1322 DEVELOPMENT OF A CORE OUTCOME SET FOR NUTRITIONAL INTERVENTION STUDIES IN OLDER ADULTS WITH MALNUTRITION AND THOSE AT RISK

Background

Malnutrition (i.e., protein-energy malnutrition) in older adults is associated with significant complications and increased mortality, highlighting the need for effective treatments. Many randomised controlled trials (RCTs) testing the effectiveness of nutritional interventions for the treatment of malnutrition showed mixed results and there is a need for meta-analyses. However, evidence synthesis is hampered by the wide variety of outcomes and assessment methods in RCTs. This project, led by EuGMS Special Interest Group Nutrition, aims to develop a Core Outcome Set (COS) for nutritional intervention studies in older adults with malnutrition and those at risk.

Methods

The project consists of five phases: 1) a scoping review (completed) to identify frequently used outcomes in published RCTs and select additional patient-reported outcome measures (PROMs). Patient and Public Involvement (PPI) representatives have been involved to provide feedback on the proposed list of outcomes resulting from the review and PROMs; 2) a modified Delphi Survey whereby experienced researchers and health care professionals working in the field of malnutrition in older adults will be invited to rate the importance of the proposed outcomes; 3) a consensus meeting to discuss and agree what critical outcomes need to be included in the COS; 4) a systematic review to determine how each COS outcome should be measured and a second consensus meeting; 5) a dissemination and implementation phase.

Conclusions

The result of this project will be a COS that should be included in any RCT testing the effectiveness of interventions to tackle malnutrition in older people as a minimum. This COS will facilitate comparison of RCT results, will promote efficient use of research resources and might reduce bias in measurement of the outcome and publication bias. Ultimately, the COS will support clinical decision making by identifying the most effective approaches for treating and preventing malnutrition in older adults.

Effects of an individualised nutritional intervention to tackle malnutrition in nursing homes: a pre-post study

PURPOSE

Individualised interventions are recommended to tackle malnutrition in older adults, but approaches for nursing home (NH) residents are scarce. This study investigated the effects of an individualised nutritional intervention in NH residents with (risk of) malnutrition.

METHODS

In a pre-post study, 6 weeks (w) of usual care were followed by 6w of intervention. The intervention consisted of up to three supplement modules (sweet and savoury protein creams and protein-energy drink, single or combined) and, if required, reshaped texture-modified meals (RTMM).

RESULTS

Fifty residents completed the study (84 ± 8 years, 74% female). One-third (32%) received RTMM. Additional 258 ± 167 kcal/day and 23 ± 15 g protein/day were offered. Mean daily energy intake increased by 207 (95%CI 47-368, p = 0.005) kcal and protein intake by 14 (7-21, p < 0.001) g (w12 vs w1). Quality of life (QoL) increased in the subscale "care relationship" (+ 9 (3-15) points, p = 0.002, w12 vs w6). Body weight, handgrip strength, and other QoL subscales did not change.

CONCLUSION

Our intervention improved dietary intake and one QoL subscale in NH residents with (risk of) malnutrition. As a next step, randomized controlled trials are needed to investigate the impact of individualised interventions more comprehensively.

Nutritional status according to the mini nutritional assessment (MNA)® as potential prognostic factor for health and treatment outcomes in patients with cancer - a systematic review

Background

Patients with cancer have an increased risk of malnutrition which is associated with poor outcome. The Mini Nutritional Assessment (MNA®) is often used in older patients with cancer but its relation to outcome is not known.

Methods

Four databases were systematically searched for studies relating MNA-results with any reported outcome. Two reviewers screened titles/abstracts and full-texts, extracted data and rated the risk of bias (RoB) independently.

Results

We included 56 studies which varied widely in patient and study characteristics. In multivariable analyses, (risk of) malnutrition assessed by MNA significantly predicts a higher chance for mortality/poor overall survival (22/27 studies), shorter progression-free survival/time to progression (3/5 studies), treatment maintenance (5/8 studies) and (health-related) quality of life (2/2 studies), but not treatment toxicity/complications (1/7 studies) or functional status/decline in (1/3 studies). For other outcomes – length of hospital stay (2 studies), falls, fatigue and unplanned (hospital) admissions (1 study each) – no adjusted results were reported. RoB was rated as moderate to high.

Conclusions

MNA®-result predicts mortality/survival, cancer progression, treatment maintenance and (health-related) quality of life and did not predict adverse treatment outcomes and functional status/ decline in patients with cancer. For other outcomes results are less clear. The moderate to high RoB calls for studies with better control of potential confounders.

Joint action malnutrition in the elderly (MaNuEL) knowledge hub: summary of project findings

PURPOSE

The Joint Action Malnutrition in the Elderly (MaNuEL) Knowledge Hub was established to extend scientific knowledge, strengthen evidence-based practice, build a sustainable, transnational network of experts and harmonize research and clinical practice in the field of protein-energy malnutrition in older persons. This paper aims to summarize the main scientific results achieved during the 2-year project and to outline the recommendations derived.

METHODS

22 research groups from seven countries (Austria, France, Germany, Ireland, Spain, The Netherlands and New Zealand) worked together on 6 relevant domains of malnutrition-i.e. prevalence, screening, determinants, treatment, policy measures and education for health care professionals-making use of existing datasets, evidence and expert knowledge.

RESULTS

Four systematic reviews, six secondary data analyses of existing cohort and intervention studies, two web-based surveys and one Delphi study were performed. In addition, a scoring system to rate malnutrition screening tools and a theoretical framework on the aetiology of malnutrition in older persons were developed. Based on these activities and taking existing evidence into consideration, 13 clinical practice, 9 research and 4 policy recommendations were developed. The MaNuEL Toolbox was created and made available to effectively distribute and disseminate the MaNuEL results and recommendations.

CONCLUSIONS

The MaNuEL Knowledge Hub successfully achieved its aims. Results and recommendations will support researchers, healthcare professionals, policy-makers as well as educational institutes to advance their efforts in tackling the increasing problem of protein-energy malnutrition in the older population.

The Refeeding Syndrome revisited: you can only diagnose what you know

BACKGROUND/OBJECTIVES

The Refeeding Syndrome (RFS) is a serious complication in patients receiving nutrition support after a period of severe malnutrition. We frequently recognize and diagnose the RFS due to increased awareness. Thus, we observe that many physicians do not know the RFS and that it is rarely diagnosed. The aim of the study was to determine whether physicians in Germany know the RFS.

SUBJECTS/METHODS

A questionnaire with a case vignette about an older person who developed the RFS after initiation of nutritional therapy was submitted to German physicians and fifth year medical students, who were participants of educational lectures.

RESULTS

Of the 281 participants who answered the respective question, 40 participants (14%) correctly diagnosed the RFS of the case vignette and 21 participants (8%) gave nearly correct answers. Indeed, the majority of the participants did not diagnose the RFS.

CONCLUSIONS

Although the RFS may lead to fatal complications, it is unknown to the majority of the queried physicians. Therefore, there is a call to implement the RFS in respective curricula and increase systematic education on this topic.

Prevalence of Risk Factors for the Refeeding Syndrome in Older Hospitalized Patients

OBJECTIVES

The incidence of refeeding syndrome (RFS) in older patients is not well-known. The aim of the study was to determine the prevalence of known risk factors for RFS in older individuals during hospitalization at geriatric hospital departments.

DESIGN AND SETTING

342 consecutive older participants (222 females) who admitted at acute geriatric hospital wards were included in a cross-sectional study. We applied the National Institute for Health and Clinical Excellence (NICE) criteria for determining patients at risk of RFS. In addition, Mini Nutritional Assessment Short Form (MNA®-SF) was used to identify patients at risk of malnutrition. Weight and height were assessed. The degree of weight loss was obtained by interview. Serum phosphate, magnesium, potassium, sodium, calcium, creatinine and urea were analyzed according to standard procedures.

RESULTS

Of 342 older participants included in the study (mean age 83.1 ± 6.8, BMI range of 14.7-43.6 kg/m2), 239 (69.9%) were considered to be at risk of RFS, in which 43.5% and 11.7% were at risk of malnutrition and malnourished, respectively, according to MNA-SF. Patients in the risk group had significantly higher weight loss, lower phosphate and magnesium levels. In a multivariate logistic regression analysis, low levels of phosphate and magnesium followed by weight loss were the major risk factors for fulfilling the NICE criteria.

CONCLUSION

The incidence of risk factors for RFS was relatively high in older individuals acutely admitted in geriatric hospital units, suggesting that, RFS maybe more frequent among older persons than we are aware of. Patients with low serum levels of phosphate and magnesium and higher weight loss are at increased risk of RFS. The clinical characteristics of the older participants at risk of RFS indicate that these patients had a relatively poor nutritional status which can help us better understand the potential scale of RFS on admission or during the hospital stay.

Size Matters! Differences in Nutritional Care between Small, Medium and Large Nursing Homes in Germany

OBJECTIVES

The aim of this study is to comprehensively describe nutritional care in German nursing homes (NHs) and to examine if nutritional care differs between small, medium and large NHs.

DESIGN

Nationwide cross-sectional postal survey.

SETTING

Nursing homes.

PARTICIPANTS

541 NHs across Germany.

MEASUREMENTS

Information on structural NH characteristics and nutritional care (food provision and menu planning, nursing care, and management and quality assurance) was collected by means of a questionnaire addressed to the management of a random sample of German NHs. NHs were grouped by size as small (≤ 50 beds), medium (50 - 100 beds) or large (> 100 beds) institutions. Frequencies were used to describe nutritional care, and Chi2-test to identify differences in nutritional care by NH size.

RESULTS

Aspects in the domain of food provision and menu planning regarding food variety and choice were widely implemented in German NHs (77 - 100 %). Best results were achieved in the domain of nursing care, where all aspects were implemented in at least 68 % of the NHs. Aspects regarding management and quality assurance, especially those concerning staffing, i.e. the availability of an interface manager (14 %), an interdisciplinary nutrition team (12 %) and a dietician (42 %), were only rarely implemented. Differences by NH size were found between small and medium or large NHs. On the one hand, small NHs stated more often to consider individual capabilities of the residents with texture-modified food (81 % vs. 60 %, p<0.05) and produce more often hot meals at ward level on a regular base (46 % vs. 32 %, p<0.05) than large NHs. On the other hand, several aspects regarding food provision and menu planning, and management and quality assurance were significantly more often implemented in larger than smaller NHs.

CONCLUSION

Whereas kitchen and nursing-related aspects of nutritional care seem to be widely implemented in German NHs, management and quality assurance demands are often not met. The differences found by NH size support the hypothesis that the number of residents living in a NH has an impact on how nutritional care is performed.

Energy and Protein Intake, Anthropometrics, and Disease Burden in Elderly Home-care Receivers--A Cross-sectional Study in Germany (ErnSIPP Study)

OBJECTIVE

To date, no study has examined the nutritional status and disease burden of elderly home-care receivers living in Germany. Aim of this cross-sectional study was, first, to assess disease burden and nutritional status, denoted in anthropometrics, and, second, to investigate associations between anthropometrics and disease burden.

DESIGN

Cross-sectional multi-centre study.

SETTING

Home-care receivers living in three urban areas of Germany in 2010.

PARTICIPANTS

353 elderly (>64 years) in home care (128 males aged 79.1 ±7.8 years, 225 females aged 82.0 ±7.5 years).

MEASUREMENTS

Nutritional status was assessed by body mass index (BMI), mid upper arm circumference (MUAC) and calf circumference (CC). Medical conditions were assessed in personal interviews. A 3-day prospective nutrition diary was kept. Metric data are reported as mean±SD or median (interquartile range), p<0.05 was considered significant.

RESULTS

Most participants were substantially (59%), and 11% severest in need of care. The seniors suffered from 5 (4-7) chronic diseases; dementia, depression, stroke, and respiratory illness were most prevalent (each 20-40%). More than one-third of participants had only moderate or poor appetite, nearly half were unable to eat independently. Chewing problems were reported for 52% of study participants, and more than one quarter of elderly had swallowing problems. Daily mean energy intake was 2017±528 kcal in men (n=123) and 1731±451 kcal in women (n=216; p<0.001). Mean protein intake amounted to 1.0 g/kg body weight. Mean BMI was 28.2±6.2 kg/m² (n=341), 14% of seniors had a BMI <22 kg/m² (including 4% with BMI <20 kg/m²). Critical MUAC (<22 cm) was indicated in 6% of subjects; and CC <31 cm in 11% of men, 21% of women (p<0.05). After adjusting for sex and age, BMI, MUAC and CC were negatively associated with high care level, hospitalization in the previous year, nausea/vomiting, prevalence of dementia, poor appetite, and eating difficulties like dependency, chewing and swallowing problems.

CONCLUSION

We recommend to pay special attention to the nutritional status of elderly persons in home-care exhibiting named disease burden.

Nutritional and Functional Status in Geriatric Day Hospital Patients - MNA Short Form Versus Full MNA

OBJECTIVES

The aims of this study were to determine the prevalence of malnutrition in patients of a geriatric day hospital using the Mini Nutritional Assessment short form (MNA-SF) and the full MNA, to compare both tools, and to examine the relationship between nutritional and functional status.

DESIGN

Cross-sectional study.

SETTING

Geriatric day hospital.

PARTICIPANTS

190 patients (72.1% female, median 80 years) aged 65 years or older.

MEASUREMENTS

In consecutively admitted geriatric day hospital patients nutritional status was assessed by MNA-SF and full MNA, and agreement between both tools calculated by Cohen´s kappa. Basic activities of daily living (ADL), instrumental activities of daily living (IADL) and short physical performance battery (SPPB) were determined and related to MNA categories (Chi2-test, Mann-Whitney-U-test).

RESULTS

36.3 % and 44.7% of the patients were at risk of malnutrition, 8.9 % and 5.8 % were malnourished according to MNA-SF and full MNA, respectively. Agreement between both MNA forms was moderate (κ=0.531). No significant associations between MNA-SF and ADL, IADL and SPPB, and between full MNA and SPPB were observed. According to full MNA, the proportion of patients with limitations in ADL and IADL significantly increased with declining nutritional status (ADL: 2.1 vs. 8.2 vs. 18.2 %, p=0.044; IADL: 25.5 vs. 47.1 vs. 54.5 %, p=0.005) with a simultaneous decrease of the proportion of patients without limitations. Well-nourished patients reached significantly higher ADL scores than patients at risk of malnutrition (95 (90-100) vs. 95 (85-100), p=0.005) and significantly higher IADL scores than patients at risk or malnourished (8 (6-8) vs. 7 (5-8) vs. 6 (4-8), p=0.004).

CONCLUSION

The high prevalence of risk of malnutrition and the observed association between functional status and nutritional status according to full MNA call for routine nutritional screening using this tool in geriatric day hospital patients.

Compliance of nursing home residents with a nutrient- and energy-dense oral nutritional supplement determines effects on nutritional status

OBJECTIVES

Administration of oral nutritional supplements (ONS) is an effective strategy to treat and avoid malnutrition, a persisting issue in nursing homes. However, little is known about compliance in the NH population. This study aimed to analyse the effects of compliance of NH residents with a low-volume, nutrient- and energy-dense ONS on nutritional status and to identify residents' characteristics associated with compliance.

DESIGN AND SETTING

Randomized, controlled trial in nursing homes.

PARTICIPANTS AND INTERVENTION

87 nursing home residents (87 ± 6y, 91% female) with malnutrition or at risk of malnutrition were randomly allocated to an intervention group (IG) receiving 2 x 125 ml ONS (2.4 kcal/ml)/d for 12 weeks, or the control group (CG) with usual care.

MEASUREMENTS

ONS intake was recorded daily and compliance calculated. Low and high compliance were defined as ≤ 30% and ≥ 80% of provided ONS actually consumed, respectively. Body weight (BW), BMI, upper-arm (UAC) and calf-circumference (CC) and MNA-SF were assessed at baseline and after 12 weeks. Associations between compliance and changes of nutritional parameters and residents' characteristics were analysed.

RESULTS

Compliance was high in 35.7% and low in 28.6% of the IG (n=42). BW change was significantly higher in subjects with high compliance (median +3.0 (interquartile range +2.1;+3.8) kg, n=15) than in those with low compliance (-0.2 (-2.2;+1.6) kg, n=12) and CG (-0.1 (-1.2; +0.6) kg, n=35; p<0.001), and significantly correlated with compliance in IG (r=0.691; p<0.001). Significant differences and correlations were also identified for BMI, UAC and MNA-SF. High compliance was more often observed in residents with malnutrition (66.7 vs. 27.3%) and chewing difficulties (77.8 vs. 24.2%) than in those without these conditions. Low compliance was more prevalent in residents who were immobile (45.0 vs. 13.6%), depressed (33.3 vs. 6.7%) or had gastrointestinal complaints (50.0 vs. 17.9%) (all p<0.05).

CONCLUSIONS

A high compliance of nursing home residents with a low volume, nutrient- and energy dense ONS was related to a significantly improved nutritional status in comparison to low compliance and therefore enhanced the effectiveness of ONS. A higher compliance may be achieved by consideration of different residents' characteristics.

Nutritional status according to Mini Nutritional Assessment is related to functional status in geriatric patients--independent of health status

OBJECTIVES

The aim of this study was to investigate the relationship between nutritional and functional status in acute geriatric patients including mobility and considering health status.

DESIGN

Cross-sectional study.

SETTING

Hospital.

PARTICIPANTS

205 geriatric patients (median age 82.0 (IQR: 80-86) years, 69.3% women).

MEASUREMENTS

Nutritional status was determined by Mini Nutritional Assessment (MNA) and patients were categorized as well-nourished (≥ 24 points), at risk of malnutrition (17-23.5 points) or as malnourished (< 17 points). Functional status was determined by Barthel Index (BI) and Timed 'Up and Go' Test (TUG) and related to MNA categories. Using binary multiple logistic regression the impact of nutritional status on functional status was examined, adjusted for health status.

RESULTS

60.3% of the patients were at risk of malnutrition and 29.8% were malnourished. Ability to perform basic activities of daily living (ADL) decreased with declining nutritional status. The proportion of patients unable to perform the TUG increased with worsening of nutritional status (45.0% vs. 50.4% vs. 77.0%, p<0.01). After adjusting for age, gender, number of diagnoses, disease severity and cognitive function, a higher MNA score significantly lowered the risk of being dependent in ADL (OR 0.85, 95 % CI 0.77-0.94) and inability to perform the TUG (OR 0.90, 95 % CI 0.82-0.99).

CONCLUSION

Nutritional status according to MNA was related to ADL as well as to mobility in acute geriatric patients. This association remained after adjusting for health status.