Feasibility of home-based dietetic intervention to improve the nutritional status of older adults post-hospital discharge

The effectiveness of a home-based dietetic intervention for community-dwelling older adults

OBJECTIVES

The aim of this study was to describe the characteristics of clients receiving home-based dietetic intervention and to evaluate the effectiveness of these interventions in improving nutritional status, functional status, and quality of life in a culturally and socioeconomically diverse client group.

METHODS

Participants referred to a home-based dietetic service were recruited to this prospective cohort study. Dietetic interventions were recommended at baseline and reviewed at 3-month follow-up. Assessment of nutritional, functional and quality of life markers was measured using the Mini Nutritional Assessment (MNA), Timed Up and Go (TUG) and EQ-5D-5L, respectively, at baseline and after home-based dietetic intervention.

RESULTS

Participants (n = 99) were recruited from consecutive referrals. Participant's weight, body mass index (BMI), total daily energy and protein intake, MNA total score, and TUG significantly improved after a 3-month nutrition intervention (effect sizes 0.257, 0.257, 0.580, 0.533, 0.577 and 0.281, respectively). The most common interventions dietitians utilised were nutrition education, use of oral nutritional supplements (ONS) and meal fortification. In total, 339 dietetic interventions were recommended to participants at baseline with 197 (58.11%) implemented at 3 months, with meal planning and referral to other relevant allied health or Commonwealth Home Support Program (CHSP) services the most implemented interventions.

CONCLUSIONS

Home-based dietetic intervention improves nutritional status, functional status and quality of life in community-dwelling older adults referred for dietetic input. Improvements observed in nutritional and functional status were consistent with benchmarks of change from published literature.

Malnutrition, Functional Decline, and Institutionalization in Older Adults after Hospital Discharge Following Community-Acquired Pneumonia

BACKGROUND AND AIMS

Community-acquired pneumonia (CAP) is a major threat to older adults, but mid-term implications are poorly described. The aim was to analyze functional decline, institutionalization, malnutrition, and risk factors after hospital admission for CAP.

METHODS

This prospective observational study included patients over 65 years discharged after CAP between May 2019 and July 2021. We performed a comprehensive geriatric assessment and a general nutritional assessment 30-60 days after CAP. This included the MNA and blood test with trace elements and vitamins. The main outcomes were functional decline, institutionalization, and malnutrition. Multivariate logistic regression was used for the analyses.

RESULTS

In total, 144 patients of 77.15 ± 7.91 years, 55.6% male, and 9% previously institutionalized were analyzed. At hospital admission, the Charlson Comorbidity Index (CCI) was 1.5 ± 1.6, the Pneumonia Severity Index was 98.1 ± 25.9, and the previous Barthel Index (BI) was 93.06 ± 17.13. Hospital stay was 9.72 ± 7.88 days. After 44.6 ± 14.4 days, 48.6% patients showed functional decline and 19.4% were institutionalized. Age (OR 1.17; CI 95% 1.09-1.26), previous institutionalization (29.1; 3.7-224.7), BI (1.09; 1.05-1.14), CCI (1.5; 1.1-2.1), and length of stay (1.1, 1.02-1.18) were independently associated with functional decline. The only predictors of new institutionalization were previous BI (0.96; 0.93-0.99) and length of stay (1.06; 1.00-1.13). The MNA indicated malnutrition in 28% of the community-dwelling patients and 67.9% of those institutionalized, with risk of malnutrition being 45.7% and 9.5%, respectively, after an average of 44.6 days of CAP diagnosis. The predictors of malnutrition were previous institutionalization (10.62; 2.20-51.21), BI (0.95; 0.92-0.98), and length of stay (1.12; 1.04-1.20). Micronutrient deficiencies were mainly zinc (61.8%), vitamin D (54.5%), and vitamin C (45.1%). An MNA score < 17 points or hypoalbuminemia showed good specificity to identify these deficiencies.

CONCLUSIONS

After CAP admission, functional decline, institutionalization, and malnutrition rates were high. Longer hospital stay was a common risk factor for all outcomes. The presence of hypoalbuminemia or an MNA < 17 in older patients should prompt suspicion of deficiencies in micronutrients, such as vitamin D, C, and zinc.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Identifying and Managing Malnutrition, Frailty and Sarcopenia in the Community: A Narrative Review

Malnutrition, frailty and sarcopenia are becoming increasingly prevalent among community-dwelling older adults; yet are often unidentified and untreated in community settings. There is an urgent need for community-based healthcare professionals (HCPs) from all disciplines, including medicine, nursing and allied health, to be aware of, and to be able to recognise and appropriately manage these conditions. This paper provides a comprehensive overview of malnutrition, frailty and sarcopenia in the community, including their definitions, prevalence, impacts and causes/risk factors; and guidance on how these conditions may be identified and managed by HCPs in the community. A detailed description of the care process, including screening and referral, assessment and diagnosis, intervention, and monitoring and evaluation, relevant to the community context, is also provided. Further research exploring the barriers/enablers to delivering high-quality nutrition care to older community-dwelling adults who are malnourished, frail or sarcopenic is recommended, to inform the development of specific guidance for HCPs in identifying and managing these conditions in the community.

Consensus-Based Nutrition Care Pathways for Hospital-to-Community Transitions and Older Adults in Primary and Community Care

BACKGROUND

Practical guidance for providers on preventing, detecting, and treating malnutrition in primary care (PC) and the community is limited. The purpose of this study was to develop nutrition care pathways for adult patients (aged ≥18 years) transitioning from hospital to community and community-dwelling older adults (aged ≥65 years) who are at risk for malnutrition.

METHODS

A review of best-practice nutrition evidence and guidelines published between 2009 and 2019 was performed using PubMed and CINAHL. Findings were summarized into two draft care pathways by the Primary Care Working Group of the Canadian Malnutrition Task Force. Diverse stakeholders (n = 21) reviewed and suggested revisions at a 1-day meeting. Revisions were made and an online survey was conducted to determine the relevance and importance of discrete care practices, and to establish consensus for which practices should be retained in the pathways. Providers (e.g., dietitians, physicians, nurses; n = 291) across healthcare settings completed the survey. Consensus on relevance and importance of practices was set at ≥80%.

RESULTS

One hundred twenty-eight resources were identified and used to develop the draft pathways. Survey participants assigned ratings of ≥80% for relevance and importance for all nutrition care practices, except community service providers monitoring patient weight and appetite.

CONCLUSION

These evidence- and consensus-based nutrition pathways offer guidance to healthcare and service providers on how to deliver nutrition care during hospital-to-community transitions for malnourished adult patients and community-dwelling older adults at risk for malnutrition. These pathways are flexible for diverse PC and community models.

Trends and Novel Research in Hospital Nutrition Care: A Narrative Review of Leading Clinical Nutrition Journals

Hospital malnutrition is a longstanding problem that continues to be underrecognized and undertreated. The aim of this narrative review is to summarize novel, solution-focused, recent research or commentary to update providers on the prevention of iatrogenic malnutrition as well as the detection and treatment of hospital malnutrition. A narrative review was completed using the top 11 clinically relevant nutrition journals. Of the 13,850 articles and editorials published in these journals between 2013 and 2019, 511 were related to hospital malnutrition. A duplicate review was used to select (n = 108) and extract key findings from articles and editorials. Key criteria for selection were population of interest (adult hospital patients, no specific diagnostic group), solution-focused, and novel perspectives. Articles were categorized (6 classified in >1 category) as Screening and Assessment (n = 17), Standard (n = 25), Advanced (n = 12) and Specialized Nutrition Care (n = 8), Transitions (n = 15), Multicomponent (n = 21), Education and Empowerment (n = 9), Economic Impact (n = 3), and Guidelines (n = 4) for summarizing. Research advances in screening implementation, standard nutrition care, transitions, and multicomponent interventions provide new strategies to consider for malnutrition prevention (iatrogenic), detection, and care. However, several areas requiring further research were identified. Specifically, larger and more rigorous studies that examine health outcomes and economic analyses are urgently needed.

Age-friendly care for older adults within rural Australian health systems: An integrative review

OBJECTIVES

To identify the core elements of interventions and models that facilitate age-friendly care for older adults within rural Australian health systems, and assess the extent to which these align with core elements of the Institute for Health Improvement's (IHI) Age-Friendly Health Systems 4Ms Model.

METHODS

Peer-reviewed journal articles examining core elements of Australian rural geriatric care models were collected and analysed using an integrative review methodology.

RESULTS

Identified models and interventions addressed all four core elements of the IHI model-what matters, medications, mobility and mentation. There was more evidence relating to mobility and mentation, with lesser evidence relating to medications and what matters. A series of core elements not aligned with the model were also identified.

CONCLUSION

The IHI 4Ms Model appears to be applicable in the rural Australian context. More high-quality, systematic evidence is needed to investigate the core elements of age-friendly care across diverse rural contexts.

Dietary Assessment Methods in Military and Veteran Populations: A Scoping Review

Optimal dietary intake is important for the health and physical performance of military personnel. For military veterans, the complex nature of transition into civilian life and sub-optimal dietary intake is a leading contributor to the increased burden of disease. A scoping review was undertaken to determine what is known about the assessment and reporting of dietary intakes within both military and veteran populations. In addition, this review determines if studies reporting on the dietary intake of military personnel or veterans include comparisons with dietary guidelines. Six databases were searched to identify papers published from the database inception to April 2019. Observational and intervention studies were searched to identify if they assessed and reported whole dietary intake data, reported data exclusively for a military or veteran population, and included only healthy populations. A total of 89 studies were included. The majority of studies used one dietary assessment method (n = 76, 85%) with fewer using multiple methods (n = 13, 15%). The most frequent methodology used was food frequency questionnaires (FFQ) (n = 40, 45%) followed by 24-hour recalls (n = 8, 9%) and food records (n = 8, 9%). The main dietary outcomes reported were macronutrients: carbohydrate, protein, fat, and alcohol (n = 66, 74%) with total energy intake reported in n = 59 (66%). Fifty four (61%) studies reported a comparison with country-specific dietary guidelines and 14 (16%) reported a comparison with the country-specific military guidelines. In conclusion, dietary intake in military settings is most commonly assessed via FFQs and 24-hour recalls. Dietary intake reporting is mainly focused around intakes of energy and macronutrients. Most studies compare against dietary guidelines, however, comparison to specific military dietary guidelines is minimal.

Nutrition risk among an ethnically diverse sample of community-dwelling older adults

Objective

To assess the prevalence of nutritional risk among an ethnically diverse group of urban community-dwelling older adults and to explore if risk varied by race/ethnicity.

Design

Demographic characteristics, Katz’s activities of daily living and health-care resource utilization were ascertained cross-sectionally via telephone surveys with trained interviewers. Nutrition risk and nutrition symptomology were assessed via the abridged Patient Generated Subjective Global Assessment (abPG-SGA); scores of ≥6 points delineated ‘high’ nutrition risk. Descriptive statistics and logistic regression analyses were conducted.

Setting

Urban.

Participants

White, Black or Hispanic community-dwelling adults, ≥55 years of age, fluent in English or Spanish, residing in the city limits of Chicago, IL, USA.

Results

A total of 1001 participants (37 % white, 37 % Black, 26 % Hispanic) were surveyed. On average, participants were 66·9 years old, predominantly female and overweight/obese. Twenty-six per cent (n 263) of participants were classified as ‘high’ nutrition risk with 24, 14 and 31 % endorsing decreased oral intake, weight loss and compromised functioning, respectively. Black respondents constituted the greatest proportion of those with high risk scores, yet Hispanic participants displayed the most concerning nutrition risk profiles. Younger age, female sex, Black or Hispanic race/ethnicity, emergency room visits, eating alone and taking three or more different prescribed or over-the-counter drugs daily were significantly associated with high risk scores (P<0·05).

Conclusions

One in four older adults living in an urban community prone to health disparities was classified as ‘high’ nutrition risk. Targeted interventions to promote healthy ageing are needed, especially for overweight/obese and minority community members.

Nutrition Care after Discharge from Hospital: An Exploratory Analysis from the More-2-Eat Study

Many patients leave hospital in poor nutritional states, yet little is known about the post-discharge nutrition care in which patients are engaged. This study describes the nutrition-care activities 30-days post-discharge reported by patients and what covariates are associated with these activities. Quasi-randomly selected patients recruited from 5 medical units across Canada (n = 513) consented to 30-days post-discharge data collection with 48.5% (n = 249) completing the telephone interview. Use of nutrition care post-discharge was reported and bivariate analysis completed with relevant covariates for the two most frequently reported activities, following recommendations post-discharge or use of oral nutritional supplements (ONS). A total of 42% (n = 110) received nutrition recommendations at hospital discharge, with 65% (n = 71/110) of these participants following those recommendations; 26.5% (n = 66) were taking ONS after hospitalization. Participants who followed recommendations were more likely to report following a special diet (p = 0.002), different from before their hospitalization (p = 0.008), compared to those who received recommendations, but reported not following them. Patients taking ONS were more likely to be at nutrition risk (p < 0.0001), malnourished (p = 0.0006), taking ONS in hospital (p = 0.01), had a lower HGS (p = 0.0013; males only), and less likely to believe they were eating enough to meet their body’s needs (p = 0.005). This analysis provides new insights on nutrition-care post-discharge.