1
|
Volkert D, Beck AM, Faxén-Irving G, Frühwald T, Hooper L, Keller H, Porter J, Rothenberg E, Suominen M, Wirth R, Chourdakis M. ESPEN guideline on nutrition and hydration in dementia - Update 2024. Clin Nutr 2024; 43:1599-1626. [PMID: 38772068 DOI: 10.1016/j.clnu.2024.04.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 04/16/2024] [Accepted: 04/30/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND & AIMS Dementia is accompanied by a variety of changes that result in an increased risk of malnutrition and low-intake dehydration. This guideline update aims to give evidence-based recommendations for nutritional care of persons with dementia in order to prevent and treat these syndromes. METHODS The previous guideline version was reviewed and expanded in accordance with the standard operating procedure for ESPEN guidelines. Based on a systematic search in three databases, strength of evidence of appropriate literature was graded by use of the SIGN system. The original recommendations were reviewed and reformulated, and new recommendations were added, which all then underwent a consensus process. RESULTS 40 recommendations for nutritional care of older persons with dementia were developed and agreed, seven at institutional level and 33 at individual level. As a prerequisite for good nutritional care, organizations caring for persons with dementia are recommended to employ sufficient qualified staff and offer attractive food and drinks with choice in a functional and appealing environment. Nutritional care should be based on a written care concept with standardized operating procedures. At the individual level, routine screening for malnutrition and dehydration, nutritional assessment and close monitoring are unquestionable. Oral nutrition may be supported by eliminating potential causes of malnutrition and dehydration, and adequate social and nursing support (including assistance, utensils, training and oral care). Oral nutritional supplements are recommended to improve nutritional status but not to correct cognitive impairment or prevent cognitive decline. Routine use of dementia-specific ONS, ketogenic diet, omega-3 fatty acid supplementation and appetite stimulating agents is not recommended. Enteral and parenteral nutrition and hydration are temporary options in patients with mild or moderate dementia, but not in severe dementia or in the terminal phase of life. In all stages of the disease, supporting food and drink intake and maintaining or improving nutrition and hydration status requires an individualized, comprehensive approach. Due to a lack of appropriate studies, most recommendations are good practice points. CONCLUSION Nutritional care should be an integral part of dementia management. Numerous interventions are available that should be implemented in daily practice. Future high-quality studies are needed to clarify the evidence.
Collapse
Affiliation(s)
- Dorothee Volkert
- Institute for Biomedicine of Aging, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nuremberg, Germany.
| | - Anne Marie Beck
- Dietetic and Nutritional Research Unit, Herlev and Gentofte University Hospital, Herlev, Denmark
| | - Gerd Faxén-Irving
- Division of Clinical Geriatrics, Department of Neurobiology, Care Science and Society, Karolinska Institutet, Stockholm, Sweden
| | - Thomas Frühwald
- Department of Geriatric Acute Care, Hietzing Municipal Hospital, Vienna, Austria
| | - Lee Hooper
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Heather Keller
- Department of Kinesiology & Health Sciences, Faculty of Health, University of Waterloo, Waterloo, Canada; Schlegel-UW Research Institute for Aging, Waterloo, Canada
| | - Judi Porter
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, Australia
| | - Elisabet Rothenberg
- Department of Nursing and Integrated Health Sciences, Faculty of Health Sciences, Kristianstad University, Kristianstad, Sweden
| | - Merja Suominen
- Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland
| | - Rainer Wirth
- Department of Geriatric Medicine, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Michael Chourdakis
- School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| |
Collapse
|
2
|
So BPH, Lai DKH, Cheung DSK, Lam WK, Cheung JCW, Wong DWC. Virtual Reality-Based Immersive Rehabilitation for Cognitive- and Behavioral-Impairment-Related Eating Disorders: A VREHAB Framework Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19105821. [PMID: 35627357 PMCID: PMC9141870 DOI: 10.3390/ijerph19105821] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 05/07/2022] [Accepted: 05/09/2022] [Indexed: 11/16/2022]
Abstract
Virtual reality (VR) technology is one of the promising directions for rehabilitation, especially cognitive rehabilitation. Previous studies demonstrated successful rehabilitation in motor, cognitive, and sensorial functions using VR. The objective of this review is to summarize the current designs and evidence on immersive rehabilitation interventions using VR on cognitive- or behavioral-related eating disorders, which was mapped using a VREHAB framework. Two authors independently searched electronic databases, including PubMed, Web of Science, Scopus, CINAHL, EMBASE, and Cochrane Library. Ten (n = 10) articles were eligible for review. Treatments for anorexia nervosa and binge eating disorder/bulimia nervosa were reported through enhanced/experimental cognitive behavior therapy (ECT), cue exposure therapy (CET), and body exposure therapy (BET) via the virtual environment. Some studies reported that the VR effects were superior or comparable to traditional treatments, while the effects may last longer using VR technology. In addition, VR was perceived as acceptable and feasible among patients and therapists and could be valuable for supplementing existing therapies, relieving manpower and caregiver burdens. Future studies may consider incorporating haptic, smell, and biofeedback to improve the experience, and thus the effects of the treatments for the users.
Collapse
Affiliation(s)
- Bryan Pak-Hei So
- Department of Biomedical Engineering, Faculty of Engineering, The Hong Kong Polytechnic University, Hong Kong 999077, China;
| | - Derek Ka-Hei Lai
- Department of Computing, Faculty of Engineering, The Hong Kong Polytechnic University, Hong Kong 999077, China;
| | - Daphne Sze-Ki Cheung
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong 999077, China;
- Research Institute of Smart Ageing, The Hong Kong Polytechnic University, Hong Kong 999077, China
- Centre for Gerontological Nursing, School of Nursing, The Hong Kong Polytechnic University, Hong Kong 999077, China
| | - Wing-Kai Lam
- Sports Information and External Affairs Centre, Hong Kong Sports Institute, Hong Kong 999077, China;
| | - James Chung-Wai Cheung
- Department of Biomedical Engineering, Faculty of Engineering, The Hong Kong Polytechnic University, Hong Kong 999077, China;
- Research Institute of Smart Ageing, The Hong Kong Polytechnic University, Hong Kong 999077, China
- Correspondence: (J.C.-W.C.); (D.W.-C.W.); Tel.: +852-2766-7673 (J.C.-W.C.); +852-2766-7669 (D.W.-C.W.)
| | - Duo Wai-Chi Wong
- Department of Biomedical Engineering, Faculty of Engineering, The Hong Kong Polytechnic University, Hong Kong 999077, China;
- Correspondence: (J.C.-W.C.); (D.W.-C.W.); Tel.: +852-2766-7673 (J.C.-W.C.); +852-2766-7669 (D.W.-C.W.)
| |
Collapse
|
3
|
Effects of oral nutrition supplements in persons with dementia: A systematic review. Geriatr Nurs 2021; 42:117-123. [PMID: 33383439 DOI: 10.1016/j.gerinurse.2020.12.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 11/30/2020] [Accepted: 12/02/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Persons with dementia are at risk of malnutrition, evidenced by low dietary intake, which has consequences for nutritional status, activity of daily living and disease progression. The effects of oral nutrition supplements (ONS) on nutritional intake, nutritional status, and cognitive and physical outcomes in older persons with dementia were evaluated. METHODS PubMed, Medline, Embase, CINAHL and the Cochrane Central Register of Controlled Trials were searched in December 2017, and this was repeated in May 2019. The Preferred Reporting Items for Systematic Reviews and Analysis (PRISMA) checklist was used. Papers were considered if they presented experimental clinical trials using oral nutritional supplements to persons diagnosed with dementia, including Alzheimer's disease and mild cognitive impairment, and conducted in hospitals, nursing homes or homes. RESULTS We included ten articles reporting nine clinical trials. A total of 407 persons with dementia were included, of whom 228 used ONS for 7 to 180 days. Nutritional intake improved by 201 to 600 kcal/day. Energy intake from ordinary foods was not affected, thus ONS improved the persons daily intake of energy and protein. Body weight, muscle mass, and nutritional biomarkers in blood improved in the intervention groups compared with the control groups. No effects on cognition or physical outcomes were observed. CONCLUSION ONS increases the intake of energy and protein and improves nutritional status in persons with dementia; however, RCTs with longer intervention periods are needed to investigate the impact on cognitive and functional outcomes.
Collapse
|
4
|
Efficacy of Mealtime Interventions for Malnutrition and Oral Intake in Persons With Dementia: A Systematic Review. Alzheimer Dis Assoc Disord 2020; 34:366-379. [PMID: 32530831 DOI: 10.1097/wad.0000000000000387] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Malnutrition and weight loss are highly prevalent in persons with Alzheimer's disease and related dementias. Oral intake is an important interventional target for addressing these nutritional consequences. However, the efficacy of interventions remains poorly understood as prior syntheses have failed to examine the impact of intervention approaches on malnutrition and hypothesized mechanisms of action in persons with dementia. This review aimed to determine the efficacy of mealtime interventions to improve oral intake and nutritional outcomes in persons with dementia. Four databases yielded 1712 studies, resulting in 32 studies that met inclusion criteria. Studies included education, environmental modifications, feeding, oral supplementation, and other pharmacologic/ecopsychological interventions. While the majority of studies reported statistically significant improvements in at least 1 nutritional outcome, study design and outcome measures were heterogenous with many lacking adequate statistical power or blinding. Collectively, we found moderate evidence to suggest the efficacy of oral supplementation, and preliminary evidence to suggest that feeding interventions, education, and environmental modifications may confer improvements. Findings clarify the state of existing evidence regarding various interventional strategies for improving malnutrition in persons with dementia. While some approaches are promising, adequately powered and rigorously designed multidimensional intervention trials are needed to inform clinical decision-making in real-world contexts.
Collapse
|
5
|
Bianchi VE, Herrera PF, Laura R. Effect of nutrition on neurodegenerative diseases. A systematic review. Nutr Neurosci 2019; 24:810-834. [PMID: 31684843 DOI: 10.1080/1028415x.2019.1681088] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Neurodegenerative diseases are characterized by the progressive functional loss of neurons in the brain, causing cognitive impairment and motoneuron disability. Although multifactorial interactions are evident, nutrition plays an essential role in the pathogenesis and evolution of these diseases. A systematic literature search was performed, and the prevalence of studies evaluated the effect of the Mediterranean diet (MeDiet), nutritional support, EPA and DHA, and vitamins on memory and cognition impairment. The data showed that malnutrition and low body mass index (BMI) is correlated with the higher development of dementia and mortality. MeDiet, nutritional support, and calorie-controlled diets play a protective effect against cognitive decline, Alzheimer's disease (AD), Parkinson disease (PD) while malnutrition and insulin resistance represent significant risk factors. Malnutrition activates also the gut-microbiota-brain axis dysfunction that exacerbate neurogenerative process. Omega-3 and -6, and the vitamins supplementation seem to be less effective in protecting neuron degeneration. Insulin activity is a prevalent factor contributing to brain health while malnutrition correlated with the higher development of dementia and mortality.
Collapse
Affiliation(s)
| | - Pomares Fredy Herrera
- Director del Centro de Telemedicina, Grupo de investigación en Atención Primaria en salud/Telesalud, Doctorado en Medicina /Neurociencias, University of Cartagena, Colombia
| | - Rizzi Laura
- Molecular Biology, School of Medicine and Surgery, University of Milano-Bicocca, Monza Brianza, Italy
| |
Collapse
|
6
|
Donaldson AIC, Smith TO, Alder S, Johnstone AM, De Roos B, Aucott LS, Gordon AL, Myint PK. Effect of nonmeat, high-protein supplementation on quality of life and clinical outcomes in older residents of care homes: a systematic review and meta-analysis. Nutr Rev 2018; 77:116-127. [DOI: 10.1093/nutrit/nuy061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Alison I C Donaldson
- Ageing Clinical & Experimental Research (ACER) Team, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom
- Academic Department of Medicine for the Elderly, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, United Kingdom
| | - Toby O Smith
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Sarah Alder
- Academic Department of Medicine for the Elderly, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, United Kingdom
| | - Alexandra M Johnstone
- Rowett Institute of Nutrition and Health, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom
| | - Baukje De Roos
- Rowett Institute of Nutrition and Health, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom
| | - Lorna S Aucott
- Medical Statistics Group, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom
| | - Adam L Gordon
- Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Phyo K Myint
- Ageing Clinical & Experimental Research (ACER) Team, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom
- Academic Department of Medicine for the Elderly, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, United Kingdom
| |
Collapse
|
7
|
Prizer LP, Zimmerman S. Progressive Support for Activities of Daily Living for Persons Living With Dementia. THE GERONTOLOGIST 2018; 58:S74-S87. [PMID: 29361063 DOI: 10.1093/geront/gnx103] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Indexed: 11/13/2022] Open
Abstract
Background and Objectives Dementia is accompanied by increasing need for support in activities of daily living (ADLs). This brief report/literature review summarizes the practices to care for early stage, middle stage, and late stage ADL needs (dressing, toileting, and eating/nutrition), and examines commonalities across ADL needs and the extent to which practices are reflected in guidelines and/or evidence. Research Design and Methods A review of the grey and peer-reviewed literature, using some but not all procedures of a systematic review. Key terms were identified for ADLs overall and for each of the 3 ADLs, and a search was conducted using these words in combination with (a) dementia, Alzheimer's disease, and similar terms, and (b) practices, interventions, guidelines, recommendations, and similar terms. Searches were conducted using databases of peer-reviewed literature as well as the Grey Literature Reports and Google search engine. Sources were included if they provided evidence or recommendations on interventions to address ADL functioning for dressing, toileting, and feeding for persons living with dementia. Results As cognitive and functional impairment increases, the number of care practices and themes that embody care practices increases. The majority of practices are evidence-based, and most evidence is incorporated into guidelines. Discussion and Implications Virtually all practices reflect person-centered care principles. Five recommendations summarize the evidence and recommendations related to providing support to persons living with dementia in relation to dressing, toileting, and eating/nutrition.
Collapse
Affiliation(s)
- Lindsay P Prizer
- Division of General Medicine & Geriatrics, Emory University School of Medicine, Atlanta, Georgia.,Atlanta VA Medical Center, Veterans Affairs Administration, Decatur, Georgia
| | - Sheryl Zimmerman
- Cecil G. Sheps Center for Health Services Research and the School of Social Work, The University of North Carolina at Chapel Hill
| |
Collapse
|
8
|
Herke M, Fink A, Langer G, Wustmann T, Watzke S, Hanff A, Burckhardt M. Environmental and behavioural modifications for improving food and fluid intake in people with dementia. Cochrane Database Syst Rev 2018; 7:CD011542. [PMID: 30021248 PMCID: PMC6513567 DOI: 10.1002/14651858.cd011542.pub2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Weight loss, malnutrition and dehydration are common problems for people with dementia. Environmental modifications such as, change of routine, context or ambience at mealtimes, or behavioural modifications, such as education or training of people with dementia or caregivers, may be considered to try to improve food and fluid intake and nutritional status of people with dementia. OBJECTIVES Primary: To assess the effects of environmental or behavioural modifications on food and fluid intake and nutritional status in people with dementia. Secondary: To assess the effects of environmental or behavioural modifications in connection with nutrition on mealtime behaviour, cognitive and functional outcomes and quality of life, in specific settings (i.e. home care, residential care and nursing home care) for different stages of dementia. To assess the adverse consequences or effects of the included interventions. SEARCH METHODS We searched the Specialized Register of Cochrane Dementia and Cognitive Improvement (ALOIS), MEDLINE, Eembase, PsycINFO, CINAHL, ClinicalTrials.gov and the World Health Organization (WHO) portal/ICTRP on 17 January 2018. We scanned reference lists of other reviews and of included articles. SELECTION CRITERIA We included randomised controlled trials (RCTs) investigating interventions designed to modify the mealtime environment of people with dementia, to modify the mealtime behaviour of people with dementia or their caregivers, or both, with the intention of improving food and fluid intake. We included people with any common dementia subtype. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies, extracted data and assessed the risk of bias of included trials. We assessed the quality of evidence for each outcome using the GRADE approach. MAIN RESULTS We included nine studies, investigating 1502 people. Three studies explicitly investigated participants with Alzheimer's disease; six did not specify the type of dementia. Five studies provided clear measures to identify the severity of dementia at baseline, and overall very mild to severe stages were covered. The interventions and outcome measures were diverse. The overall quality of evidence was mainly low to very low.One study implemented environmental as well as behavioural modifications by providing additional food items between meals and personal encouragement to consume them. The control group received no intervention. Differences between groups were very small and the quality of the evidence from this study was very low, so we are very uncertain of any effect of this intervention.The remaining eight studies implemented behavioural modifications.Three studies provided nutritional education and nutrition promotion programmes. Control groups did not receive these programmes. After 12 months, the intervention group showed slightly higher protein intake per day (mean difference (MD) 0.11 g/kg, 95% confidence interval (CI) -0.01 to 0.23; n = 78, 1 study; low-quality evidence), but there was no clear evidence of a difference in nutritional status assessed with body mass index (BMI) (MD -0.26 kg/m² favouring control, 95% CI -0.70 to 0.19; n = 734, 2 studies; moderate-quality evidence), body weight (MD -1.60 kg favouring control, 95% CI -3.47 to 0.27; n = 656, 1 study; moderate-quality evidence), or score on Mini Nutritional Assessment (MNA) (MD -0.10 favouring control, 95% CI -0.67 to 0.47; n = 656, 1 study; low-quality evidence). After six months, the intervention group in one study had slightly lower BMI (MD -1.79 kg/m² favouring control, 95% CI -1.28 to -2.30; n = 52, 1 study; moderate-quality evidence) and body weight (MD -8.11 kg favouring control, 95% CI -2.06 to -12.56; n = 52, 1 study; moderate-quality evidence). This type of intervention may have a small positive effect on food intake, but little or no effect, or a negative effect, on nutritional status.Two studies compared self-feeding skills training programmes. In one study, the control group received no training and in the other study the control group received a different self-feeding skills training programme. For both comparisons the quality of the evidence was very low and we are very uncertain whether these interventions have any effect.One study investigated general training of nurses to impart knowledge on how to feed people with dementia and improve attitudes towards people with dementia. Again, the quality of the evidence was very low so that we cannot be certain of any effect.Two studies investigated vocal or tactile positive feedback provided by caregivers while feeding participants. After three weeks, the intervention group showed an increase in calories consumed per meal (MD 200 kcal, 95% CI 119.81 to 280.19; n = 42, 1 study; low-quality evidence) and protein consumed per meal (MD 15g, 95% CI 7.74 to 22.26; n = 42, 1 study; low-quality evidence). This intervention may increase the intake of food and liquids slightly; nutritional status was not assessed. AUTHORS' CONCLUSIONS Due to the quantity and quality of the evidence currently available, we cannot identify any specific environmental or behavioural modifications for improving food and fluid intake in people with dementia.
Collapse
Affiliation(s)
- Max Herke
- Martin Luther University Halle‐WittenbergInstitute for Medical SociologyMagdeburger Str. 8Halle (Saale)Germany06112
| | - Astrid Fink
- Martin Luther University Halle‐WittenbergInstitute for Medical SociologyMagdeburger Str. 8Halle (Saale)Germany06112
| | - Gero Langer
- Martin Luther University Halle‐WittenbergInstitute of Health and Nursing SciencesMagdeburger Strasse 8Halle (Saale)Germany06112
| | - Tobias Wustmann
- Martin Luther University Halle‐WittenbergDepartment of Psychiatry, Psychotherapy and PsychosomaticsJulius Kühn Strasse 7Halle (Saale)Germany06112
| | - Stefan Watzke
- Martin Luther University Halle‐WittenbergDepartment of Psychiatry, Psychotherapy and PsychosomaticsJulius Kühn Strasse 7Halle (Saale)Germany06112
| | | | - Marion Burckhardt
- Martin Luther University Halle‐WittenbergInstitute of Health and Nursing SciencesMagdeburger Strasse 8Halle (Saale)Germany06112
| | | |
Collapse
|
9
|
Pivi GAK, Vieira NMDA, da Ponte JB, de Moraes DSC, Bertolucci PHF. Nutritional management for Alzheimer’s disease in all stages: mild, moderate, and severe. ACTA ACUST UNITED AC 2017. [DOI: 10.1186/s41110-016-0025-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
|
10
|
Baldwin C, Kimber KL, Gibbs M, Weekes CE. Supportive interventions for enhancing dietary intake in malnourished or nutritionally at-risk adults. Cochrane Database Syst Rev 2016; 12:CD009840. [PMID: 27996085 PMCID: PMC6463805 DOI: 10.1002/14651858.cd009840.pub2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Supportive interventions such as serving meals in a dining room environment or the use of assistants to feed patients are frequently recommended for the management of nutritionally vulnerable groups. Such interventions are included in many policy and guideline documents and have implications for staff time but may incur additional costs, yet there appears to be a lack of evidence for their efficacy. OBJECTIVES To assess the effects of supportive interventions for enhancing dietary intake in malnourished or nutritionally at-risk adults. SEARCH METHODS We identified publications from comprehensive searches of the Cochrane Library, MEDLINE, Embase, AMED, British Nursing Index, CINAHL, SCOPUS, ISI Web of Science databases, scrutiny of the reference lists of included trials and related systematic reviews and handsearching the abstracts of relevant meetings. The date of the last search for all databases was 31 March 2013. Additional searches of CENTRAL, MEDLINE, ClinicalTrials.gov and WHO ICTRP were undertaken to September 2016. The date of the last search for these databases was 14 September 2016. SELECTION CRITERIA Randomised controlled trials of supportive interventions given with the aim of enhancing dietary intake in nutritionally vulnerable adults compared with usual care. DATA COLLECTION AND ANALYSIS Three review authors and for the final search, the editor, selected trials from titles and abstracts and independently assessed eligibility of selected trials. Two review authors independently extracted data and assessed risk of bias, as well as evaluating overall quality of the evidence utilising the GRADE instrument, and then agreed as they entered data into the review. The likelihood of clinical heterogeneity amongst trials was judged to be high as trials were in populations with widely different clinical backgrounds, conducted in different healthcare settings and despite some grouping of similar interventions, involved interventions that varied considerably. We were only able, therefore, to conduct meta-analyses for the outcome measures, 'all-cause mortality', 'hospitalisation' and 'nutritional status (weight change)'. MAIN RESULTS Forty-one trials (10,681 participants) met the inclusion criteria. Trials were grouped according to similar interventions (changes to organisation of nutritional care (N = 13; 3456 participants), changes to the feeding environment (N = 5; 351 participants), modification of meal profile or pattern (N = 12; 649 participants), additional supplementation of meals (N = 10; 6022 participants) and home meal delivery systems (N = 1; 203 participants). Follow-up ranged from 'duration of hospital stay' to 12 months.The overall quality of evidence was moderate to very low, with the majority of trials judged to be at an unclear risk of bias in several risk of bias domains. The risk ratio (RR) for all-cause mortality was 0.78 (95% confidence interval (CI) 0.66 to 0.92); P = 0.004; 12 trials; 6683 participants; moderate-quality evidence. This translates into 26 (95% CI 9 to 41) fewer cases of death per 1000 participants in favour of supportive interventions. The RR for number of participants with any medical complication ranged from 1.42 in favour of control compared with 0.59 in favour of supportive interventions (very low-quality evidence). Only five trials (4451 participants) investigated health-related quality of life showing no substantial differences between intervention and comparator groups. Information on patient satisfaction was unreliable. The effects of supportive interventions versus comparators on hospitalisation showed a mean difference (MD) of -0.5 days (95% CI -2.6 to 1.6); P = 0.65; 5 trials; 667 participants; very low-quality evidence. Only three of 41 included trials (4108 participants; very low-quality evidence) reported on adverse events, describing intolerance to the supplement (diarrhoea, vomiting; 5/34 participants) and discontinuation of oral nutritional supplements because of refusal or dislike of taste (567/2017 participants). Meta-analysis across 17 trials with adequate data on weight change revealed an overall improvement in weight in favour of supportive interventions versus control: MD 0.6 kg (95% CI 0.21 to 1.02); 2024 participants; moderate-quality evidence. A total of 27 trials investigated nutritional intake with a majority of trials not finding marked differences in energy intake between intervention and comparator groups. Only three trials (1152 participants) reported some data on economic costs but did not use accepted health economic methods (very low-quality evidence). AUTHORS' CONCLUSIONS There is evidence of moderate to very low quality to suggest that supportive interventions to improve nutritional care results in minimal weight gain. Most of the evidence for the lower risk of all-cause mortality for supportive interventions comes from hospital-based trials and more research is needed to confirm this effect. There is very low-quality evidence regarding adverse effects; therefore whilst some of these interventions are advocated at a national level clinicians should recognise the lack of clear evidence to support their role. This review highlights the importance of assessing patient-important outcomes in future research.
Collapse
Affiliation(s)
- Christine Baldwin
- King's College LondonDiabetes & Nutritional Sciences Division, School of MedicineFranklin Wilkins Building150 Stamford StreetLondonUKSE1 9NH
| | - Katherine L Kimber
- School of Medicine, King's College LondonDiabetes & Nutritional Sciences DivisionFranklin Wilkin’s Building, Stamford StreetLondonUKSE1 9NH
| | - Michelle Gibbs
- King's College LondonDiabetes & Nutritional Sciences Division, School of MedicineFranklin Wilkins Building150 Stamford StreetLondonUKSE1 9NH
| | - Christine Elizabeth Weekes
- Guy's & St Thomas NHS Foundation TrustDepartment of Nutrition & DieteticsLambeth Palace RoadLondonUKSE1 7EH
| | | |
Collapse
|
11
|
Abdelhamid A, Bunn D, Copley M, Cowap V, Dickinson A, Gray L, Howe A, Killett A, Lee J, Li F, Poland F, Potter J, Richardson K, Smithard D, Fox C, Hooper L. Effectiveness of interventions to directly support food and drink intake in people with dementia: systematic review and meta-analysis. BMC Geriatr 2016; 16:26. [PMID: 26801619 PMCID: PMC4722767 DOI: 10.1186/s12877-016-0196-3] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Accepted: 01/12/2016] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Eating and drinking difficulties are recognised sources of ill health in people with dementia. In the EDWINA (Eating and Drinking Well IN dementiA) systematic review we aimed to assess effectiveness of interventions to directly improve, maintain or facilitate oral food and drink intake, nutrition and hydration status, in people with cognitive impairment or dementia (across all settings, levels of care and support, types and degrees of dementia). Interventions included oral nutrition supplementation, food modification, dysphagia management, eating assistance and supporting the social element of eating and drinking. METHODS We comprehensively searched 13 databases for relevant intervention studies. The review was conducted with service user input in accordance with Cochrane Collaboration's guidelines. We duplicated assessment of inclusion, data extraction, and validity assessment, tabulating data, carrying out random effects meta-analysis and narrative synthesis. RESULTS Forty-three controlled interventions were included, disappointingly none were judged at low risk of bias. Oral nutritional supplementation studies suggested small positive short term but unclear long term effects on nutritional status. Food modification or dysphagia management studies were smaller and of low quality, providing little evidence of an improved nutritional status. Eating assistance studies provided inconsistent evidence, but studies with a strong social element around eating/drinking, although small and of low quality provided consistent suggestion of improvements in aspects of quality of life. There were few data to address stakeholders' questions. CONCLUSIONS We found no definitive evidence on effectiveness, or lack of effectiveness, of specific interventions but studies were small and short term. People with cognitive impairment and their carers have to tackle eating problems despite this lack of evidence, so promising interventions are listed. The need remains for high quality trials tailored for people with cognitive impairment assessing robust outcomes. SYSTEMATIC REVIEW REGISTRATION The systematic review protocol was registered (CRD42014007611) and is published, with the full MEDLINE search strategy, on Prospero.
Collapse
Affiliation(s)
- Asmaa Abdelhamid
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norfolk, NR4 7TJ, UK.
- Present address: Royal College of Paediatrics and Child Health, 5-11 Theobalds Road, London, WC1X 8SH, UK.
| | - Diane Bunn
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norfolk, NR4 7TJ, UK.
| | - Maddie Copley
- Age UK Norfolk, 300 St Faith's Road, Old Catton, Norwich, NR6 7BJ, UK.
| | - Vicky Cowap
- NorseCare, Lancaster House 16 Central Avenue St Andrew's Business Park, Norwich, NR7 0HR, UK.
| | - Angela Dickinson
- School of Health and Social Work, University of Hertfordshire, Hatfield, Hertfordshire, AL10 9AB, UK.
| | - Lucy Gray
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norfolk, NR4 7TJ, UK.
| | - Amanda Howe
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norfolk, NR4 7TJ, UK.
| | - Anne Killett
- School of Health Sciences, University of East Anglia, Norwich Research Park, Norfolk, NR4 7TJ, UK.
| | - Jin Lee
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norfolk, NR4 7TJ, UK.
| | - Francesca Li
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norfolk, NR4 7TJ, UK.
| | - Fiona Poland
- School of Health Sciences, University of East Anglia, Norwich Research Park, Norfolk, NR4 7TJ, UK.
| | - John Potter
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norfolk, NR4 7TJ, UK.
- Norfolk and Norwich University Hospital, Colney Lane, Norwich, NR4 7UY, UK.
| | - Kate Richardson
- Norfolk and Norwich University Hospital, Colney Lane, Norwich, NR4 7UY, UK.
| | - David Smithard
- King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK.
| | - Chris Fox
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norfolk, NR4 7TJ, UK.
- Norfolk and Suffolk NHS Foundation Trust, Hellesdon Hospital, Drayton High Road, Norwich, NR6 5BE, UK.
| | - Lee Hooper
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norfolk, NR4 7TJ, UK.
| |
Collapse
|
12
|
Simmons SF, Keeler E, An R, Liu X, Shotwell MS, Kuertz B, Silver HJ, Schnelle JF. Cost-Effectiveness of Nutrition Intervention in Long-Term Care. J Am Geriatr Soc 2015; 63:2308-16. [PMID: 26503137 DOI: 10.1111/jgs.13709] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To determine the cost-effectiveness of two nutrition interventions on food, beverage, and supplement intake and body weight. DESIGN Randomized, controlled trial. SETTING Five skilled nursing home facilities. PARTICIPANTS Long-stay residents with orders for nutrition supplementation (N = 154). INTERVENTION Participants were randomized into a usual care control group, an oral liquid nutrition supplement (ONS) intervention group, or a snack intervention group. Research staff provided ONS, according to orders or a variety of snack foods and beverages twice per day between meals, 5 days per week for 24 weeks and assistance to promote consumption. MEASUREMENTS Research staff independently weighed residents at baseline and monthly during the 24-week intervention. Resident food, beverage and supplement intake and the amount of staff time spent providing assistance were assessed for 2 days at baseline and 2 days per month during the intervention using standardized observation and weighed intake procedures. RESULTS The ONS intervention group took in an average of 265 calories more per day and the snack intervention group an average of 303 calories more per day than the control group. Staff time required to provide each intervention averaged 11 and 14 minutes per person per offer for ONS and snacks, respectively, and 3 minutes for usual care. Both interventions were cost-effective in increasing caloric intake, but neither intervention had a significant effect on body weight, despite positive trends. CONCLUSION Oral liquid nutrition supplements and snack offers were efficacious in promoting caloric intake when coupled with assistance to promote consumption and a variety of options, but neither intervention resulted in significant weight gain.
Collapse
Affiliation(s)
- Sandra F Simmons
- Center for Quality Aging, Division of Geriatrics, Vanderbilt University, Nashville, Tennessee.,Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Nashville, Tennessee
| | - Emmett Keeler
- Rand Corporation, Santa Monica, California.,Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Champaign, Illinois
| | - Ruopeng An
- Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Champaign, Illinois
| | - Xulei Liu
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee
| | - Matthew S Shotwell
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee
| | - Brittany Kuertz
- Center for Quality Aging, Division of Geriatrics, Vanderbilt University, Nashville, Tennessee
| | - Heidi J Silver
- Division of Gastroenterology, Hepatology and Nutrition, School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - John F Schnelle
- Center for Quality Aging, Division of Geriatrics, Vanderbilt University, Nashville, Tennessee.,Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Nashville, Tennessee
| |
Collapse
|
13
|
Volkert D, Chourdakis M, Faxen-Irving G, Frühwald T, Landi F, Suominen MH, Vandewoude M, Wirth R, Schneider SM. ESPEN guidelines on nutrition in dementia. Clin Nutr 2015; 34:1052-73. [PMID: 26522922 DOI: 10.1016/j.clnu.2015.09.004] [Citation(s) in RCA: 221] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 09/10/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND Older people suffering from dementia are at increased risk of malnutrition due to various nutritional problems, and the question arises which interventions are effective in maintaining adequate nutritional intake and nutritional status in the course of the disease. It is of further interest whether supplementation of energy and/or specific nutrients is able to prevent further cognitive decline or even correct cognitive impairment, and in which situations artificial nutritional support is justified. OBJECTIVE It is the purpose of these guidelines to cover these issues with evidence-based recommendations. METHODS The guidelines were developed by an international multidisciplinary working group in accordance with officially accepted standards. The GRADE system was used for assigning strength of evidence. Recommendations were discussed, submitted to Delphi rounds and accepted in an online survey among ESPEN members. RESULTS 26 recommendations for nutritional care of older persons with dementia are given. In every person with dementia, screening for malnutrition and close monitoring of body weight are recommended. In all stages of the disease, oral nutrition may be supported by provision of adequate, attractive food in a pleasant environment, by adequate nursing support and elimination of potential causes of malnutrition. Supplementation of single nutrients is not recommended unless there is a sign of deficiency. Oral nutritional supplements are recommended to improve nutritional status but not to correct cognitive impairment or prevent cognitive decline. Artificial nutrition is suggested in patients with mild or moderate dementia for a limited period of time to overcome a crisis situation with markedly insufficient oral intake, if low nutritional intake is predominantly caused by a potentially reversible condition, but not in patients with severe dementia or in the terminal phase of life. CONCLUSION Nutritional care and support should be an integral part of dementia management. In all stages of the disease, the decision for or against nutritional interventions should be made on an individual basis after carefully balancing expected benefit and potential burden, taking the (assumed) patient will and general prognosis into account.
Collapse
Affiliation(s)
- Dorothee Volkert
- Institute for Biomedicine of Aging (IBA), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Nuremberg, Germany.
| | - Michael Chourdakis
- Department of Medicine, Aristotle University of Thessaloniki (AUTH), Greece
| | - Gerd Faxen-Irving
- Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Thomas Frühwald
- Department of Geriatric Acute Care, Krankenhaus Hietzing, Vienna, Austria
| | - Francesco Landi
- Department of Geriatrics, Neurosciences and Orthopedics, Catholic University of the Sacred Heart, Rome, Italy
| | - Merja H Suominen
- Unit of Primary Health Care, Helsinki University Central Hospital, Helsinki, Finland
| | - Maurits Vandewoude
- Department of Geriatrics, Medical School, University of Antwerp, Belgium
| | - Rainer Wirth
- Institute for Biomedicine of Aging (IBA), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Nuremberg, Germany; St. Marien-Hospital Borken, Department for Internal Medicine and Geriatrics, Borken, Germany
| | - Stéphane M Schneider
- Nutritional Support Unit, Centre Hospitalier Universitaire de Nice, Nice, France
| |
Collapse
|
14
|
Daradkeh G, Essa MM, Al-Adawi SS, Koshy RP, Al-Asmi A, Waly MI. Nutritional status and cognitive impairment in elderly. Pak J Biol Sci 2014; 17:1098-1105. [PMID: 26027153 DOI: 10.3923/pjbs.2014.1098.1105] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The elderly population is increasing worldwide and it has been suggested that senior citizens will continue to constitute the bulk of the population in many countries. Nutritional status of senior citizens are adversely affected by their frailty, chronic condition and declining cognitive functioning. Conversely, malnourished elderly further deteriorate their frailty, chronic disease and cognitive functioning. The aim of this review article is to recognize the importance of nutritional assessment of elderly population particularly those with cognitive impairment. First part is to highlight characteristic cognitive impairment among senior citizens and the second one highlight t he background in which malnutrition is a factor that leads to increased risk of morbidity and mortality in the elderly. This review also highlight salgorithms for safeguarding nutritional status among senior citizen and focuses on importance of nutritional screening, assessment and early intervention for safeguarding further deterioration of elderly who are likely to prone to cognitive impairment.
Collapse
|
15
|
Jansen S, Ball L, Desbrow B, Morgan K, Moyle W, Hughes R. Nutrition and dementia care: Informing dietetic practice. Nutr Diet 2014. [DOI: 10.1111/1747-0080.12144] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Sarah Jansen
- Centre for Health Practice Innovation Griffith University Australia
| | - Lauren Ball
- Centre for Health Practice Innovation Griffith University Australia
| | - Ben Desbrow
- Centre for Health Practice Innovation Griffith University Australia
| | | | - Wendy Moyle
- Centre for Health Practice Innovation Griffith University Australia
| | | |
Collapse
|
16
|
Droogsma E, van Asselt D, van Steijn J, Veeger N, van Dusseldorp I, De Deyn PP. Nutritional interventions in community-dwelling Alzheimer patients with (risk of) undernutrition: a systematic review. Int Psychogeriatr 2014; 26:1-9. [PMID: 24846712 DOI: 10.1017/s1041610214000817] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
ABSTRACT Background: Weight loss and undernutrition are common in patients with Alzheimer's disease (AD) and associated with negative health outcomes. In the current guidelines on diagnosis and treatment of AD, no recommendations for treatment of (risk of) undernutrition in community-dwelling AD patients are given. Methods: We conducted a systematic review on the effect of nutritional interventions in community-dwelling AD patients with (risk of) undernutrition, according to the methods outlined by the Cochrane Collaboration. Three electronic databases and three trial registers were searched from inception till April 2013. Results: Literature search in the electronic databases yielded 546 records of which one was relevant for this review. This study, with a high risk of bias, demonstrated that oral nutritional supplements improved nutritional outcomes without effect on clinical and biochemical outcomes. The search in the trial registers yielded 369 records of which two were relevant. One trial was terminated because of failing inclusion, the other is ongoing. Conclusions: This systematic review on the effect of nutritional interventions in community-dwelling AD patients with (risk of) undernutrition, reveals a serious lack of evidence. Therefore, it is not possible to state what the best approach is.
Collapse
Affiliation(s)
- Erika Droogsma
- Department of Geriatric Medicine,Medical Center Leeuwarden,Leeuwarden,the Netherlands
| | - Dieneke van Asselt
- Department of Geriatric Medicine,Medical Center Leeuwarden,Leeuwarden,the Netherlands
| | - Jolanda van Steijn
- Department of Geriatric Medicine,Medical Center Leeuwarden,Leeuwarden,the Netherlands
| | - Nic Veeger
- Department of Epidemiology,Medical Center Leeuwarden,Leeuwarden,the Netherlands
| | | | - Peter Paul De Deyn
- Department of Neurology and Alzheimer Research Center,University Medical Center Groningen,University of Groningen,Groningen,the Netherlands
| |
Collapse
|
17
|
Liu W, Cheon J, Thomas SA. Interventions on mealtime difficulties in older adults with dementia: A systematic review. Int J Nurs Stud 2014; 51:14-27. [DOI: 10.1016/j.ijnurstu.2012.12.021] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2012] [Revised: 12/12/2012] [Accepted: 12/28/2012] [Indexed: 12/21/2022]
|
18
|
Allen VJ, Methven L, Gosney MA. Use of nutritional complete supplements in older adults with dementia: Systematic review and meta-analysis of clinical outcomes. Clin Nutr 2013; 32:950-7. [DOI: 10.1016/j.clnu.2013.03.015] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2012] [Revised: 02/08/2013] [Accepted: 03/19/2013] [Indexed: 10/27/2022]
|
19
|
Allen VJ, Methven L, Gosney M. Impact of serving method on the consumption of nutritional supplement drinks: randomized trial in older adults with cognitive impairment. J Adv Nurs 2013; 70:1323-33. [DOI: 10.1111/jan.12293] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2013] [Indexed: 11/26/2022]
Affiliation(s)
- Victoria J. Allen
- Royal Berkshire NHS Foundation Trust; Reading UK
- Clinical Health Sciences; University of Reading; UK
| | - Lisa Methven
- Food and Nutritional Sciences; University of Reading; UK
| | | |
Collapse
|
20
|
Allen V, Methven L, Gosney M. The influence of nutritional supplement drinks on providing adequate calorie and protein intake in older adults with dementia. J Nutr Health Aging 2013; 17:752-5. [PMID: 24154647 DOI: 10.1007/s12603-013-0364-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Investigate the impact of the provision of ONS on protein and energy intake from food and ability to meet protein and calorie requirements in people with dementia. DESIGN After consent by proxy was obtained, participants took part in a cross over study comparing oral intake on an intervention day to an adjacent control day. SETTING The study occurred in Nursing homes and hospitalised settings. PARTICIPANTS Older adults with dementia over the age of 65 were recruited. 26 participants (aged 83.9+/-8.4years, MMSE 13.08+/-8.13) took part. Intervention (if any): On the intervention day nutritional supplement drinks were provided three times. Each drink provided 283.3+/-41.8 Kcal of energy and 13.8+/-4.7g of protein. Supplements were removed approximately 1 hour before meals were served and weighed waste (g) was obtained. MEASUREMENTS Intake of food consumed was determined on intervention and control days using the quartile method (none, quarter, half, three quarters, all) for each meal component. RESULTS More people achieved their energy and protein requirements with the supplement drink intervention with no sufficient impact on habitual food consumption. CONCLUSION Findings from these 26 participants with dementia indicate that supplement drinks may be beneficial in reducing the prevalence of malnutrition within the group as more people meet their nutritional requirements. As the provision of supplement drinks is also demonstrated to have an additive effect to consumption of habitual foods these can be used alongside other measures to also improve oral intake.
Collapse
Affiliation(s)
- V Allen
- Victoria Allen, The Royal Berkshire NHS Foundation Trust, Reading, RG1 5AN and Clinical Health Sciences, The University of Reading, RG1 5AQ. UK,
| | | | | |
Collapse
|
21
|
Gordon AL, Logan PA, Jones RG, Forrester-Paton C, Mamo JP, Gladman JRF. A systematic mapping review of randomized controlled trials (RCTs) in care homes. BMC Geriatr 2012; 12:31. [PMID: 22731652 PMCID: PMC3503550 DOI: 10.1186/1471-2318-12-31] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Accepted: 06/25/2012] [Indexed: 01/02/2023] Open
Abstract
Background A thorough understanding of the literature generated from research in care homes is required to support evidence-based commissioning and delivery of healthcare. So far this research has not been compiled or described. We set out to describe the extent of the evidence base derived from randomized controlled trials conducted in care homes. Methods A systematic mapping review was conducted of the randomized controlled trials (RCTs) conducted in care homes. Medline was searched for “Nursing Home”, “Residential Facilities” and “Homes for the Aged”; CINAHL for “nursing homes”, “residential facilities” and “skilled nursing facilities”; AMED for “Nursing homes”, “Long term care”, “Residential facilities” and “Randomized controlled trial”; and BNI for “Nursing Homes”, “Residential Care” and “Long-term care”. Articles were classified against a keywording strategy describing: year and country of publication; randomization, stratification and blinding methodology; target of intervention; intervention and control treatments; number of subjects and/or clusters; outcome measures; and results. Results 3226 abstracts were identified and 291 articles reviewed in full. Most were recent (median age 6 years) and from the United States. A wide range of targets and interventions were identified. Studies were mostly functional (44 behaviour, 20 prescribing and 20 malnutrition studies) rather than disease-based. Over a quarter focussed on mental health. Conclusions This study is the first to collate data from all RCTs conducted in care homes and represents an important resource for those providing and commissioning healthcare for this sector. The evidence-base is rapidly developing. Several areas - influenza, falls, mobility, fractures, osteoporosis – are appropriate for systematic review. For other topics, researchers need to focus on outcome measures that can be compared and collated.
Collapse
Affiliation(s)
- Adam L Gordon
- Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UK.
| | | | | | | | | | | | | |
Collapse
|
22
|
Pivi GAK, Bertolucci PHF, Schultz RR. Nutrition in severe dementia. Curr Gerontol Geriatr Res 2012; 2012:983056. [PMID: 22645608 PMCID: PMC3356862 DOI: 10.1155/2012/983056] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2011] [Revised: 02/18/2012] [Accepted: 02/21/2012] [Indexed: 11/17/2022] Open
Abstract
An increasing proportion of older adults with Alzheimer's disease or other dementias are now surviving to more advanced stages of the illness. Advanced dementia is associated with feeding problems, including difficulty in swallowing and respiratory diseases. Patients become incompetent to make decisions. As a result, complex situations may arise in which physicians and families decide whether artificial nutrition and hydration (ANH) is likely to be beneficial for the patient. The objective of this paper is to present methods for evaluating the nutritional status of patients with severe dementia as well as measures for the treatment of nutritional disorders, the use of vitamin and mineral supplementation, and indications for ANH and pharmacological therapy.
Collapse
Affiliation(s)
| | | | - Rodrigo Rizek Schultz
- Behavior Neurology Section, Federal University of São Paulo (UNIFESP), 04025-000 São Paulo SP, Brazil
| |
Collapse
|
23
|
Three-week Nutritional Supplementation Effect on Long-term Nutritional Status of Patients With Mild Alzheimer Disease. Alzheimer Dis Assoc Disord 2012; 26:119-23. [DOI: 10.1097/wad.0b013e31822c5bb3] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
24
|
Cawood AL, Elia M, Stratton RJ. Systematic review and meta-analysis of the effects of high protein oral nutritional supplements. Ageing Res Rev 2012; 11:278-96. [PMID: 22212388 DOI: 10.1016/j.arr.2011.12.008] [Citation(s) in RCA: 252] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2011] [Revised: 12/04/2011] [Accepted: 12/14/2011] [Indexed: 12/16/2022]
Abstract
Disease-related malnutrition is common, detrimentally affecting the patient and healthcare economy. Although use of high protein oral nutritional supplements (ONS) has been recommended to counteract the catabolic effects of disease and to facilitate recovery from illness, there is a lack of systematically obtained evidence to support these recommendations. This systematic review involving 36 randomised controlled trials (RCT) (n=3790) (mean age 74 years; 83% of trials in patients >65 years) and a series of meta-analyses of high protein ONS (>20% energy from protein) demonstrated a range of effects across settings and patient groups in favour of the high protein ONS group. These included reduced complications (odds ratio (OR) 0.68 (95%CI 0.55-0.83), p<0.001, 10 RCT, n=1830); reduced readmissions to hospital (OR 0.59 (95%CI 0.41-0.84), p=0.004, 2 RCT, n=546); improved grip strength (1.76 kg (95%CI 0.36-3.17), p<0.014, 4 RCT, n=219); increased intake of protein (p<0.001) and energy (p<0.001) with little reduction in normal food intake and improvements in weight (p<0.001). There was inadequate information to compare standard ONS (<20% energy from protein) with high protein ONS (>20% energy from protein). The systematic review and meta-analysis provides evidence that high protein supplements produce clinical benefits, with economic implications.
Collapse
Affiliation(s)
- A L Cawood
- Institute of Human Nutrition, University of Southampton, UK.
| | | | | |
Collapse
|
25
|
Navas-Carretero S, Abete I, Zulet MA, Martínez JA. Chronologically scheduled snacking with high-protein products within the habitual diet in type-2 diabetes patients leads to a fat mass loss: a longitudinal study. Nutr J 2011; 10:74. [PMID: 21756320 PMCID: PMC3155966 DOI: 10.1186/1475-2891-10-74] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Accepted: 07/14/2011] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Obesity is the most relevant overnutrition disease worldwide and is associated to different metabolic disorders such as insulin resistance and type-2 diabetes. Low glycemic load foods and diets and moderately high protein intake have been shown to reduce body weight and fat mass, exerting also beneficial effects on LDL-cholesterol, triglyceride concentrations, postprandial glucose curve and HDL-cholesterol levels. The present study aimed at studying the potential functionality of a series of low glycemic index products with moderately high protein content, as possible coadjuvants in the control of type-2 diabetes and weight management following a chronologically planned snacking offer (morning and afternoon). METHODS The current trial followed a single group, sequential, longitudinal design, with two consecutive periods of 4 weeks each. A total of 17 volunteers participated in the study. The first period was a free living period, with volunteers' habitual ad libitum dietary pattern, while the second period was a free-living period with structured meal replacements at breakfast, morning snack and afternoon snack, which were exchanged by specific products with moderately high protein content and controlled low glycemic index, following a scheduled temporal consumption. Blood extractions were performed at the beginning and at the end of each period (free-living and intervention). Parameters analysed were: fasting glucose, insulin, glycosylated hemoglobin, total-, HDL- and LDL-cholesterol, triglyceride, C - reactive protein and Homocysteine concentrations. Postprandial glucose and insulin were also measured. Anthropometrical parameters were monitored each 2 weeks during the whole study. RESULTS A modest but significant (p = 0.002) reduction on body weight (1 kg) was observed during the intervention period, mainly due to the fat mass loss (0.8 kg, p = 0.02). This weight reduction was observed without apparently associated changes in total energy intake. None of the biochemical biomarkers measured was altered throughout the whole study. CONCLUSIONS Small changes in the habitual dietary recommendations in type-2 diabetes patients by the inclusion of specific low-glycemic, moderately high-protein products in breakfast, morning and afternoon snacks may promote body weight and fat-mass loss, without apparently altering biochemical parameters and cardiovascular risk-related factors. TRIAL REGISTRATION Trial registered at clinicaltrials.gov NCT01264523.
Collapse
Affiliation(s)
- Santiago Navas-Carretero
- Department of Nutrition, Food Science, Physiology and Toxicology, University of Navarra, Pamplona, Spain
| | | | | | | |
Collapse
|
26
|
Ooi CP, Loke SC, Yassin Z, Hamid T. Carbohydrates for improving the cognitive performance of independent-living older adults with normal cognition or mild cognitive impairment. Cochrane Database Syst Rev 2011; 2011:CD007220. [PMID: 21491398 PMCID: PMC7388979 DOI: 10.1002/14651858.cd007220.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Mild cognitive impairment (MCI) is an intermediate state between normal cognition and dementia in which daily function is largely intact. This condition may present an opportunity for research into the prevention of dementia. Carbohydrate is an essential and easily accessible macronutrient which influences cognitive performance. A better understanding of carbohydrate-driven cognitive changes in normal cognition and mild cognitive impairment may suggest ways to prevent or reduce cognitive decline. OBJECTIVES To assess the effectiveness of carbohydrates in improving cognitive function in older adults. SEARCH STRATEGY We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group Specialized Register on 22 June 2010 using the terms: carbohydrates OR carbohydrate OR monosaccharides OR disaccharides OR oligosaccharides OR polysaccharides OR CARBS. ALOIS contains records from all major healthcare databases (The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, LILACS) as well as from many trial databases and grey literature sources. SELECTION CRITERIA All randomised controlled trials (RCT) that have examined the efficacy of any form of carbohydrates in normal cognition and MCI. DATA COLLECTION AND ANALYSIS One review author selected and retrieved relevant articles for further assessment. The remaining authors independently assessed whether any of the retrieved trials should be included. Disagreements were resolved by discussion. MAIN RESULTS There is no suitable RCT of any form of carbohydrates involving independent-living older adults with normal cognition or mild cognitive impairment. AUTHORS' CONCLUSIONS There are no suitable RCTs on which to base any recommendations about the use of any form of carbohydrate for enhancing cognitive performance in older adults with normal cognition or mild cognitive impairment. More studies of many different carbohydrates are needed to tease out complex nutritional issues and further evaluate memory improvement.
Collapse
Affiliation(s)
- Cheow Peng Ooi
- Faculty of Medicine and Health Sciences, Universiti Putra MalaysiaEndocrine Unit, Department of MedicineSerdangSelangor DEMalaysia43400
| | - Seng Cheong Loke
- Universiti Putra MalaysiaInstitute of GerontologySerdangSelangor DEMalaysia43400
| | - Zaitun Yassin
- University Putra MalaysiaDepartment of Nutrition and Dietetics, Faculty of Medicine & Health Sciences43400 UPM SerdangSelangorMalaysia
| | - Tengku‐Aizan Hamid
- Universiti Putra MalaysiaInstitute of GerontologySerdangSelangor DEMalaysia43400
| | | |
Collapse
|
27
|
Abstract
UNLABELLED To review the benefits of oral feeding options in people with dementia. DESIGN Systematic literature search with review of potentially eligible studies by two independent investigators. SETTING PubMed/MEDLINE, EMBASE, the Cochrane Library, CINAHL, and PsychINFO literature indices between January 1990 and October 2009. PARTICIPANTS Clinical trials with random or nonrandom control groups were included if they reported on clinical outcomes of oral feeding interventions for people with dementia. MEASUREMENTS Investigators abstracted data from included studies using a structured instrument. Studies were graded on quality and potential bias, and overall strength of evidence was summarized. RESULTS Thirteen controlled trials provided data on use of supplements for people with dementia, and 12 controlled trials tested assisted feeding or other interventions. Studies provide moderate-strength evidence for high-calorie supplements, and low-strength evidence for appetite stimulants, assisted feeding, and modified foods to promote weight gain in people with dementia. The few studies measuring function or survival showed no difference. CONCLUSION High-calorie supplements and other oral feeding options can help people with dementia with feeding problems to gain weight; they are unlikely to improve other outcomes. These treatments can be offered alone or in combination as an alternative to tube feeding.
Collapse
Affiliation(s)
- Laura C Hanson
- Division of Geriatric Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
| | | | | | | |
Collapse
|
28
|
Kenkmann A, Price GM, Bolton J, Hooper L. Health, wellbeing and nutritional status of older people living in UK care homes: an exploratory evaluation of changes in food and drink provision. BMC Geriatr 2010; 10:28. [PMID: 20507560 PMCID: PMC2890011 DOI: 10.1186/1471-2318-10-28] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2009] [Accepted: 05/27/2010] [Indexed: 01/24/2023] Open
Abstract
Background Food and drink are important determinants of physical and social health in care home residents. This study explored whether a pragmatic methodology including routinely collected data was feasible in UK care homes, to describe the health, wellbeing and nutritional status of care home residents and assess effects of changed provision of food and drink at three care homes on residents' falls (primary outcome), anaemia, weight, dehydration, cognitive status, depression, lipids and satisfaction with food and drink provision. Methods We measured health, wellbeing and nutritional status of 120 of 213 residents of six care homes in Norfolk, UK. An intervention comprising improved dining atmosphere, greater food choice, extended restaurant hours, and readily available snacks and drinks machines was implemented in three care homes. Three control homes maintained their previous system. Outcomes were assessed in the year before and the year after the changes. Results Use of routinely collected data was partially successful, but loss to follow up and levels of missing data were high, limiting power to identify trends in the data. This was a frail older population (mean age 87, 71% female) with multiple varied health problems. During the first year 60% of residents had one or more falls, 40% a wound care visit, and 40% a urinary tract infection. 45% were on diuretics, 24% antidepressants, and 43% on psychotropic medication. There was a slight increase in falls from year 1 to year 2 in the intervention homes, and a much bigger increase in control homes, leading to a statistically non-significant 24% relative reduction in residents' rate of falls in intervention homes compared with control homes (adjusted rate ratio 0.76, 95% CI 0.57 to 1.02, p = 0.06). Conclusions Care home residents are frail and experience multiple health risks. This intervention to improve food and drink provision was well received by residents, but effects on health indicators (despite the relative reduction in falls rate) were inconclusive, partly due to problems with routine data collection and loss to follow up. Further research with more homes is needed to understand which, if any, components of the intervention may be successful. Trial registration Trial registration: ISRCTN86057119.
Collapse
Affiliation(s)
- Andrea Kenkmann
- School of Medicine, Health Policy and Practice, University of East Anglia, Norwich NR4 7TJ, UK
| | | | | | | |
Collapse
|
29
|
Nourhashémi F, Olde Rikkert MG, Burns A, Winblad B, Frisoni GB, Fitten J, Vellas B. Follow-up for Alzheimer patients: European Alzheimer Disease Consortium position paper. J Nutr Health Aging 2010; 14:121-30. [PMID: 20126960 DOI: 10.1007/s12603-010-0023-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND AND PURPOSE Alzheimer disease (AD) is one of the leading causes of dependence in the elderly. Providing care for patients with AD is complex and the type of care required depends on the stage of the disease and varies over time. The aim of this article is to discuss available care strategies once the AD diagnosis has been made and to propose a follow-up plan as standard of care at a European level. METHODS The proposals developed in this article stem from the collaborative work of a panel of multidisciplinary experts involved in the care of AD patients (European Alzheimer Disease Consortium) based on the results of published scientific studies and on their experience from clinical practice. CONCLUSION Suggestions for follow-up frequency and easily administered and scored assessment tools are provided, thereby increasing efficiency and quality of care for patients with Alzheimer disease.
Collapse
|
30
|
Johnson S, Nasser R, Banow T, Cockburn T, Voegeli L, Wilson O, Coleman J. Use of Oral Nutrition Supplements In Long-term Care Facilities. CAN J DIET PRACT RES 2009; 70:194-8. [PMID: 19958575 DOI: 10.3148/70.4.2009.194] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Purpose: Practices related to oral nutrition supplement (ONS) use were examined in elderly people living in longterm care (LTC) facilities. Methods: Thirteen LTC facilities within a large regional health authority participated, and 17 people responsible for prescribing ONS in their facilities were interviewed, using a key informant telephone survey. A survey on ONS practice wasmodified, pilot tested, and used. Results:Oral nutrition supplements were primarily prescribed by nursing staff (59%), followed by physicians, registered dietitians, or other staff; ONS use was prescribed for decreased intake, unintentional weight loss, or wound healing. Various ONS products (e.g., Ensure, Boost, or Resource 2.0) were prescribed. Only 18% of respondents reported using alternative food options first to supplement nutritional intake, before introducing ONS. In terms of follow-up and evaluation, the measures of improvement included weight gain, wound healing, or improved well-being; reasons for discontinuation included weight gain, increased intake, or death. Conclusions: Within LTC settings, the prescription and monitoring of ONS vary considerably. Evidence-based guidelines for the prescription and monitoring of ONS and for the use of a food-first strategy should be developed, implemented, and evaluated to optimize the nutritional health of the elderly in LTC facilities.
Collapse
Affiliation(s)
- Shanthi Johnson
- Faculty of Kinesiology and Health Studies, Saskatchewan Population Health and Evaluation Research Unit, University of Regina, Regina, SK
| | - Roseann Nasser
- Dietetic Internship Programme and Clinical Nutrition Services, Department of Nutrition and Food Services, Regina Qu’Appelle Health Region, Regina, SK
| | - Tiffany Banow
- Dietetic Internship Programme and Clinical Nutrition Services, Department of Nutrition and Food Services, Regina Qu’Appelle Health Region, Regina, SK
| | - Tanya Cockburn
- Dietetic Internship Programme and Clinical Nutrition Services, Department of Nutrition and Food Services, Regina Qu’Appelle Health Region, Regina, SK
| | - Leah Voegeli
- Dietetic Internship Programme and Clinical Nutrition Services, Department of Nutrition and Food Services, Regina Qu’Appelle Health Region, Regina, SK
| | - Orina Wilson
- Dietetic Internship Programme and Clinical Nutrition Services, Department of Nutrition and Food Services, Regina Qu’Appelle Health Region, Regina, SK
| | - Jean Coleman
- Dietetic Internship Programme and Clinical Nutrition Services, Department of Nutrition and Food Services, Regina Qu’Appelle Health Region, Regina, SK
| |
Collapse
|
31
|
Bourdel-Marchasson I. How to improve nutritional support in geriatric institutions. J Am Med Dir Assoc 2009; 11:13-20. [PMID: 20129210 DOI: 10.1016/j.jamda.2009.04.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2009] [Accepted: 04/15/2009] [Indexed: 12/31/2022]
Abstract
Nutritional problems are frequent in nursing homes including undernutrition, obesity, and diabetes mellitus, mainly related to disability and behavior troubles. Adequate nutritional care relies both on the quality of menus for regular and modified diet (texture-modified and enriched food) and on the staff knowledge of nutritional problems, particularly undernutrition. Self-assessment of professional practices for all staff categories that are involved in this area can be used to increase training of staff and quality of nutritional care.
Collapse
|
32
|
Milne AC, Potter J, Vivanti A, Avenell A. Protein and energy supplementation in elderly people at risk from malnutrition. Cochrane Database Syst Rev 2009; 2009:CD003288. [PMID: 19370584 PMCID: PMC7144819 DOI: 10.1002/14651858.cd003288.pub3] [Citation(s) in RCA: 264] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Evidence for the effectiveness of nutritional supplements containing protein and energy, often prescribed for older people, is limited. Malnutrition is more common in this age group and deterioration of nutritional status can occur during illness. It is important to establish whether supplementing the diet is an effective way of improving outcomes for older people at risk from malnutrition. OBJECTIVES This review examined trials for improvement in nutritional status and clinical outcomes when extra protein and energy were provided, usually as commercial 'sip-feeds'. SEARCH STRATEGY We searched The Cochrane Library, MEDLINE, EMBASE, Healthstar, CINAHL, BIOSIS, CAB abstracts. We also hand searched nutrition journals and reference lists and contacted 'sip-feed' manufacturers. SELECTION CRITERIA Randomised and quasi-randomised controlled trials of oral protein and energy supplementation in older people, with the exception of groups recovering from cancer treatment or in critical care. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed trials prior to inclusion and independently extracted data and assessed trial quality. Authors of trials were contacted for further information as necessary. MAIN RESULTS Sixty-two trials with 10,187 randomised participants have been included in the review. Maximum duration of intervention was 18 months. Most included trials had poor study quality. The pooled weighted mean difference (WMD) for percentage weight change showed a benefit of supplementation of 2.2% (95% confidence interval (CI) 1.8 to 2.5) from 42 trials. There was no significant reduction in mortality in the supplemented compared with control groups (relative risk (RR) 0.92, CI 0.81 to 1.04) from 42 trials. Mortality results were statistically significant when limited to trials in which participants (N = 2461) were defined as undernourished (RR 0.79, 95% CI 0.64 to 0.97).The risk of complications was reduced in 24 trials (RR 0.86, 95% CI 0.75 to 0.99). Few trials were able to suggest any functional benefit from supplementation. The WMD for length of stay from 12 trials also showed no statistically significant effect (-0.8 days, 95% CI -2.8 to 1.3). Adverse effects included nausea or diarrhoea. AUTHORS' CONCLUSIONS Supplementation produces a small but consistent weight gain in older people. Mortality may be reduced in older people who are undernourished. There may also be a beneficial effect on complications which needs to be confirmed. However, this updated review found no evidence of improvement in functional benefit or reduction in length of hospital stay with supplements. Additional data from large-scale multi-centre trials are still required.
Collapse
Affiliation(s)
- Anne C Milne
- Stonelea, Prospect Terrace, Port Elphinstone, InverurieAberdeenAberdeenshire, ScotlandUKAB51 3UN
| | - Jan Potter
- South East Sydney and Illawarra Area Health ServiceAged Care Southern Hospital NetworkLMB 8808South Coast Mail Centre WollongongNew South WalesAustralia2521
| | - Angela Vivanti
- Princess Alexandra HospitalDepartment of Nutrition and DieteticsIpswich RoadWoolloongabbaQueenslandAustralia4103
| | - Alison Avenell
- University of AberdeenHealth Services Research UnitForesterhillAberdeenUKAB25 2ZD
| | | |
Collapse
|
33
|
Van Wymelbeke V, Jiang T, Pfitzenmeyer P. Change in taste preference in undernourished elderly hospitalized subjects during periods of infection and convalescence. J Nutr Health Aging 2009; 13:40-5. [PMID: 19151907 DOI: 10.1007/s12603-009-0008-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
AIM To determine the impact of taste pleasure supplements on modifications of food intake in hospitalized frail elderly patients. METHODS Thirty hospitalized frail elderly patients tasted different formulas of a high-protein coffee supplement: -supplement C, commercial version; - supplement CA with artificial coffee flavor; - supplement CS with sucrose and - supplement CAS with sucrose and artificial coffee flavor. The preference for the supplements was analyzed by the Friedman test followed by a post hoc Tukey's test. The food intakes in each period were compared by repeated ANOVA and the food intakes of the two periods were compared using Student's t test. All measurements were made during periods of infection and convalescence. RESULTS The supplements CAS and CS were significantly more appreciated than the current commercial version C (P < .05). The patients could be classified into two groups: consumers (consuming the supplements) and nonconsumers (just tasting the supplements). Taking supplements can increase the total energy intake for consumers (P < .01), especially during periods of infection; no modification was observed in the non-consumers. CONCLUSION The use of supplements to increase sensory pleasure can be one feasible way to increase energy intake in hospitalized elderly patients with an infectious disease.
Collapse
Affiliation(s)
- V Van Wymelbeke
- Hôpital de Champmaillot, Service de Médecine Gériatrique, CHU de Dijon, Dijon, France.
| | | | | |
Collapse
|
34
|
Silver HJ. Oral strategies to supplement older adults’ dietary intakes: comparing the evidence. Nutr Rev 2009; 67:21-31. [DOI: 10.1111/j.1753-4887.2008.00131.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
|
35
|
Whiteman E, Ward K, Simmons SF, Sarkisian CA, Moore AA. Testing the effect of specific orders to provide oral liquid nutritional supplements to nursing home residents: a quality improvement project. J Nutr Health Aging 2008; 12:622-5. [PMID: 18953459 DOI: 10.1007/bf03008272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To improve nursing home (NH) staff delivery of oral liquid nutritional supplements between meals to residents with a history of weight loss. DESIGN Pre-Post intervention study. SETTING Two skilled nursing homes. PARTICIPANTS Eighteen long term care residents. INTERVENTION At baseline all participants had a non-specific physician's order to receive a nutritional supplement. The intervention consisted of specifying the physician's order as follows: "Give 4 oz high protein supplement at 10 am, 2 pm, and 7 pm". MEASUREMENTS Research staff conducted direct observations for two days during and between meals for a total of 4 days, or 12 possible observation periods per participant before and one week following the intervention. Research staff documented NH staff delivery of snacks (including high protein supplements) and amount consumed (fluid ounces) for the high protein supplements using a standardized protocol during each observation period. RESULTS Before the specific order was written participants were offered any type of snack an average of 1.82 times per day and a high protein supplement 0.59 times per day. After the specific order was written participants were offered any type of snack an average of 1.59 times per day and a high protein supplement 0.91 times per day. There were no statistically significant differences in the average number of times snacks or supplements were offered before and after the specific order was written. The proportion of snacks offered that were high protein supplements did increase after the specific order was written (p<0.001). When a high protein supplement was provided, most residents consumed 100% of it. CONCLUSIONS Oral liquid nutritional supplements were not provided consistent with orders in NH practice. The specificity of the order related to type of supplement and time of delivery did not influence when and how often supplements are provided to residents but it did influence the type of nutritional supplement offered.
Collapse
Affiliation(s)
- E Whiteman
- University of California, Los Angeles, David Geffen School of Medicine, Department of Medicine, Division of Geriatrics, Los Angeles, CA 90095-1687, USA.
| | | | | | | | | |
Collapse
|
36
|
Smith KL, Greenwood CE. Weight Loss and Nutritional Considerations in Alzheimer Disease. ACTA ACUST UNITED AC 2008; 27:381-403. [DOI: 10.1080/01639360802265939] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
37
|
Simmons SF, Keeler E, Zhuo X, Hickey KA, Sato HW, Schnelle JF. Prevention of unintentional weight loss in nursing home residents: a controlled trial of feeding assistance. J Am Geriatr Soc 2008; 56:1466-73. [PMID: 18637983 DOI: 10.1111/j.1532-5415.2008.01801.x] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To determine the effects of a feeding assistance intervention on food and fluid intake and body weight. DESIGN Crossover controlled trial. SETTING Four skilled nursing homes (NHs). PARTICIPANTS Seventy-six long-stay NH residents at risk for unintentional weight loss. INTERVENTION Research staff provided feeding assistance twice per day during or between meals, 5 days per week for 24 weeks. MEASUREMENTS Research staff independently weighed residents at baseline and monthly during a 24-week intervention and 24-week control period. Residents' food and fluid intake and the amount of staff time spent providing assistance to eat was assessed for 2 days at baseline and 3 and 6 months during each 24-week period. RESULTS The intervention group showed a significant increase in estimated total daily caloric intake and maintained or gained weight, whereas the control group showed no change in estimated total daily caloric intake and lost weight over 24 weeks. The average amount of staff time required to provide the interventions was 42 minutes per person per meal and 13 minutes per person per between-meal snack, versus usual care, during which residents received, on average, 5 minutes of assistance per person per meal and less than 1 minute per person per snack. CONCLUSION Two feeding assistance interventions are efficacious in promoting food and fluid intake and weight gain in residents at risk for weight loss. Both interventions require more staff time than usual NH care. The delivery of snacks between meals requires less time than mealtime assistance and thus may be more practical to implement in daily NH care practice.
Collapse
Affiliation(s)
- Sandra F Simmons
- Division of General Internal Medicine and Public Health, Center for Quality Aging, School of Medicine, Vanderbilt University, Nashville, Tennessee 37232-2400, USA.
| | | | | | | | | | | |
Collapse
|
38
|
Suominen MH, Sandelin E, Soini H, Pitkala KH. How well do nurses recognize malnutrition in elderly patients? Eur J Clin Nutr 2007; 63:292-6. [PMID: 17882130 DOI: 10.1038/sj.ejcn.1602916] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND AND OBJECTIVE Malnutrition is a common and underrecognized clinical problem among aged institutionalized patients. The aim of this study was to investigate how well nurses recognize malnutrition in elderly patients in long-term care hospitals in Helsinki. SUBJECTS AND METHODS In this descriptive, cross-sectional study, the nutritional status of 1043 elderly patients was assessed with the Mini Nutritional Assessment (MNA), their body mass indices (BMIs) (kg m(-2)) were counted, and factors related to their nutritional care were queried using a structured questionnaire. In addition, we asked the opinions of 53 nurses on whether they considered their patients to suffer from malnutrition. All the long-term care hospitals in Helsinki, Finland participated in this study. RESULTS The mean age of the patients was 81 years. The nurses considered only 15.2% of the patients to be malnourished, although the MNA showed that 56.7% were malnourished (MNA<17 points). Those recognized as malnourished were truly anorectic, with a mean BMI of 17.2. Of those patients having a BMI<20 and MNA<17, the nurses considered only one-third to be malnourished. Of those having a BMI>24 but MNA<17, only 2% were recognized as having malnutrition. Even those patients considered to be malnourished received snacks and nutritional supplements less than the patients that the nurses considered to have normal nutritional status. However, only one in six of the malnourished patients received oral nutritional supplements. CONCLUSIONS The nurses recognized malnutrition in their aged patients poorly. Nutrition education for nurses is urgently needed, as malnutrition and weight loss have been considered significant problems, and the benefits of nutritional care are well established.
Collapse
Affiliation(s)
- M H Suominen
- The Central Union for the Welfare of the Aged, Helsinki, Finland.
| | | | | | | |
Collapse
|
39
|
Desai J, Winter A, Young KWH, Greenwood CE. Changes in type of foodservice and dining room environment preferentially benefit institutionalized seniors with low body mass indexes. ACTA ACUST UNITED AC 2007; 107:808-14. [PMID: 17467377 DOI: 10.1016/j.jada.2007.02.018] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2006] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare energy intakes in seniors with cognitive impairment residing in long-term care and receiving meals by bulk (cafeteria style with waitress service) vs traditional tray delivery systems and determine subject characteristics that identify responsiveness to type of foodservice provided. DESIGN AND SUBJECTS/SETTING: Usual energy intakes were compared in subjects residing in cognitive impairment units in either the old (tray delivery, n=23) or new (bulk delivery, n=26) nursing home at Baycrest, a teaching facility associated with University of Toronto Medical School. INTERVENTION Changes to foodservice and physical environment (from institutional to more home-like environment). MAIN OUTCOME MEASURES Twenty-one consecutive day investigator-weighed energy and macronutrient intakes and behavioral function (London Psychogeriatric Rating Scale). STATISTICAL ANALYSES PERFORMED Analysis of variance determined mean differences in intake and regression analyses identified predictors of sensitivity to type of food delivery systems. RESULTS Higher 24-hour total (P<0.001) and dinner (P<0.001) energy intakes in subjects receiving bulk compared to tray delivery were predominantly associated with greater carbohydrate intakes (P<0.001). Higher energy, carbohydrate, and protein, but not fat intakes, with bulk delivery were more apparent in individuals with lower body mass indexes (BMIs) (food delivery by BMI interaction, all P values <0.05). CONCLUSIONS High-risk, cognitively impaired individuals with low BMI benefited the most from the changed foodservice and physical environment, whereas individuals with higher BMIs did not show substantive changes in intake. Bulk foodservice and a home-like dining environment optimize energy intake in individuals at high risk for malnutrition, particularly those with low BMIs and cognitive impairment.
Collapse
Affiliation(s)
- Jyotika Desai
- Kunin-Lunenfeld Applied Research Unit, Baycrest, North York, Ontario, Canada
| | | | | | | |
Collapse
|
40
|
Parrott MD, Young KWH, Greenwood CE. Energy-containing nutritional supplements can affect usual energy intake postsupplementation in institutionalized seniors with probable Alzheimer's disease. J Am Geriatr Soc 2006; 54:1382-7. [PMID: 16970646 DOI: 10.1111/j.1532-5415.2006.00844.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To determine whether increases in caloric intake associated with consumption of a mid-morning nutritional supplement for 3 weeks were maintained in the week after stopping the supplement and to investigate the effects of body mass index (BMI) and cognitive and behavioral measures on this response. DESIGN Secondary analysis of a previously published randomized, crossover, nonblinded clinical trial. SETTING A fully accredited geriatric care facility affiliated with the University of Toronto. PARTICIPANTS Thirty institutionalized seniors with probable Alzheimer's disease (AD) who ate independently. MEASUREMENTS Investigator-weighed food intake, body weight, cognitive (Severe Impairment Battery; Global Deterioration Scale) and behavioral (Neuropsychiatric Inventory--Nursing Home version; London Psychogeriatric Rating Scale) assessments. RESULTS Individuals who responded successfully to supplementation as indicated by increases in daily energy intake were likely to maintain 58.8% of that increase postsupplementation, although stopping the supplement was associated with decreased habitual energy intake in low-BMI individuals who reduced their daily intakes during supplementation in response to the extra calories. Cognitive/behavioral tests were not reliable predictors of postsupplement intake. CONCLUSION Institutionalized seniors with probable AD are likely to alter their usual energy intakes to maintain changes resulting from 3 weeks of supplementation. This effect may allow for rotating supplementation schedules in nursing homes that could reduce staff burden, but only for those individuals who are most likely to respond favorably. These data indicate that nutritional supplements and diet plans should be carefully prescribed in low-BMI individuals to limit variability in total energy provided and thus prevent lower-than-normal intake.
Collapse
Affiliation(s)
- Matthew D Parrott
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Canada.
| | | | | |
Collapse
|
41
|
Simmons SF, Patel AV. Nursing Home Staff Delivery of Oral Liquid Nutritional Supplements to Residents at Risk for Unintentional Weight Loss. J Am Geriatr Soc 2006; 54:1372-6. [PMID: 16970644 DOI: 10.1111/j.1532-5415.2006.00688.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To describe nursing home (NH) staff delivery of oral liquid nutritional supplements to residents with an order to receive supplementation. DESIGN Descriptive. SETTING Six skilled NHs. PARTICIPANTS One hundred thirty-two long-stay residents. MEASUREMENTS Research staff conducted direct observations for 2 days during and between meals and documented NH staff delivery of supplements, amount consumed (fluid ounces), and amount of assistance (minutes) provided by staff to encourage consumption. RESULTS Eighty-eight percent had an order to receive a supplement one to three times daily (mode = 3); 12% had an order to receive a supplement four to six times daily. Fewer than 10% received the supplement consistent with their orders during the 2 observation days. On average, NH staff provided a supplement less than once per participant per day during or between meals. When a supplement was provided, residents consumed an average+/-standard deviation of 4.91+/-2.19 fluid ounces during meals with 6.16+/-7.46 minutes of staff assistance and 3.98+/-2.60 fluid ounces between meals with less than 1 minute of staff assistance. Participants with orders that specified time of delivery received the supplement at a significantly higher frequency between meals. CONCLUSION Oral liquid nutritional supplements are not provided consistent with orders in NH practice. Staff spends little time promoting supplement consumption during or between meals. The specificity of the order related to time of delivery may influence when and how often supplements are provided to residents.
Collapse
Affiliation(s)
- Sandra F Simmons
- Department of Geriatrics, Borun Center for Gerontological Research, School of Medicine, University of California, Los Angeles, Los Angeles, California, USA.
| | | |
Collapse
|
42
|
Keller HH, Gibbs-Ward A, Randall-Simpson J, Bocock MA, Dimou E. Meal Rounds: An Essential Aspect of Quality Nutrition Services in Long-term Care. J Am Med Dir Assoc 2006; 7:40-5. [PMID: 16413434 DOI: 10.1016/j.jamda.2005.06.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION AND RATIONALE Weight change and, specifically, weight loss are common in residents of long-term care facilities (LTCFs). The occurrence of weight change results from multifactorial processes, some of which can be considered nutrition risk factors. Meal rounds can be a continuous quality improvement activity to readily identify nutrition risk factors that can influence weight change. METHODS This brief report will describe the activity of meal rounds and how they can be used to improve nutrition services. Baseline data from a previously published study on 37 residents will provide proportions of nutrition risk factors identified during meal rounds that can influence weight change. OUTCOMES Feeding and eating difficulties are prevalent in residents with dementia (eg, agitation 29.7%, resisting assistance 21.6%). Early identification of these difficulties using meal rounds may be a means of preventing weight change and promoting quality nutrition care in LTCFs. The proposed intervention of meal rounds conducted as described can improve the quality of nutrition services in LTCFs.
Collapse
Affiliation(s)
- Heather H Keller
- Department of Family Relations and Applied Nutrition, University of Guelph, Guelph, ON, Canada.
| | | | | | | | | |
Collapse
|
43
|
Abstract
PURPOSE OF REVIEW Nutritional issues have received little attention in geriatric psychiatry research. This review focuses on literature published in 2003 and 2004 on nutritional factors in mental illness in the elderly and proposes directions for future research. RECENT FINDINGS There has been more research on the role of micronutrients in psychiatric disorders of older adults but studies examining nutritional state in this population are lacking. The former research suggests associations between low folic acid/vitamin B12 status and depression in older adults whereas evidence for other micronutrients is still tentative. In the latter work, there is only one study that examines malnutrition in psychogeriatric patients despite the availability of well-validated screening tools for assessing nutritional state in the elderly and the known impact of undernutrition in ageing and the development of frailty. The role of obesity in ageing is also relevant especially as more people with schizophrenia live longer, although the current evidence in the non-mentally ill elderly suggests that being overweight may have protective effects in the elderly. SUMMARY Malnutrition is likely to have considerable impact on the mental and physical state of the elderly.
Collapse
|
44
|
Young KWH, Greenwood CE, van Reekum R, Binns MA. A randomized, crossover trial of high-carbohydrate foods in nursing home residents with Alzheimer's disease: associations among intervention response, body mass index, and behavioral and cognitive function. J Gerontol A Biol Sci Med Sci 2005; 60:1039-45. [PMID: 16127110 DOI: 10.1093/gerona/60.8.1039] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Despite recognition that weight loss is a problem in elderly persons with probable Alzheimer's disease (AD), increasing their food intake remains a challenge. To effectively enhance intake, interventions must work with individuals' changing needs and intake patterns. Previously, the authors reported greater food consumption at breakfast, a high-carbohydrate meal, compared with dinner, and shifts toward carbohydrate preference at dinner in those with increased behavioral difficulties, low body mass index, or both. METHODS Thirty-four nursing home residents with probable AD who ate independently participated in a randomized, crossover, nonblinded study of two nutrition interventions. The intervention described here included replacing 12 nonconsecutive "traditional" dinners with meals high in carbohydrate but comparable to traditional dinners in protein. Measures included weighed food intake, body weight, cognitive function (as assessed using the Severe Impairment Battery and Global Deterioration Scale), behavioral disturbances (as assessed using the Neuropsychiatric Inventory-Nursing Home Version), and behavioral function (as assessed using the London Psychogeriatric Rating Scale). RESULTS Group mean dinner and 24-hour energy intake increased during the intervention phase compared with baseline, protein intake was unaffected, and carbohydrate intake increased. Increased dinner intake, attributable to intervention foods, was achieved in 20 of 32 of participants who completed the study and was associated with increased carbohydrate preference, poorer memory, and increased aberrant motor behavior. Those with low body mass indices were the most resistant to the intervention. CONCLUSIONS Providing a high-carbohydrate meal for dinner increases food intake in seniors at later stages of the disease who are experiencing cognitive and behavioral difficulties, possibly as a result of a shift in preference for high-carbohydrate foods.
Collapse
Affiliation(s)
- Karen W H Young
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada M5S 3E2.
| | | | | | | |
Collapse
|
45
|
Rahman AN, Simmons SF. Individualizing Nutritional Care With Between-Meal Snacks for Nursing Home Residents. J Am Med Dir Assoc 2005; 6:215-8. [PMID: 15894253 DOI: 10.1016/j.jamda.2005.03.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Anna N Rahman
- University of California, Los Angeles, School of Medicine, Department of Geriatrics, Borun Center for Gerontological Research, Los Angeles, CA 91335, USA.
| | | |
Collapse
|
46
|
Greenwood CE, Tam C, Chan M, Young KWH, Binns MA, van Reekum R. Behavioral Disturbances, Not Cognitive Deterioration, Are Associated With Altered Food Selection in Seniors With Alzheimer's Disease. J Gerontol A Biol Sci Med Sci 2005; 60:499-505. [PMID: 15933391 DOI: 10.1093/gerona/60.4.499] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE We previously reported alterations in circadian patterns of food intake that are associated with measures of functional and cognitive deterioration in seniors with probable Alzheimer's disease (AD). This study further explored disturbed eating patterns in AD, focusing on alterations in macronutrient (protein, carbohydrate, and fat) selection, and their association with measures of functional and behavioral losses. METHODS Forty-nine days of food intake collections were conducted on 32 residents (26 females, 6 males; age = 88.4 +/- 4.1 years; body mass index = 24.1 +/- 4.0 kg/m(2)) with probable AD residing at a nursing home (a fully accredited geriatric teaching facility affiliated with the University of Toronto's Medical School). All residents ate their meals independently. The relationships between patterns of habitual food consumption and measures of cognitive function (Severe Impairment Battery), behavioral disturbances (Neuropsychiatric Inventory-Nursing Home Version) and behavioral function (London Psychogeriatric Rating Scale) were examined, cross-sectionally. RESULTS Consistent with our previous studies, breakfast intakes were not predicted by any of the measures of behavioral, cognitive, or functional deterioration, although those residents with greater functional deterioration, especially disengagement, attained lower 24-hour energy intakes. The presence of "psychomotor disturbances," including irritability, agitation, and disinhibition, were strongly associated with shifts in eating patterns toward carbohydrate and away from protein, placing individuals with these conditions at increased risk for inadequate protein intakes. Between-individual differences in intake patterns could not be explained by the use of either anorexic or orexigenic medications. CONCLUSIONS Behavioral, not cognitive, deterioration is associated with appetite modifications that increase risk of poor protein intake, perhaps indicating a common monoaminergic involvement.
Collapse
Affiliation(s)
- Carol E Greenwood
- Kunin-Lunenfeld Applied Research Unit, Baycrest Centre for Geriatric Care, Toronto, Ontario, Canada.
| | | | | | | | | | | |
Collapse
|