What does it cost to feed aged care residents in Australia?

The Impact of Food-Shaping Techniques on Nutrition, Mealtime Experiences, and Quality of Life for Older Adults in Aged Care Settings: A Systematic Review

OBJECTIVE

Food-shaping methods, particularly for texture-modified foods, present numerous opportunities to improve the visual appeal of food and potentially the nutrition of older people with dysphagia (swallowing difficulty). This review appraises and synthesizes the evidence on the use of food-shaping methods to enhance nutrition in older adults with swallowing difficulties.

METHODS

In August 2022, five electronic databases (PubMed, CINAHL, Scopus, Cochrane Library, and Web of Science) were searched for original research related to the intersection of nutrition, food shaping, and older adults with swallowing difficulties. Characteristics of included studies were described and data from results and findings extracted for analysis across studies.

RESULTS

Eighteen studies met the inclusion criteria and encompassed a variety of settings, including aged care settings (n = 15) and food science laboratories (n = 3). Qualitative and quantitative findings demonstrated a variety of impacts of food shaping for the older adult with swallowing difficulty, including enhanced nutrition and wellbeing. The content themes identified across studies were: links between food shaping and nutrition, shaping food for individual choice, food shaping for enjoyment, a combination of supporting factors, collaborative inter-disciplinary teams and roles, and implementation aligns with local contexts.

CONCLUSION

With recent growth in research on food shaping, the body of studies reviewed identified an influence of food-shaping methods on the nutritional status of older adults with swallowing difficulties. Given the identified potential benefit of food shaping and attention to the visual appeal of food for older people, further research examining links between food shaping and nutrition are warranted.

Costing Foodservices in Aged Care Is More Than Food Alone: The Development of the FCT

Foodservices in residential aged-care homes (RACHs) play a vital role in providing meals and maintaining residents’ health through good nutrition. However, foodservices are often required to work within a budget, and the costs involved in foodservices are often misunderstood and underestimated. The aim of this work was to design a costing tool that included all relevant costs of a foodservice. A systems approach was used to inform the development of the Foodservice Costing Tool (FCT). Eight domains were identified, including costs that are both directly and indirectly associated with foodservices. The tool was piloted and trialled in the Australian aged-care setting and compared to currently available national estimates of costs. Through four pilots and subsequent trials, the FCT was able to capture the costs of a foodservice system in a small sample of RACHs, although the low response rate may have biased the sample toward those homes that had fewer problems with the FCT. The results highlighted the limitations of currently reported estimates, which underestimate total costs, as they fail to encompass the complexity of foodservices and to recognise that costs extend beyond the kitchen. The FCT is a useful tool and has the potential to be used by RACHs to both measure and understand their costs at a more granular level to ensure cost effectiveness and accountability. Further research is required to validate the tool and investigate the implementation of the FCT on a larger scale.

Examining the Content and Outcomes of Training in Dysphagia and Mealtime Management: A Systematic Review Informing Co-Design of New Training

PURPOSE

Dysphagia (swallowing difficulty) impacts physical health, quality of life, and mealtime enjoyment. Staff who provide mealtime assistance to people with dysphagia require adequate training to help ensure that the mealtimes are safe and enjoyable. This systematic review examined literature relating to training in dysphagia (e.g., recognizing signs and symptoms) and mealtime assistance, its components, and benefits for people with dysphagia.

METHOD

In July 2020, five scientific databases were searched for papers meeting the inclusion criteria relating to mealtime assistance training. The quality of the studies was evaluated using the Quality Assessment Tool for Studies of Diverse Design, with scores ranging from 38.1% to 83.3%. We completed a qualitative synthesis using the data extracted from the included studies.

RESULTS

Twenty-four studies met the inclusion criteria. Participants in these studies benefited from both group training and one-on-one training. Training programs had many formats including computer-based, face-to-face, individual training, and group training. Each included study demonstrated some level of positive impact to the learners, such as improved knowledge and skills in mealtime management for people with dysphagia. No studies reported negative outcomes. Training duration ranged from 30 min to 5 days.

CONCLUSIONS

The benefits of different components of mealtime training (e.g., group training, or face-to-face training) for mealtime assistance for people with dysphagia were reviewed. Further research is needed to compare the effectiveness of different training formats, involving not only the assistant but also people with dysphagia as both trainers and trainees, and determine the health outcomes of training programs for people with dysphagia.

Can fortified, nutrient-dense and enriched foods and drink-based nutrition interventions increase energy and protein intake in residential aged care residents? A systematic review with meta-analyses

BACKGROUND

Food fortification as part of the food-first approach in nursing homes is a strategy that may increase energy and protein intake.

OBJECTIVES

This review aimed to determine the effect of nutrition interventions using fortification, nutrient-dense or enriched food and/or drinks on energy and protein intake in residents living in nursing homes, compared to the standard menu with or without oral nutritional support products. The secondary aim was to identify and synthesise outcomes of these interventions on weight change, nutritional status, acceptability, cost-effectiveness, and cost-benefit.

METHODS

A systematic search of seven databases was undertaken. After reviewing all titles/abstracts then full-text papers, key data were extracted and synthesised narratively and through meta-analysis. The quality of included studies was assessed using the Quality Criteria Checklist for Primary Research.

RESULTS

Of 3,098 articles retrieved, 16 were included, 13 in the meta-analysis. There were 891 participants, with the study duration ranging from four to 26 weeks. The groups receiving the fortified diet had a significantly higher energy intake (Hedges' g = 0.69 (CI 0.36-1.03), p < 0.0001) and protein intake (Hedges' g = 0.46 (CI 0.17-0.74), p = 0.003) compared with the groups receiving the standard menu +/- ONS. The meta-analysis revealed I² values of 77% for energy (p < 0.0001) and 60% for protein (p = 0.003), indicating considerable statistical heterogeneity across included studies. Benefits to weight and nutritional status of residents were recorded in some studies. Where reported, cost-effectiveness and cost-benefit of menu fortification/supplementation were variable.

CONCLUSIONS

This systematic review with meta-analyses has shown that fortified menus may significantly increase energy and protein intakes compared with standard menus in nursing homes. As such, the findings of this review support further use of fortified diets in this setting. Further research is warranted comparing food fortification to standard menus, with a particular focus on evaluating the effect on weight, nutritional status and cost-effectiveness of the intervention.

STUDY REGISTRATION

PROSPERO no. CRD42020162796.

Protein-energy malnutrition in older Australians: A narrative review of the prevalence, causes and consequences of malnutrition, and strategies for prevention

ISSUE ADDRESSED

Protein-energy malnutrition (PEM) is a condition of involuntary weight and muscle loss caused by inadequate nutritional intake. In Australia, it is predominantly associated with chronic diseases, as are common in the older population. Given the ageing population of Australia, and the poor outcomes associated with PEM, there is a need to identify the contributing factors, and to explore strategies to prevent PEM.

METHODS

Two databases were searched for pertinent keywords, including malnutrition, Australia and elderly, with relevant articles selected for inclusion. The citations and references of these articles were also searched for further articles.

RESULTS

PEM is associated with increasing age and institutionalisation. The contributing factors are multifactorial, and include physiological, pathophysiological and structural causes. PEM is a significant public health issue for Australia, in terms of its consequences on both quality of life for older adults, and the burden on the healthcare system. However, there are strategies that can be implemented at the community, organisation and policy level to prevent PEM.

CONCLUSION

PEM is a common problem for older Australians, and this has important physiological and public health consequences, especially in the context of the ageing Australian population. However, there is significant scope for preventing PEM. SO WHAT?: Readers can be advised that PEM is a significant public health issue that will increase in importance as the population continues to age. It is important that communities, organisations and governments develop strategies to prevent PEM.

An investigation of recommended serve food portions and attaining energy and protein requirements in older adults living in residential care

BACKGROUND

Ageing populations show a propensity for reduced food intake, which impacts nutritional adequacy. Nutrition guidelines for residential care homes (RCHs) are currently based on serve size of core food groups and do not consider nutrient density. The present study aimed to investigate the weight of foods served/consumed compared to recommended serve sizes and to compare energy and protein intake with individual requirements.

METHODS

This was an observational study of older adults living in four RCHs. Dietary intake was estimated through the difference between weighed reference meals and a single, double-weighed 24-h food plate waste collected from each participant. FoodWorks9^® (Xyris^® Software, Brisbane, Australia) was used to calculate energy, protein and serves of core food groups from food intake and the menu provided to recommended serve sizes. Individual intake was compared with nutrition guidelines and estimated energy and protein requirements.

RESULTS

Across 420 participants, 9.8% completed a main meal (lunch or dinner). The servings provided [248 g; interquartile range (IQR) = 206-290 g] were less than the recommended servings for a main meal (306 g = protein/starch/two vegetables), with 157 g (IQR = 109-221 g) consumed. The menu provided for minimum serves of all core food groups except for dairy. Median energy intake (n = 389) (5272 kJ day^-1 , IQR = 4229-6720 kJ) and protein intake (47.3 g day^-1 , IQR = 35.9-60.8 g) were less than estimated requirements (8181 kJ day^-1 , IQR = 7300-9338 kJ day^-1 ; 76.7 g day^-1 , IQR = 66.7-90.8 g).

CONCLUSIONS

Nutritional needs were not met in this cohort. The findings of the present study highlight the need for smaller, nutrient-dense meals and revised menu standards to ensure nutritional adequacy in this vulnerable population.

Measuring the prevalence of 60 health conditions in older Australians in residential aged care with electronic health records: a retrospective dynamic cohort study

BACKGROUND

The number of older Australians using aged care services is increasing, yet there is an absence of reliable data on their health. Multimorbidity in this population has not been well described. A clear picture of the health status of people using aged care is essential for informing health practice and policy to support evidence-based, equitable, high-quality care. Our objective was to describe the health status of older Australians living in residential aged care facilities (RACFs) and develop a model for monitoring health conditions using data from electronic health record systems.

METHODS

Using a dynamic retrospective cohort of 9436 RACF residents living in 68 RACFs in New South Wales and the Australian Capital Territory from 2014 to 2017, we developed an algorithm to identify residents' conditions using aged care funding assessments, medications administered, and clinical notes from their facility electronic health record (EHR). We generated age- and sex-specific prevalence estimates for 60 health conditions. Agreement between conditions recorded in aged care funding assessments and those documented in residents' EHRs was evaluated using Cohen's kappa. Cluster analysis was used to describe combinations of health conditions (multimorbidity) occurring among residents.

RESULTS

Using all data sources, 93% of residents had some form of circulatory disease, with hypertension the most common (62%). Most residents (93%) had a mental or behavioural disorder, including dementia (58%) or depression (54%). For most conditions, EHR data identified approximately twice the number of people with the condition compared to aged care funding assessments. Agreement between data sources was highest for multiple sclerosis, Huntington's disease, and dementia. The cluster analysis identified seven groups with distinct combinations of health conditions and demographic characteristics and found that the most complex cluster represented a group of residents that had on average the longest lengths of stay in residential care.

CONCLUSIONS

The prevalence of many health conditions among RACF residents in Australia is underestimated in previous reports. Aged care EHR data have the potential to be used to better understand the complex health needs of this vulnerable population and can help fill the information gaps needed for population health surveillance and quality monitoring.

Increasing the uptake of vitamin D supplement use in Australian residential aged care facilities: results from the vitamin D implementation (ViDAus) study

BACKGROUND

Adequate (≥800 IU/day) vitamin D supplement use in Australian residential aged care facilities (RACFs) is variable and non-optimal. The vitamin D implementation (ViDAus) study aimed to employ a range of strategies to support the uptake of this best practice in participating facilities. The aim of this paper is to report on facility level prevalence outcomes and factors associated with vitamin D supplement use.

METHODS

This trial followed a stepped wedge cluster, non-randomised design with 41 individual facilities serving as clusters pragmatically allocated into two wedges that commenced the intervention six months apart. This multifaceted, interdisciplinary knowledge translation intervention was led by a project officer, who worked with nominated champions at participating facilities to provide education and undertake quality improvement (QI) planning. Local barriers and responsive strategies were identified to engage stakeholders and promote widespread uptake of vitamin D supplement use.

RESULTS

This study found no significant difference in the change of vitamin D supplement use between the intervention (17 facilities with approx. 1500 residents) and control group (24 facilities with approx. 1900 residents) at six months (difference in prevalence change between groups was 1.10, 95% CI - 3.8 to 6.0, p = 0.6). The average overall facility change in adequate (≥800 IU/day) vitamin D supplement use over 12 months was 3.86% (95% CI 0.6 to 7.2, p = 0.02), which achieved a facility level average prevalence of 59.6%. The variation in uptake at 12 months ranged from 25 to 88% of residents at each facility. In terms of the types of strategies employed for implementation, there were no statistical differences between facilities that achieved a clinically meaningful improvement (≥10%) or a desired prevalence of vitamin D supplement use (80% of residents) compared to those that did not.

CONCLUSIONS

This work confirms the complex nature of implementation of best practice in the RACF setting and indicates that more needs to be done to ensure best practice is translated into action. Whilst some strategies appeared to be associated with better outcomes, the statistical insignificance of these findings and the overall limited impact of the intervention suggests that the role of broader organisational and governmental support for implementation should be investigated further.

TRIAL REGISTRATION

Retrospectively registered (ANZCTR ID: ACTRN12616000782437 ).

Does a High-Energy High-Protein Diet Reduce Unintentional Weight Loss in Residential Aged Care Residents?

Malnutrition and unintentional weight loss are known to occur in residential aged care facilities (RACFs). The use of oral nutritional supplements (ONS) and high-energy high-protein (HEHP) diets are two foodservice strategies that may be implemented in efforts to reduce unintentional weight loss in RACFs. This observational study aimed to determine whether incorporation of a structured high-energy high-protein diet (sHEHP) into the standard menu could reduce unintentional weight loss in RACF residents. RACFs in this study were facilities that provide long-term care to older adult residents. Weight change, body mass index and subjective global assessment scores of participants were measured at baseline and at six months across five RACFs receiving usual care with ONS or a sHEHP diet. Groups were different at baseline, with a high prevalence of severe malnutrition observed in the ONS group. Over the six-month period, there was a small but statistically significant difference in weight change within the groups: -1.64 ± 3.62 kg, ONS group; 0.56 ± 2.76 kg, sHEHP group, P = 0.0004. Both approaches investigated are feasible, however, future research using high-quality methods is needed to determine the most effective approach to deliver best practice nutrition care for residents into the future.

Home Enteral Nutrition in Singapore's Long-Term Care Homes-Incidence, Prevalence, Cost, and Staffing

Introduction: Data on home enteral nutrition (HEN) in long-term care facilities (LTCF) in Singapore is scarce. This study aims to determine the prevalence and incidence of chewing/swallowing impairment and HEN, and the manpower and costs related. Methods: A validated cross-sectional survey was sent to all 69 LTCFs in Singapore in May 2019. Local costs (S$) for manpower and feeds were used to tabulate the cost of HEN. Results: Nine LTCFs (13.0%) responded, with a combined 1879 beds and 240 residents on HEN. An incidence rate (IR) of 15.7 per 1000 people-years (PY) and a point prevalence (PP) of 136.6 per 1000 residents were determined for HEN, and an IR of 433.0 per 1000 PY, with PP of 385.6 per 1000 residents for chewing/swallowing impairment. Only 2.5% of residents had a percutaneous endoscopic gastrostomy (PEG). The mean length of residence in LTCF was 45.9 ± 12.3 months. More than half of the residents received nasogastric tube feeding (NGT) for ≥36 months. Median monthly HEN cost per resident was S$799.47 (interquartile range (IQR): 692.11, 940.30). Nursing costs for feeding contributed to 63% of total HEN costs. Conclusions: The high usage and length of time on NGT feeding warrants exploration and education of PEG usage. A national HEN database may improve the care of LTCF residents.

Improving the quality of life of aged care residents through the joy of food: The Lantern Project

OBJECTIVE

Mealtimes directly impact the quality of life of residents in aged care. The objective of The Lantern Project is to improve the dining experience of aged care residents to reduce malnutrition risk through improving dietary intake, meal.

METHODS

A transdisciplinary team of aged care professionals and resident advocates was formed as a collaboration collectively known as The Lantern Project.

RESULTS

This paper outlines the journey and timeline of The Lantern Project collaboration since its inception and the interplay between the monthly stakeholder meetings and inter-related research projects demonstrating improved outcomes.

CONCLUSION

Transdisciplinary collaboration offers well-grounded benefits and realistic strategies sensitive to the complexity of the aged care setting.

Altered Eating Attitudes in Nursing Home Residents and Its Relationship with their Cognitive and Nutritional Status

BACKGROUND

although eating disorders are usually linked to young adolescents, these mental disorders can also appear in the elderly, especially in those living in nursing homes, which might be associated or not with the cognitive decline; however, there are few data regarding elderly subjects.

OBJECTIVES

the objective of the present work was to evaluate the presence of abnormal eating attitudes in nursing home residents and its relation with several cognitive, nutritional and psychological factors that could be influencing their nutritional state.

DESIGN AND SETTING

a observational experimental study was carried out at several nursing homes of Murcia, Spain.

SUBJECTS

139 nursing home residents.

METHODS

EAT-26 test was used to screen classic eating disorders (anorexia and bulimia). Blandford's scale was employed to determine aversive eating attitudes. Moreover, subjective appetite sensations, body image perception, nutritional (MNA and diet composition) and biochemical data were also evaluated.

RESULTS

33% of the subjects had malnutrition. No subject showed symptoms of anorexia or bulimia; however, subjects with cognitive decline frequently showed aversive feeding behaviours (21.6%). Albumin values were significantly lower in subjects with cognitive impairment.

CONCLUSIONS

our data showed a clear relation between cognitive impairment and altered eating attitudes, which was reflected by both biochemical (albumin) and nutritional parameters, while no classic eating disorder was observed in residents with normal cognitive-status. These data confirm the need to strengthen our efforts towards maintaining the nutritional status of the subjects with cognitive impairment.