associated with a decreased risk of nursing home residence by 0.17 percentage points (p 0.056).

CONCLUSIONS

Consistent with other studies, our findings suggest that state policies favoring an emphasis on HCBS may reduce nursing home residence among low-income older adults with hip fracture who are at high risk for institutionalization.

Housing First/HUD-VASH: Importance, Flaws, and Potential for Transformation: Response to Commentary

This paper consists of responses to issues raised in the accompanying Commentary. Our response is organized under three topics: (1) reasons regarding the importance of issues, (2) the need for a comprehensive framework in housing placement, and (3) conceptualization and scientific design (with details on contemporary methods for investigating unanticipated consequences when randomization is no longer feasible). Recurrences to substance use disorder in the American Society of Addiction Medicine (ASAM) housing placement condition are noted within hours or days, with rapid implementation of planned contingencies, and avoidance of enabling. Recurrences in the Housing First/HUD-VASH (HF/H-V) condition escape notice for weeks to months, and continued use is accepted as a core principle of the program. HF/H-V contingencies occur later for major disruptions, leading to discharge. For patients recruited from our clinic, HF/H-V performed poorly when compared to a long-accepted standard of care, the ASAM placement criteria.

Nutritional Vulnerability in Older Adults: A Continuum of Concerns. Curr Nutr Rep. 2015;4:176-184. [PMID: 26042189 DOI: 10.1007/s13668-015-0118-6]

A nutritionally vulnerable older adult has a reduced physical reserve that limits the ability to mount a vigorous recovery in the face of an acute health threat or stressor. Often this vulnerability contributes to more medical complications, longer hospital stays, and increased likelihood of nursing home admission. We have characterized in this review the etiology of nutritional vulnerability across the continuum of the community, hospital, and long term care settings. Frail older adults may become less vulnerable with strong, consistent, and individualized nutritional care. Interventions for the vulnerable older adult must take their nutritional needs into account to optimize resiliency in the face of the acute and/or chronic health challenges they will surely face in their life course.

A Model Home-Delivered Meals Program to Support Transitions from Hospital to Home

Meals On Wheels, Inc. of Tarrant County (MOWI) collaborated with local community-based organizations and hospitals to provide home-delivered meals and an evidence-based medication management intervention as a care transition service. The model program was designed to address risk factors commonly associated with preventable hospital readmissions. MOWI staff provided meals to 121 patients recently discharged from an inpatient hospitalization or emergency department visit from March 2013 through March 2014. A total of 18,010 meals were delivered to the 121 clients. On average, clients received 6.25 meals per week with meal delivery starting, on average, 8.95 days postdischarge. Ninety-three of the 121 clients also elected to receive the HomeMeds program. Client self-report of health care utilization (e.g., hospital readmission) at three months and six months was lower than expected given client characteristics. Positive changes in the Emergent Care Assessment and resolution of medication alerts provide additional evidence of a positive effect of the home-delivered meals program. More research is needed to document the benefits of home-based care supports following hospitalization.

Does Participation in Home-Delivered Meals Programs Improve Outcomes for Older Adults? Results of a Systematic Review

Participation in home-delivered meals programs may contribute to the health and independence of older adults living in the community, especially those who are food insecure or those who are making transitions from acute, subacute, and chronic care settings to the home. The purpose of this study was to conduct a comprehensive and systematic review of all studies related to home-delivered meals in order to shed light on the state of the science. A complete review of articles appearing in PubMed using the keyword "Meal" was conducted; and titles, abstracts, and full-texts were screened for relevance. Included in this review are 80 articles. Most studies are descriptive and do not report on outcomes. Frequently reported outcomes included nutritional status based on self-reported dietary intake. Additionally, most studies included in this review are cross-sectional, have a small sample size, and/or are limited to a particular setting or participant population. More rigorous research is needed to (1) gain insight into why so few eligible older adults access home-delivered meals programs, (2) support expansion of home-delivered meals to all eligible older adults, (3) better identify what home-delivered meals models alone and in combination with other services works best and for whom, and (4) better target home-delivered meals programs where and when resources are scarce.

A state-level examination of the association between home and community-based services and rates of nursing home residency with special attention to nutrition programs

Federal food and nutrition programs implemented by the Administration on Aging and funded by the Older Americans Act (OAA) seek to enable older adults to remain in their homes and communities through a comprehensive, coordinated, and cost-effective array of services. We hypothesized that expenditures devoted to nutrition programs for home and community-based nutrition services were inversely related to changes in state-level rates of institutionalization for older adults from one year to the next, such that states that spend more money per capita on community-based nutrition programs would have smaller increases or greater decreases in rates of institutionalization, controlling for expenditures on other home and community-based services. We found, however, that there was not an effect of OAA Nutrition Services on the change in rates of nursing home residency. We noted, though, that states that direct a greater proportion of their long-term care expenditures to home and community-based services appear to have more reduction in their rates of nursing home residency. Further longitudinal work at the state and individual levels is warranted.

A randomized controlled trial of a theoretically-based behavioral nutrition intervention for community elders: lessons learned from the Behavioral Nutrition Intervention for Community Elders Study

Older adults with multiple comorbidities are often undernourished or at high risk for becoming so, especially after a recent hospitalization. Randomized controlled trials of effective, innovative interventions are needed to support evidence-based approaches for solving nutritional problems in this population. Self-management approaches where participants select their own behavioral goals can enhance success of interventions. The purpose of this study was to evaluate the feasibility and efficacy of a multilevel self-management intervention to improve nutritional status in a group of high-risk older adults. The Behavioral Nutrition Intervention for Community Elders (B-NICE) trial used a prospective randomized controlled design to determine whether the intervention, compared to standard care, maintained or increased caloric intake (depending on baseline body mass index) and, consequently, stabilized or increased body weight. Participants were 34 Medicare-eligible, age 65 years old or older, homebound adults who were consuming insufficient calories and/or had a history of weight loss ≥2.5% over 6 months. The intervention took place within participants' homes. Outcome measures, including energy intake (based on collection of three 24-hour dietary recalls) and body weights were assessed at baseline and at 60 days post randomization. The primary analyses included analyses of covariance and Pearson's χ(2). We hypothesized that the intervention would result in increased caloric intake and weight gain in underweight older adults and increased or stabilized caloric intake and weight for everyone else. The intervention was feasible; however, it did not result in differences between groups for desired outcomes of either caloric intake or body weight. Future interventions might either deliberately involve caregivers or reduce burden for both patients and caregivers.

Malnutrition self-screening by using MUST in hospital outpatients: validity, reliability, and ease of use

BACKGROUND

Although nutritional screening with a tool such as the Malnutrition Universal Screening Tool (MUST) is recommended for outpatients, staff are under pressure to undertake a variety of other tasks. Little attention has been paid to the validity of patient self-screening with MUST.

OBJECTIVE

This study in 205 outpatients with a mean (±SD) age of 55 ± 17 y (56% male) assessed the practicalities of self-screening, its agreement with screening undertaken by a trained health care professional (HCP), and its test-retest reliability.

DESIGN

After the participants provided consent, screening was undertaken by the patients themselves and then by a trained HCP who was unaware of the self-screening results. All patients completed an ease-of-use questionnaire. Test-retest reliability of self-screening was established in a subset of 60 patients.

RESULTS

A total of 19.6% of patients categorized themselves as "at risk" of malnutrition (9.8% medium, 9.8% high). For the 3-category classification of MUST (low, medium, high), agreement between self-screening and HCP screening was 90% (κ = 0.70; SE = 0.058, P < 0.001). For the 2-category classification (low risk, medium + high risk), agreement was 93% (κ = 0.78, SE = 0.057, P < 0.001). Disagreements were not systematically under- or overcategorized. Test-retest reliability was almost perfect (κ = 0.94, P < 0.001). Most patients (71%) completed self-screening in <5 min. Patients found the tool easy or very easy to understand (96%) and complete (98%), with 94% reporting that they were happy to screen themselves.

CONCLUSION

Self-screening involving MUST in outpatients is acceptable to patients, user-friendly, reliable, and associated with good agreement with HCP screening. This trial was registered at clinicaltrials.gov as NCT00714324.

Home food environment of older adults transitioning from hospital to home

Only anecdotal information is known about foods available in the home of hospital-discharged older adults. This study describes the home food environment of this population and examines associations between health/nutrition risk factors and ability to shop and prepare meals. Data were collected from 512 hospital-discharged older adults residing in 6 U.S. states; food available within the home was assessed. Most households had a variety of food present; however, 20% of households lacked fresh fruit, 15% lacked fresh vegetables, and 35% had no fresh meat. About 35% of participants reported an inability to both prepare meals and shop for food. Among those unable to do both activities, the prevalence of depressive symptoms, food-related anxiety, and poor self-rated health was significantly (p < 0.01) higher than those able to do both activities. Homebound older adults may face additional challenges to recuperation from illness based on inability to prepare meals, regardless of availability of food following hospital discharge.