Risk for Low Weight in Community-Dwelling, Older Adults

Ageing rate of older adults affects the factors associated with, and the determinants of malnutrition in the community: a systematic review and narrative synthesis

BACKGROUND

Malnutrition negatively impacts on health, quality of life and disease outcomes in older adults. The reported factors associated with, and determinants of malnutrition, are inconsistent between studies. These factors may vary according to differences in rate of ageing. This review critically examines the evidence for the most frequently reported sociodemographic factors and determinants of malnutrition and identifies differences according to rates of ageing.

METHODS

A systematic search of the PubMed Central and Embase databases was conducted in April 2019 to identify papers on ageing and poor nutritional status. Numerous factors were identified, including factors from demographic, food intake, lifestyle, social, physical functioning, psychological and disease-related domains. Where possible, community-dwelling populations assessed within the included studies (N = 68) were categorised according to their ageing rate: 'successful', 'usual' or 'accelerated'.

RESULTS

Low education level and unmarried status appear to be more frequently associated with malnutrition within the successful ageing category. Indicators of declining mobility and function are associated with malnutrition and increase in severity across the ageing categories. Falls and hospitalisation are associated with malnutrition irrespective of rate of ageing. Factors associated with malnutrition from the food intake, social and disease-related domains increase in severity in the accelerated ageing category. Having a cognitive impairment appears to be a determinant of malnutrition in successfully ageing populations whilst dementia is reported to be associated with malnutrition within usual and accelerated ageing populations.

CONCLUSIONS

This review summarises the factors associated with malnutrition and malnutrition risk reported in community-dwelling older adults focusing on differences identified according to rate of ageing. As the rate of ageing speeds up, an increasing number of factors are reported within the food intake, social and disease-related domains; these factors increase in severity in the accelerated ageing category. Knowledge of the specific factors and determinants associated with malnutrition according to older adults' ageing rate could contribute to the identification and prevention of malnutrition. As most studies included in this review were cross-sectional, longitudinal studies and meta-analyses comprehensively assessing potential contributory factors are required to establish the true determinants of malnutrition.

Validity assessment of the nutrition screening initiative checklist in older adults

OBJECTIVE

To ascertain whether the NSI (Nutrition Screening Initiative Checklist) is a valid screening instrument for diagnosing nutritional risk in an older population from a medium-size city in the south of Brazil.

METHODS

The study population comprised individuals aged 60 years or older selected from a population-based cross-sectional survey. Data collection was carried out at two different timepoints: first, the NSI (instrument under test) was applied and later a dietary recall (gold standard) based on the previous day. Validity analyses were performed based on sensitivity and specificity as well as the Receiver Operating Characteristic Curve.

RESULTS

A total of 183 older adults were studied. Agreement between the dietary recall and the NSI for positive and negative results was 54.6%.The sensitivity and specificity values were low for all cut-off points of the instrument. The area under the curve was 0.52 (95%CI: 0.44-0.62) for the cut-off point ≥6.

CONCLUSION

Based on sensitivity and specificity values, the NSI proved ineffective for application in the population studied.

Association of Depressive Symptoms and Micronutrient Deficiency With Cardiac Event-Free Survival in Patients With Heart Failure

BACKGROUND

Depressive symptoms and malnutrition independently predict cardiac events in heart failure (HF) patients. However, the relationships among depressive symptoms, nutritional intake, and cardiac event-free survival have not been examined.

METHODS AND RESULTS

A total of 232 patients with HF completed the Patient Health Questionnaire 9 (PHQ-9) to measure depressive symptoms and a 3-day food diary to determine the number of micronutrient deficiencies. Patients were followed for 2 years to collect data on cardiac event-free survival. Patients were divided into 4 groups by a PHQ-9 score of 10 and the median value of micronutrient deficiencies. Cox regressions were used to determine the relationships among depressive symptoms, micronutrient deficiency, and cardiac event-free survival. Depressive symptoms conferred greater risk of cardiac events in patients with a high number of micronutrient deficiencies than in those with a low number of micronutrient deficiencies. Patients with a PHQ-9 score ≥10 and number of micronutrient deficiencies >5 had 2.4 times higher risk for cardiac events compared with patients with a PHQ-9 score <10 and micronutrient deficiency ≤5 (P = .005).

CONCLUSIONS

There was a synergistic effect on the association of depressive symptoms with cardiac event-free survival in HF patients that differed by micronutrient deficiency.

The link of unintentional weight loss to cardiac event-free survival in patients with heart failure

BACKGROUND

Patients with heart failure (HF) commonly have unintentional weight loss, depressive symptoms, and elevated levels of high-sensitivity C-reactive protein (hsCRP). Each of these variables has been independently associated with shorter cardiac event-free survival. However, little data exist on the relationships of unintentional weight loss, hsCRP level, and depressive symptoms to cardiac event-free survival.

OBJECTIVE

The aims of this study were to determine (1) whether depressive symptoms and elevated hsCRP level predicted unintentional weight loss and (2) whether unintentional weight loss predicted shorter cardiac event-free survival.

METHODS

This was a prospective study of 243 consecutive HF patients (61% men, 61 ± 14 years old) enrolled during an index hospitalization for HF exacerbation. Patients provided blood samples to measure hsCRP level and completed the Beck Depression Inventory to assess depressive symptoms at discharge. Body weight was measured at discharge and 6 months later. Unintentional weight loss was defined as weight loss of greater than 6% of body weight since discharge. Cardiac event-free survival was followed for 1 year after the second measurement of body weight through monthly telephone interviews. Hierarchical logistic regression was used to determine whether depressive symptoms and elevated hsCRP level predicted unintentional weight loss. Cox hazard regression was used to determine whether unintentional weight loss predicted cardiac event-free survival.

RESULTS

Thirty-five patients (14.4%) experienced unintentional weight loss at 6 months after discharge. Hierarchical Cox hazard regression revealed that patients with unintentional weight loss had a 3.2 times higher risk for cardiac events, adjusting for other clinical factors (P < .001). In hierarchical logistic regression, elevated hsCRP level (odds ratio, 1.49; 95% confidence interval, 1.15-1.92) and depressive symptoms (odds ratio, 1.07, 95% confidence interval, 1.02-1.12) independently predicted unintentional weight loss.

CONCLUSIONS

Unintentional weight loss was an independent predictor of poor outcomes. Heart failure patients with depressive symptoms and elevated hsCRP levels are at a higher risk for unintentional weight loss.

Ethical aspects of caregivers' experience with persons with dementia at mealtimes

BACKGROUND

Persons with dementia are at risk of malnutrition and thus in need of assistance during mealtimes. Research suggest interventions for caregivers to learn how to facilitate mealtimes and eating, while other suggest a working environment enabling the encounter needed to provide high-quality care. However, the phenomenon of caring for this unique population needs to be elucidated from several perspectives before suggesting suitable implications that ensure their optimal health.

OBJECTIVES

To illustrate the meanings within caregivers' experiences of caring for persons with dementia during mealtime situations. We also measured weight and food intake among individuals with dementia to explain better the phenomenon of caring for them during mealtimes.

METHODS

Mixed method including focus group interviews with seven caregivers analyzed using phenomenological hermeneutics. In addition, for nine persons with dementia, weight and food intake were collected and descriptive statistics were calculated.

ETHICAL CONSIDERATIONS

Ethical review was obtained from an ethics committee, and all caregivers signed a consent form after being informed on the issue of research ethics. Relatives for persons with dementia were informed and signed the consent. In addition, throughout the study, the persons' expressions were observed aiming to respect their vulnerability, integrity, and dignity.

FINDINGS

One theme emerged from interviews (struggling between having the knowledge and not the opportunity), which was built upon three subthemes (being engaged and trying; feeling abandoned and insufficient; being concerned and feeling guilty). Seven of nine persons with dementia lost a minimum of 1.3 kg of weight and ate a maximum of 49.7% of the food served.

CONCLUSION

Caregivers struggle because they have knowledge about how to provide high-quality care but are unable to provide this care due to organizational structures. The weight loss and insufficient eating among the persons with dementia may support this conclusion. Sufficient time for adequate care should be provided.

Determinants of protein-energy malnutrition in community-dwelling older adults: a systematic review of observational studies

Protein-energy malnutrition is associated with numerous poor health outcomes, including high health care costs, mortality rates and poor physical functioning in older adults. This systematic literature review aims to identify and provide an evidence based overview of potential determinants of protein-energy malnutrition in community-dwelling older adults. A systematic search was conducted in PUBMED, EMBASE, CINAHL and COCHRANE from the earliest possible date through January 2013. Observational studies that examined determinants of protein-energy malnutrition were selected and a best evidence synthesis was performed to summarize the results. In total 28 studies were included in this review from which 122 unique potential determinants were derived. Thirty-seven determinants were examined in sufficient number of studies and were included in a best evidence synthesis. The best evidence score comprised design (cross-sectional, longitudinal) and quality of the study (high, moderate) to grade the evidence level. Strong evidence for an association with protein-energy malnutrition was found for poor appetite, and moderate evidence for edentulousness, having no diabetes, hospitalization and poor self-reported health. Strong evidence for no association was found for anxiety, chewing difficulty, few friends, living alone, feeling lonely, death of spouse, high number of diseases, heart failure and coronary failure, stroke (CVA) and the use of anti-inflammatory medications. This review shows that protein-energy malnutrition is a multifactorial problem and that different domains likely play a role in the pathway of developing protein-energy malnutrition. These results provide important knowledge for the development of targeted, multifactorial interventions that aim to prevent the development of protein-energy malnutrition in community-dwelling older adults.

Malnutrition as a Precursor of Pressure Ulcers

Significance: Numerous studies have reported associations between declining nutrition status and risk for pressure ulcers. Oral eating problems, weight loss, low body weight, undernutrition, and malnutrition are associated with an increased risk for pressure ulcers. Moreover, inadequate nutrient intake and low body weight are associated with slow and nonhealing wounds. However, the biologic significance of deterioration in nutrition status and consistent methodologies to quantify malnutrition and diminished micronutrient stores as predictors of skin breakdown remains controversial. Recent Advances: The Academy of Nutrition and Dietetics (Academy) and the American Society for Parenteral and Enteral Nutrition (ASPEN) Consensus Statement: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition provide a standardized and measureable set of criterion for all health professionals to use to identify malnutrition. The Agency for Healthcare Research and Quality identified malnutrition as one of the common geriatric syndromes associated with increased risk for institutionalization and mortality that may be impacted by primary and secondary preventions. Critical Issues: The purpose of this article is to examine the Academy/ASPEN consensus statement on characteristics of adult malnutrition in the context of the National Pressure Ulcer Advisory Panel (NPUAP)/European Pressure Ulcer Advisory Panel (EPUAP) Guidelines on the Prevention and Treatment of Pressure Ulcers. Future Directions: Moreover, clinicians, and in particular, registered dietitians have the opportunity to integrate the Characteristics of Malnutrition with the NPUAP/EPUAP 2009 Prevention and Treatment Clinical Practice Guidelines, into clinical assessment and documentation using the Nutrition Care Process. Consensus guidelines will provide consistent research criteria yielding more useful data than presently available.

Nutritional screening of older home-dwelling Norwegians: a comparison between two instruments

Background

It is important to obtain knowledge about the prevalence of nutritional risk and associated factors among older home-dwelling people in order to be able to meet nutritional challenges in this group in the future and to plan appropriate interventions. The aim of this survey was to investigate the prevalence of home-dwelling older people at nutritional risk and to identify associated factors using two different nutritional screening instruments as self-report instruments.

Methods

This study had a cross-sectional design. A postal questionnaire, including the Norwegian versions of the Nutritional Form for the Elderly (NUFFE-NO) and Mini Nutritional Assessment – Short Form (MNA-SF), background variables, and health-related questions was sent to a randomized sample of 6033 home-dwelling older people in southern Norway. A total of 2106 (34.9%) subjects were included in the study. Data were analyzed using descriptive statistics and logistic regression analyses.

Results

When using the NUFFE-NO and MNA-SF, 426 (22.3%) and 258 (13.5%) older persons, respectively, were identified to be at nutritional risk. The risk of undernutrition increased with age. Several predictors for being at risk of undernutrition, including chronic disease/handicap and receiving family help, as well as protective factors, including sufficient food intake and having social contacts, were identified.

Conclusion

Health professionals must be aware of older people’s vulnerability to risk of undernutrition, perform screening, and have a plan for preventing under-nutrition. For that purpose, MNA-SF and NUFFE-NO can be suggested for screening older people living at home.

Causes of death in forensic autopsy cases of malnourished persons

PURPOSE

Medical examiners and forensic pathologists often encounter emaciated bodies in postmortem examinations. However, the main disease that caused death is often not clear and measures to prevent the unexpected death of malnourished persons have not been established. In this study, we examined the underlying causes of death among a large number of forensic autopsy cases that showed emaciation to clarify the features of sudden, unexpected death in malnourished persons.

METHODS

Documents of autopsy cases without putrefaction handled during 2007-2010 by the Tokyo Medical Examiner's Office were reviewed (n=7227). The body mass index (BMI) was calculated for each case. The causes of death for cases with severe malnutrition (BMI<16; n=885) were closely examined.

RESULTS

About 70% of all deaths in malnourished cases (BMI<16) was due to disease, and the causative diseases are more varied than in those with less severe malnutrition and those without malnutrition (BMI⩾16). A higher proportion of malnutrition as the cause of death was observed in younger persons for both sexes, and a higher proportion of having a history of psychiatric diseases was observed in younger deceased women. In addition, a higher proportion of alcohol-related digestive diseases was observed especially in younger men, some of whom had a history of alcohol dependence. On the other hand, the proportion of organic diseases, such as neoplasms and gastroduodenal ulcer, was higher in older deceased persons, especially among men. Around 70% of all respiratory diseases comprised pneumonia in both sexes. Among non-disease-related causes of death, poisoning was the most frequent cause in women under 55years old (35.3%), with the majority having had a history of psychiatric disease.

CONCLUSIONS

Because autopsy cases of malnourished persons show various causes of death, physicians have to pay more attention in making death diagnosis in such cases. From a preventative point of view, early detection of organic diseases, a better approach toward managing psychiatric diseases, and implementation of vaccination for pneumonia will contribute to reduction of future unexpected deaths among malnourished persons.

High nutritional risk is associated with worse health-related quality of life in patients with heart failure beyond sodium intake

BACKGROUND

The most desirable outcome in heart failure (HF) management is to improve health-related quality of life (HRQoL) as a patient-centred health outcome. Nutrition is assumed to be important in HF management, whereas there is little evidence that nutritional risk affects HRQoL, except for sodium.

PURPOSE

We aimed to determine whether nutritional risk is associated with worse HRQoL after controlling for daily sodium intake.

METHODS

A total of 134 consecutive patients with HF [age 63 ± 11 years, 35% female, 45% New York Heart Association (NYHA) class III/IV, ejection fraction (EF) 33 ± 13%] completed the Nutrition Screening Initiative (NSI) to assess nutritional risk and a 24-h urine sodium excretion assessment to estimate daily sodium intake at baseline. The Minnesota Living with HF Questionnaire was used to evaluate HRQoL at baseline and 6 months later. Hierarchical linear regressions were used to determine whether nutritional risk predicted HRQoL at baseline and 6 months later.

RESULTS

Seventy-eight (58.2%) patients had high nutritional risk as indicated by a total NSI score ≥ 6. Increased nutritional risk was independently associated with worse HRQoL at baseline and 6 months later (β = 0.33, p < 0.001; β = 0.35, p < 0.001, respectively), after controlling for age, gender, aetiology, body mass index, NYHA class, EF, total comorbidity score, prescribed medications, and daily sodium intake.

CONCLUSION

These findings show that higher nutritional risk beyond sodium intake affects worse HRQoL in patients with HF. Further work is required to provide specific dietary guidelines to improve health outcomes for patients with HF.

Effect of human placental extract on health status in elderly koreans

Objectives. Human placental extract (HPE) has begun to be used in Korea in various ways to improve health, even though evidence-based data is insufficient. This study investigated the effects of HPE on health status in elderly Koreans. Design. Randomized, single-blind, and case-control study design. Setting and Participants. Thirty-nine community-dwelling healthy Koreans ≥65 years of age. Intervention. The participants were randomly categorized into a placebo group (n = 17) and HPE group (n = 22). The HPE group received abdominal subcutaneous injections of HPE for 8 weeks. The placebo group was injected with normal saline. Measurements. The degree of health status was surveyed by the Korean health status measure for the elderly (KoHSME V1.0) at baseline and the end of the study. Results. In the HPE group, the scores of physical function, sexual life, and general heath perception at the end of the study period were significantly improved from baseline (P = .007, .020, and .005, resp.), while the health status of the placebo group remained unchanged during the study period. There was a significant difference over the study period between the two groups in the mean change of the physical function score (P = .036). Conclusion. A HPE injection regimen can improve the health status in elderly Koreans.

Intensive dietary intervention by a dietitian as a case manager among community dwelling older adults: the EDIT study

BACKGROUND

Clinical trials that have assessed the best approach for treating under-nutrition in old age are scarce.

OBJECTIVE

To determine the impact of an intensive nutritional intervention program led by a dietitian on the health and nutritional status of malnourished community dwelling older adults.

METHODS

Sixty-eight eligible participants (age<75) were randomly assigned to a Dietetic Intervention Treatment (DIT), an intensive nutritional intervention led by a dietitian, or a Medical Treatment (MT), a physician-led standard care group, with an educational booklet regarding dietary requirements and recommendations for older adults. An additional 59 eligible participants who were unable to participate in the randomization were included as a non-randomized "untreated nutrition" group (UNG).

RESULTS

Over the 6-month follow-up, the DIT group showed significant improvement in cognitive function (from 25.8±4.5 to 26.8±4, p=0.04), and depression score (from 7.3±3.9 to 5.4±3.9, p=0.04) compared with the change in the other 2 groups. The DIT group showed a significant improvement in intake of carbohydrates (+15% vs. +1% in the MT and +3% in the UNG), protein (+8% vs. +2% in the MT and -3% in the UNG), vitamin B6 (+20% vs. +7% in the MT and +8% in the UNG), and vitamin B1 (+22% vs. +11% in the MT and 0% in the UNG). The DIT group had a significantly lower cost of physician visits than the other 2 groups ($172.1±232.0 vs. $417.2±368.0 in the MT and $428.1±382.3 in the UNG, p=0.005).

CONCLUSION

Intensive dietary intervention was moderately effective in lowering cost of services used and improving medical and nutritional status among community dwelling older adults.

Early determinants for the development of undernutrition in an older general population: Longitudinal Aging Study Amsterdam

Undernutrition may be an important modifiable risk factor for poor clinical outcomes in older individuals. To achieve earlier detection or prevention of undernutrition, more information is needed about risk factors for the development of undernutrition in community-dwelling older individuals. The objective was to identify early determinants of incident undernutrition in a prospective population-based study. Baseline data (1992–3) on socio-economic, psychological, medical, functional, lifestyle and social factors of 1120 participants aged 65–85 years of the Longitudinal Aging Study Amsterdam were used. Undernutrition, defined as a BMI < 20 kg/m2 or self-reported involuntary weight loss ≥  5 % in the last 6 months, was assessed every 3 years during a 9-year follow-up period. Cox proportional-hazards regression analysis was used to investigate the association between early determinants at baseline and incident undernutrition. In 9 years, 156 participants (13·9 %) developed undernutrition. In univariate analyses, female sex, depressive symptoms, anxiety symptoms, multiple chronic diseases, high medication use (women), poor appetite, no alcohol use v. light alcohol use, loneliness, not having a partner, limitations in performing normal activities due to a health problem, low physical performance (participants aged < 75 years) and reporting difficulties walking stairs (participants aged < 75 years) were statistically significantly associated with incident undernutrition. In a multivariate model, poor appetite and reporting difficulties walking stairs (participants aged < 75 years) remained early determinants. The results of the present study can be used to identify subgroups of older individuals with increased risk of undernutrition and to identify modifiable determinants for the purpose of prevention of undernutrition.

Sharing meals with institutionalized people with dementia: a natural experiment

Nutritional deficiency can have dramatic effects on the physical and psychological status of older adults. Although food supplements can enhance nutritional status, several authors suggest that more ecological means could also have beneficial impacts. Therefore, a natural experiment was conducted to study the impact of changed mealtime experiences for people with Alzheimer-type dementia. Two special care units (in separate facilities) in France were included in this study: one implemented shared meal times between residents and caregivers and the other served as a comparison group. Weight was measured and staff observations were collected. Positive outcomes were observed for the experimental group. Implications for practice are discussed.