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Riddle E, Munoz N, Clark K, Collins N, Coltman A, Nasrallah L, Nishioka S, Scollard T, Simon JR, Moloney L. Prevention and Treatment of Malnutrition in Older Adults Living in Long-Term Care or the Community: an Evidence-based Nutrition Practice Guideline. J Acad Nutr Diet 2024:S2212-2672(24)00146-1. [PMID: 38583584 DOI: 10.1016/j.jand.2024.03.013] [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: 03/13/2024] [Accepted: 03/27/2024] [Indexed: 04/09/2024]
Abstract
Malnutrition in older adults can decrease quality of life and increase risk of morbidities and mortality. Accurate and timely identification of malnutrition, as well as subsequent implementation of effective interventions, are essential to decrease poor outcomes associated with malnutrition in older adults. The Academy of Nutrition and Dietetics Evidence Analysis Center conducted a systematic review of the literature to develop an evidence-based nutrition practice guideline for the prevention and treatment of malnutrition in older adults. The objective of this guideline was to provide evidence-based recommendations to identify, prevent, or treat protein-energy malnutrition in older adults (mean age ≥65 years) living in long-term care and community settings. This guideline provides 11 nutrition recommendations to inform shared decision making among dietitians, members of the health care team, family members or caregivers, and older adults living in long-term care or the community to prevent or treat malnutrition. Topics include dietitian effectiveness, nutrition assessment tools, oral nutrition supplements, food fortification, and home-delivered and congregate meals. Guideline implementation should include consideration of the importance of comprehensive individualized nutrition care for older adults. Future research is needed to address gaps that were identified related to the validity, reliability, and feasibility of nutrition assessment tools, as well as the effectiveness of dietitian interventions on outcomes of interest in older adults living in long-term care and the community.
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Affiliation(s)
- Emily Riddle
- State University of New York at Oneonta, Oneonta, New York
| | - Nancy Munoz
- Veterans Affairs Southern Nevada Healthcare System, Las Vegas, Nevada
| | | | | | - Anne Coltman
- Commission on Dietetic Registration, Chicago, Illinois
| | - Lamia Nasrallah
- Outpatient Nutrition Services, University of North Carolina Hospitals, Chapel Hill, North Carolina
| | - Shinta Nishioka
- Department of Clinical Nutrition and Food Services, Nagasaki Rehabilitation Hospital, Nagasaki, Japan
| | | | - Judy R Simon
- Nutrition and Health Promotion Consultant, Easton, Maryland
| | - Lisa Moloney
- Academy of Nutrition and Dietetics, Chicago, Illinois.
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Arensberg MB, Brunton C, Richardson B, Bolhack S. The Case for Malnutrition Quality Measures and Nutrition-Focused Quality Improvement Programs (QIPs) in US Skilled Nursing Facilities. Healthcare (Basel) 2022; 10:healthcare10030549. [PMID: 35327026 PMCID: PMC8949306 DOI: 10.3390/healthcare10030549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 03/08/2022] [Accepted: 03/14/2022] [Indexed: 01/22/2023] Open
Abstract
As skilled nursing in the United States moves to a value-based model, malnutrition care remains a critical gap area that is associated with multiple poor health outcomes, including hospital readmissions and declines in functional status, psychosocial well-being, and quality of life. Malnutrition is often undiagnosed/untreated, even though it impacts up to half of skilled nursing facility (SNF) residents, and COVID-19 infections/related symptoms have likely further increased this risk. In acute care, malnutrition quality measures have been both developed/tested, and nutrition-focused quality improvement programs (QIPs) have been shown to reduce costs and effectively improve care processes and patient outcomes. Less is known about such quality initiatives in SNF care. This perspective paper reviewed malnutrition-related quality measures and nutrition-focused QIPs in SNFs and nursing home care. It identified that although the Centers for Medicare & Medicaid Services (CMS) has had a nursing home Quality Assurance and Performance Improvement (QAPI) program for 10 years and has had SNF quality measures for nearly 20 years, there are no malnutrition-specific quality measures for SNFs and very few published nutrition-focused QIPs in SNFs. This represents an important care gap that should be addressed to improve resident health outcomes as SNFs more fully move to a value-based care model.
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Affiliation(s)
- Mary Beth Arensberg
- Abbott Nutrition Division of Abbott, Columbus, OH 43219, USA;
- Correspondence:
| | - Cory Brunton
- Abbott Nutrition Division of Abbott, Columbus, OH 43219, USA;
| | | | - Scott Bolhack
- The Wound Care Center at Northwest Hospital, Tucson, AZ 85741, USA;
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Arias-Casais N, Amuthavalli Thiyagarajan J, Rodrigues Perracini M, Park E, Van den Block L, Sumi Y, Sadana R, Banerjee A, Han ZA. What long-term care interventions have been published between 2010 and 2020? Results of a WHO scoping review identifying long-term care interventions for older people around the world. BMJ Open 2022; 12:e054492. [PMID: 35105637 PMCID: PMC8808408 DOI: 10.1136/bmjopen-2021-054492] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 12/20/2021] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVE The global population is rapidly ageing. To tackle the increasing prevalence of older adults' chronic conditions, loss of intrinsic capacity and functional ability, long-term care interventions are required. The study aim was to identify long-term care interventions reported in scientific literature from 2010 to 2020 and categorise them in relation to WHO's public health framework of healthy ageing. DESIGN Scoping review conducted on PubMed, CINHAL, Cochrane and Google Advanced targeting studies reporting on long-term care interventions for older and frail adults. An internal validated Excel matrix was used for charting.Setting nursing homes, assisted care homes, long-term care facilities, home, residential houses for the elderly and at the community. INCLUSION CRITERIA Studies published in peer-reviewed journals between 1 January 2010 to 1 February 2020 on implemented interventions with outcome measures provided in the settings mentioned above for subjects older than 60 years old in English, Spanish, German, Portuguese or French. RESULTS 305 studies were included. Fifty clustered interventions were identified and organised into four WHO Healthy Ageing domains and 20 subdomains. All interventions delved from high-income settings; no interventions from low-resource settings were identified. The most frequently reported interventions were multimodal exercise (n=68 reports, person-centred assessment and care plan development (n=22), case management for continuum care (n=16), multicomponent interventions (n=15), psychoeducational interventions for caregivers (n=13) and interventions mitigating cognitive decline (n=13). CONCLUSION The identified interventions are diverse overarching multiple settings and areas seeking to prevent, treat and improve loss of functional ability and intrinsic capacity. Interventions from low-resource settings were not identified.
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Affiliation(s)
- Natalia Arias-Casais
- ATLANTES Global Observatory for Palliative Care, University of Navarra, Pamplona, Spain
| | | | | | - Eunok Park
- College of Nursing, Jeju National University, Jeju, Republic of Korea
| | - Lieve Van den Block
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel, Brussels, Belgium
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium
| | - Yuka Sumi
- Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Ritu Sadana
- Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Anshu Banerjee
- Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Zee-A Han
- Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
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Sossen L, Bonham M, Porter J. Can fortified, nutrient-dense and enriched foods and drink-based nutrition interventions increase energy and protein intake in residential aged care residents? A systematic review with meta-analyses. Int J Nurs Stud 2021; 124:104088. [PMID: 34717275 DOI: 10.1016/j.ijnurstu.2021.104088] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 05/26/2021] [Accepted: 09/01/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Food fortification as part of the food-first approach in nursing homes is a strategy that may increase energy and protein intake. OBJECTIVES This review aimed to determine the effect of nutrition interventions using fortification, nutrient-dense or enriched food and/or drinks on energy and protein intake in residents living in nursing homes, compared to the standard menu with or without oral nutritional support products. The secondary aim was to identify and synthesise outcomes of these interventions on weight change, nutritional status, acceptability, cost-effectiveness, and cost-benefit. METHODS A systematic search of seven databases was undertaken. After reviewing all titles/abstracts then full-text papers, key data were extracted and synthesised narratively and through meta-analysis. The quality of included studies was assessed using the Quality Criteria Checklist for Primary Research. RESULTS Of 3,098 articles retrieved, 16 were included, 13 in the meta-analysis. There were 891 participants, with the study duration ranging from four to 26 weeks. The groups receiving the fortified diet had a significantly higher energy intake (Hedges' g = 0.69 (CI 0.36-1.03), p < 0.0001) and protein intake (Hedges' g = 0.46 (CI 0.17-0.74), p = 0.003) compared with the groups receiving the standard menu +/- ONS. The meta-analysis revealed I2 values of 77% for energy (p < 0.0001) and 60% for protein (p = 0.003), indicating considerable statistical heterogeneity across included studies. Benefits to weight and nutritional status of residents were recorded in some studies. Where reported, cost-effectiveness and cost-benefit of menu fortification/supplementation were variable. CONCLUSIONS This systematic review with meta-analyses has shown that fortified menus may significantly increase energy and protein intakes compared with standard menus in nursing homes. As such, the findings of this review support further use of fortified diets in this setting. Further research is warranted comparing food fortification to standard menus, with a particular focus on evaluating the effect on weight, nutritional status and cost-effectiveness of the intervention. STUDY REGISTRATION PROSPERO no. CRD42020162796.
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Affiliation(s)
- Lisa Sossen
- Department of Nutrition, Dietetics and Food, Monash University, Level 1, 264 Ferntree Gully Road, Notting Hill VIC 3168, Australia.
| | - Maxine Bonham
- Department of Nutrition, Dietetics and Food, Monash University, Level 1, 264 Ferntree Gully Road, Notting Hill VIC 3168, Australia.
| | - Judi Porter
- Department of Nutrition, Dietetics and Food, Monash University, Level 1, 264 Ferntree Gully Road, Notting Hill VIC 3168, Australia; Institute for Physical Activity and Nutrition (IPAN), School of Exercise and Nutrition Sciences, Deakin University, Geelong, Australia.
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Moloney L, Jarrett B. Nutrition Assessment and Interventions for the Prevention and Treatment of Malnutrition in Older Adults: An Evidence Analysis Center Scoping Review. J Acad Nutr Diet 2021; 121:2108-2140.e6. [PMID: 34581276 DOI: 10.1016/j.jand.2020.09.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 09/04/2020] [Indexed: 12/21/2022]
Abstract
Older adults living in the community or long-term residence such as a nursing home are at increased risk for malnutrition due to factors such as depression and isolation. The purpose of this scoping review is to identify the best available research that evaluates the validity and reliability of nutrition assessment tools, and the effectiveness of nutrition interventions to prevent or treat malnutrition among older adults. A literature search was conducted in Medline, Embase, CINAHL, and Cochrane Central databases to identify clinical trials, published in the English language, evaluating assessment and intervention methods aimed to treat or prevent malnutrition among older adults living in the community or their long-term residence such as nursing homes. Articles were screened by 2 reviewers, then data were extracted and narratively synthesized. The literature search retrieved 20,937 articles and 197 articles were included in narrative synthesis. A total of 73 assessment articles were identified, 36 of which were validity and reliability trials. A total of 122 intervention articles were identified, the majority of which were randomized controlled trials. A few of the most commonly evaluated interventions were oral nutrition supplements, medical nutrition therapy, fortification and enrichment, and nutrition education. Several systematic reviews were identified, however, that did not meet the criteria of this review. There is a need to conduct systematic reviews for nutrition assessment and intervention trials to guide development of evidence-based nutrition practice recommendations for older adults living in the community or their long-term residence.
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Affiliation(s)
- Lisa Moloney
- Academy of Nutrition and Dietetics, Evidence Analysis Center, Chicago, IL.
| | - Brittany Jarrett
- Division of Nutritional Sciences, Cornell University, Ithaca, NY
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Malafarina V, Serra Rexach JA, Masanés F, Cervera-Díaz MC, Lample Lacasa L, Ollero Ortigas A, Cruz-Jentoft AJ. Results of High-Protein, High-Calorie Oral Nutritional Supplementation in Malnourished Older People in Nursing Homes: An Observational, Multicenter, Prospective, Pragmatic Study (PROT-e-GER). J Am Med Dir Assoc 2021; 22:1919-1926.e5. [PMID: 33819452 DOI: 10.1016/j.jamda.2021.02.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 02/12/2021] [Accepted: 02/25/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To assess if the impact of oral nutritional supplements (ONS) on nutritional and functional status in malnourished older persons living in nursing homes shown by clinical trials are also found outside a trial setting. DESIGN Observational, multicenter, prospective, pragmatic study. SETTING AND PARTICIPANTS This study was carried out in 38 nursing homes throughout Spain. Nursing home physicians recruited consecutive residents, older than 65 years, with a diagnosis of malnutrition, when a clinical decision to start ONS had been taken after unsuccessful initial management with dietary interventions. INTERVENTION The participants received daily 2 bottles of an energy-rich, high-protein commercial ONS for 3 months. MEASURES Primary outcomes were changes in nutritional status [body weight, body mass index (BMI), and Mini Nutritional Assessment-Short Form (MNA-SF)]; secondary outcomes were functional changes [Functional Ambulation Classification, Barthel index, handgrip strength, and Short Physical Performance Battery (SPPB)], as well as safety and adherence after 12 weeks of follow-up. RESULTS A total of 282 residents (median age 86 years, 67% women) were included, and 244 (86.5%) completed the follow-up. At baseline, 77.3% of the participants were malnourished (BMI 19.7 kg/m2, interquartile range 18.3-21.8). After 12 weeks of follow-up, participants experienced significant increases in body weight (2.6 ± 3.1 kg, 5.2 ± 5.9%), BMI (1.0 ± 1.2 kg/m2) and MNA-SF (4.0 ± 2.5 points). There were also significant improvements in functional status measured by the Barthel index, handgrip strength, SPPB, and gait speed. Good adherence was registered in 94.6% of the participants. No relevant side effects were found. CONCLUSIONS AND IMPLICATIONS Improvements in nutritional and functional status can be found when using a high-protein, high-calorie ONS in older undernourished people living in nursing homes.
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Affiliation(s)
- Vincenzo Malafarina
- Department of Nutrition, Food Science, and Physiology, School of Pharmacy and Nutrition, Universidad de Navarra, Pamplona, Spain; Department of Geriatrics, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - José A Serra Rexach
- Departamento de Geriatría, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Facultad de Medicina, Universidad Complutense, CIBERFES, Madrid, Spain
| | - Ferrán Masanés
- Departamento de Medicina Interna, Hospital Clinic, Barcelona, Spain
| | - Ma Carmen Cervera-Díaz
- Unidad de Geriatría, Hospital Clínico Universitario, Valladolid, Spain; Asociación Casa de Beneficencia, Valladolid, Spain
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Ballesteros-Pomar MD, Cherubini A, Keller H, Lam P, Rolland Y, Simmons SF. Texture-Modified Diet for Improving the Management of Oropharyngeal Dysphagia in Nursing Home Residents: An Expert Review. J Nutr Health Aging 2020; 24:576-581. [PMID: 32510109 DOI: 10.1007/s12603-020-1377-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVES This paper provides evidence-based and, when appropriate, expert reviewed recommendations for long-stay residents who are prescribed texture-modified diets (TMDs), with the consideration that these residents are at high risk of worsening oropharyngeal dysphagia (OD), malnutrition, dehydration, aspiration pneumonia, and OD-associated mortality, poorer quality of life and high costs. DESIGN Nestlé Health Science funded an initial virtual meeting attended by all authors, in which the unmet needs and subsequent recommendations for OD management were discussed. The opinions, results, and recommendations detailed in this paper are those of the authors, and are independent of funding sources. SETTING OD is common in nursing home (NH) residents, and is defined as the inability to initiate and perform safe swallowing. The long-stay NH resident population has specific characteristics marked by a shorter life expectancy relative to community-dwelling older adults, high prevalence of multimorbidity with a high rate of complications, dementia, frailty, disability, and often polypharmacy. As a result, OD is associated with malnutrition, dehydration, aspiration pneumonia, functional decline, and death. Complications of OD can potentially be prevented with the use of TMDs. RESULTS This report presents expert opinion and evidence-informed recommendations for best practice on the nutritional management of OD. It aims to highlight the practice gaps between the evidence-based management of OD and real-world patterns, including inadequate dietary provision and insufficient staff training. In addition, the unmet need for OD screening and improvements in therapeutic diets are explored and discussed. CONCLUSION There is currently limited empirical evidence to guide practice in OD management. Given the complex and heterogeneous population of long-stay NH residents, some 'best practice' approaches and interventions require extensive efficacy testing before further changes in policy can be implemented.
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Affiliation(s)
- M D Ballesteros-Pomar
- María Ballesteros-Pomar, Department of Endocrinology and Nutrition, Complejo Asistencial Universitario de León, León, Spain,
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Allmark G, Calder PC, Marino LV. Research identified variation in nutrition practice by community prescribing dietitians with regards to the identification and management of malnutrition amongst community dwelling adults. Nutr Res 2019; 76:94-105. [PMID: 31837829 DOI: 10.1016/j.nutres.2019.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 09/30/2019] [Accepted: 10/15/2019] [Indexed: 01/29/2023]
Abstract
To improve nutritional outcomes of community dwelling adults with malnutrition we identified three related hypotheses to be tested: i) Southampton Community Prescribing Support Service dietitians achieve 100% compliance with selected standards of the National Institute for Health and Clinical Excellence Clinical Guideline (CG) 32, ii) patient service satisfaction amongst community dwelling adults accessing the prescribing support service is high (90%), and iii) nationally, dietitians use weight gain goal >10% and BMI >18.5 kg/m2 as outcome measures from the service phases of prescribing support. A retrospective audit of records of 100 community-dwelling adults accessing local services considered CG32 "Indications for nutrition support in hospital and community standard 1.3.1" and CG32 "Monitoring of nutrition support in hospital and community standard 1.5.6". A questionnaire was distributed to community-dwelling adults (n = 52) accessing the service, in addition to a national survey of dietetic practice. Compliance with standard 1.3.1 was 46% and with standard 1.5.6 it was 82%. The majority of patients (86%; n = 13) reported satisfaction with the support service. Nationally, 89% (n = 51) of dietitians use weight and 87% (n = 50) use BMI as an outcome measure for success of nutritional intervention. All research hypotheses were rejected. These results suggest there is considerable variation in the identification and management of malnutrition amongst community dwelling adults, which may impact on clinical and nutritional outcomes. Future work should consider quality improvement projects to address potential barriers to achieving best practice by community prescribing dietitians through the use of nutrition pathways to support older adults with malnutrition.
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Affiliation(s)
- Grace Allmark
- Department of Dietetics/Speech and Language Therapy, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom.
| | - Philip C Calder
- Faculty of Medicine, University of Southampton, Southampton, United Kingdom; NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, United Kingdom
| | - Luise V Marino
- Department of Dietetics/Speech and Language Therapy, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, United Kingdom; Faculty of Health Sciences, University of Southampton, Southampton, United Kingdom
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Reber E, Norman K, Endrich O, Schuetz P, Frei A, Stanga Z. Economic Challenges in Nutritional Management. J Clin Med 2019; 8:jcm8071005. [PMID: 31295852 PMCID: PMC6678224 DOI: 10.3390/jcm8071005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 06/24/2019] [Accepted: 07/04/2019] [Indexed: 01/17/2023] Open
Abstract
Disease-related malnutrition (DRM) is a highly prevalent independent risk and cost factor with significant influence on mortality, morbidity, length of hospital stay (LOS), functional impairment and quality of life. The aim of our research was to estimate the economic impact of the introduction of routinely performed nutritional screening (NS) in a tertiary hospital, with subsequent nutritional interventions (NI) in patients with potential or manifest DRM. Economic impact analysis of natural detection of inpatients at risk and estimation of the change in economic activity after the implementation of a systematic NS were performed. The reference population for natural detection of DRM is about 20,000 inpatients per year. Based on current data, DRM prevalence is estimated at 20%, so 4000 patients with potential and manifest DRM should be detected. The NI costs were estimated at CHF 0.693 million, with savings of CHF 1.582 million (LOS reduction) and CHF 0.806 million in additional revenue (SwissDRG system). Thus, the introduction of routine NS generates additional costs of CHF 1.181 million that are compensated by additional savings of CHF 2.043 million and an excess in additional revenue of CHF 2.071 million. NS with subsequent adequate nutritional intervention shows an economic potential for hospitals.
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Affiliation(s)
- Emilie Reber
- Department for Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Bern University Hospital, and University of Bern, 3010 Bern, Switzerland.
| | - Kristina Norman
- Department of Nutrition and Gerontology, German Institute for Human Nutrition Potsdam-Rehbrücke, 14558 Nuthetal, Germany
- Research Group on Geriatrics, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 13347 Berlin, Germany
| | - Olga Endrich
- Health Data Management and Health Economics, Medical Directorate, Bern University Hospital, and University of Bern, 3010 Bern, Switzerland
| | - Philipp Schuetz
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, 5001 Aarau, Switzerland
| | - Andreas Frei
- Freelance Health Economist, 4133 Pratteln, Switzerland
| | - Zeno Stanga
- Department for Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Bern University Hospital, and University of Bern, 3010 Bern, Switzerland
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Batchelor-Murphy M, Kennerly SM, Horn SD, Barrett R, Bergstrom N, Boss L, Yap TL. Impact of Cognition and Handfeeding Assistance on Nutritional Intake for Nursing Home Residents. J Nutr Gerontol Geriatr 2019; 38:262-276. [PMID: 31124418 PMCID: PMC7187960 DOI: 10.1080/21551197.2019.1617221] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In nursing homes (NHs), residents are at risk for malnutrition and weight loss. The purpose of this secondary data analysis was to examine the impact of resident cognitive status and level of feeding assistance provided by NH staff on resident's daily nutritional intake and body weight. As part of a large, multisite clinical trial (N = 786), residents with and without dementia were examined according to level of feeding assistance required during mealtimes (independent, set-up only, needs help eating) over a 21-day period. Outcomes analyzed were percent of meal intake by meal type (breakfast, lunch, dinner) and overall daily intake (meals + snacks/supplements). Residents with dementia who required meal set-up assistance had significantly lower meal intake for all three meals. Residents without dementia requiring meal set-up assistance experienced significantly lower intake for breakfast and dinner, but not lunch. When snacks and supplements were offered between meals, residents with dementia consumed approximately 163 additional calories/day, and residents without dementia consumed approximately 156 additional calories/day. This study adds new evidence that residents at greatest risk for low intake are those who are only provided set-up assistance for meals and/or have cognitive impairment.
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Affiliation(s)
| | - Susan M Kennerly
- b College of Nursing, East Carolina University , Greenville , NC , USA
| | - Susan D Horn
- c School of Medicine, University of Utah , Salt Lake City , UT , USA
| | - Ryan Barrett
- d International Severity Information Systems and the Institute for Clinical Outcomes Research , Salt Lake City , UT , USA
| | - Nancy Bergstrom
- e School of Nursing, University of Texas Health Science Center at Houston , Houston , TX , USA
| | - Lisa Boss
- f Memorial Hermann Northeast Medical Center , Humble , TX , USA
| | - Tracey L Yap
- g School of Nursing, Duke University , Durham , NC , USA
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Simmons SF, Coelho CS, Sandler A, Schnelle JF. A System for Managing Staff and Quality of Dementia Care in Assisted Living Facilities. J Am Geriatr Soc 2018; 66:1632-1637. [DOI: 10.1111/jgs.15463] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 05/03/2018] [Accepted: 05/04/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Sandra F. Simmons
- Center for Quality Aging; Vanderbilt University Medical Center; Nashville Tennessee
- Division of Geriatrics, Department of Medicine; Vanderbilt University Medical Center; Nashville Tennessee
- Geriatric Research, Education and Clinical Center; Veterans Affairs Tennessee Valley Healthcare System; Nashville Tennessee
| | - Chris S. Coelho
- Abe's Garden; Alzheimer's and Memory Care Center of Excellence; Nashville Tennessee
| | - Andrew Sandler
- Abe's Garden; Alzheimer's and Memory Care Center of Excellence; Nashville Tennessee
| | - John F. Schnelle
- Center for Quality Aging; Vanderbilt University Medical Center; Nashville Tennessee
- Division of Geriatrics, Department of Medicine; Vanderbilt University Medical Center; Nashville Tennessee
- Geriatric Research, Education and Clinical Center; Veterans Affairs Tennessee Valley Healthcare System; Nashville Tennessee
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Hugo C, Isenring E, Miller M, Marshall S. Cost-effectiveness of food, supplement and environmental interventions to address malnutrition in residential aged care: a systematic review. Age Ageing 2018; 47:356-366. [PMID: 29315355 DOI: 10.1093/ageing/afx187] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 11/22/2017] [Indexed: 12/18/2022] Open
Abstract
Background observational studies have shown that nutritional strategies to manage malnutrition may be cost-effective in aged care; but more robust economic data is needed to support and encourage translation to practice. Therefore, the aim of this systematic review is to compare the cost-effectiveness of implementing nutrition interventions targeting malnutrition in aged care homes versus usual care. Setting residential aged care homes. Methods systematic literature review of studies published between January 2000 and August 2017 across 10 electronic databases. Cochrane Risk of Bias tool and GRADE were used to evaluate the quality of the studies. Results eight included studies (3,098 studies initially screened) reported on 11 intervention groups, evaluating the effect of modifications to dining environment (n = 1), supplements (n = 5) and food-based interventions (n = 5). Interventions had a low cost of implementation (<£2.30/resident/day) and provided clinical improvement for a range of outcomes including weight, nutritional status and dietary intake. Supplements and food-based interventions further demonstrated a low cost per quality adjusted life year or unit of physical function improvement. GRADE assessment revealed the quality of the body of evidence that introducing malnutrition interventions, whether they be environmental, supplements or food-based, are cost-effective in aged care homes was low. Conclusion this review suggests supplements and food-based nutrition interventions in the aged care setting are clinically effective, have a low cost of implementation and may be cost-effective at improving clinical outcomes associated with malnutrition. More studies using well-defined frameworks for economic analysis, stronger study designs with improved quality, along with validated malnutrition measures are needed to confirm and increase confidence with these findings.
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Affiliation(s)
- Cherie Hugo
- Faculty of Health Sciences and Medicine, Bond University, Robina, Queensland 4226, Australia
| | - Elisabeth Isenring
- Faculty of Health Sciences and Medicine, Bond University, Robina, Queensland 4226, Australia
| | - Michelle Miller
- Dean of People and Resources at Flinders University, Australia
| | - Skye Marshall
- Faculty of Health Sciences and Medicine, Bond University, Robina, Queensland 4226, Australia
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Simmons SF, Coelho CS, Sandler A, Schnelle JF. A Quality Improvement System to Manage Feeding Assistance Care in Assisted-Living. J Am Med Dir Assoc 2018; 19:262-269. [DOI: 10.1016/j.jamda.2017.12.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 12/14/2017] [Accepted: 12/15/2017] [Indexed: 10/18/2022]
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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.
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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
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Simmons SF, Hollingsworth EK, Long EA, Liu X, Shotwell MS, Keeler E, An R, Silver HJ. Training Nonnursing Staff to Assist with Nutritional Care Delivery in Nursing Homes: A Cost-Effectiveness Analysis. J Am Geriatr Soc 2016; 65:313-322. [PMID: 28198565 DOI: 10.1111/jgs.14488] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVES To determine the effect and cost-effectiveness of training nonnursing staff to provide feeding assistance for nutritionally at-risk nursing home (NH) residents. DESIGN Randomized, controlled trial. SETTING Five community NHs. PARTICIPANTS Long-stay NH residents with an order for caloric supplementation (N = 122). INTERVENTION Research staff provided an 8-hour training curriculum to nonnursing staff. Trained staff were assigned to between-meal supplement or snack delivery for the intervention group; the control group received usual care. MEASUREMENTS Research staff used standardized observations and weighed-intake methods to measure frequency of between-meal delivery, staff assistance time, and resident caloric intake. RESULTS Fifty staff (mean 10 per site) completed training. The intervention had a significant effect on between-meal caloric intake (F = 56.29, P < .001), with the intervention group consuming, on average, 163.33 (95% CI = 120.19-206.47) calories per person per day more than the usual care control group. The intervention costs were $1.27 per person per day higher than usual care (P < .001). The incremental cost-effectiveness ratio for the intervention was 134 kcal per dollar. The increase in cost was due to the higher frequency and number of snack items given per person per day and the associated staff time to provide assistance. CONCLUSION It is cost effective to train nonnursing staff to provide caloric supplementation, and this practice has a positive effect on residents' between-meal intake.
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Affiliation(s)
- Sandra F Simmons
- Division of Geriatrics, Department of Medicine, Vanderbilt University, Nashville, Tennessee.,Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University, Center for Quality Aging, Nashville, Tennessee.,Geriatric Research, Education and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Emily K Hollingsworth
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University, Center for Quality Aging, Nashville, Tennessee
| | - Emily A Long
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University, Center for Quality Aging, Nashville, Tennessee
| | - Xulei Liu
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee
| | - Matthew S Shotwell
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee
| | | | - Ruopeng An
- Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Champaign, Illinois
| | - Heidi J Silver
- Division of Gastroenterology, Hepatology and Nutrition, School of Medicine, Vanderbilt University, Nashville, Tennessee
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Hollingsworth EK, Long EA, Simmons SF. Comparison Between Quality of Care Provided by Trained Feeding Assistants and Certified Nursing Assistants During Between-Meal Supplementation in Long-Term Care Settings. J Appl Gerontol 2016; 37:1391-1410. [DOI: 10.1177/0733464816669806] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The purpose of this study was to compare the quality of feeding assistance provided by trained non-nursing staff with care provided by certified nursing assistants (CNAs). Research staff provided an 8-hr training course that met federal and state requirements to non-nursing staff in five community long-term care facilities. Trained staff were assigned to between-meal supplement and/or snack delivery for 24 weeks. Using standardized observations, research staff measured feeding assistance care processes between meals across all study weeks. Trained staff, nurse aides, and upper level staff were interviewed at 24 weeks to assess staff perceptions of program impact. Trained staff performed significantly better than CNAs for 12 of 13 care process measures. Residents also consumed significantly more calories per snack offer from trained staff ( M = 130 ± 126 [ SD] kcal) compared with CNAs ( M = 77 ± 94 [ SD] kcal). The majority of staff reported a positive impact of the training program.
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Affiliation(s)
| | - Emily A. Long
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sandra F. Simmons
- Vanderbilt University Medical Center, Nashville, TN, USA
- Tennessee Valley Healthcare System, Nashville, TN, USA
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