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Helping Understand Nutritional Gaps in the Elderly (HUNGER): A Prospective Study of Patient Factors Associated With Inadequate Nutritional Intake in Older Medical Inpatients
Abstract
Malnutrition and poor intake during hospitalisation are common in older medical patients. Better understanding of patient-specific factors associated with poor intake may inform nutritional interventions. The aim of this study was to measure the proportion of older medical patients with inadequate nutritional intake, and identify patient-related factors associated with this outcome.
Prospective cohort study enrolling consecutive consenting medical inpatients aged 65 years or older. Primary outcome was energy intake less than resting energy expenditure estimated using weight-based equations. Energy intake was calculated for a single day using direct observation of plate waste. Explanatory variables included age, gender, number of co-morbidities, number of medications, diagnosis, usual residence, nutritional status, functional and cognitive impairment, depressive symptoms, poor appetite, poor dentition, and dysphagia.
Of 134 participants (mean age 80 years, 51% female), only 41% met estimated resting energy requirements. Mean energy intake was 1220 kcal/day (SD 440), or 18.1 kcal/kg/day. Factors associated with inadequate energy intake in multivariate analysis were poor appetite, higher BMI, diagnosis of infection or cancer, delirium and need for assistance with feeding.
Inadequate nutritional intake is common, and patient factors contributing to poor intake should be considered in designing nutritional interventions.
... La búsqueda inicial arrojó 4508 registros, de los cuales se seleccionaron 28 que cumplían los criterios de inclusión, 10 proporcionaron datos sobre los factores clínicos y del paciente relacionados con la baja ingesta de nutrientes (12,(15)(16)(17)(18)(19)(20)(21)(22) ; 15 examinaron la relación entre la calidad de la dieta y el déficit calórico-proteico (23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37) , y tres aportaron datos sobre las experiencias y percepciones alimentarias hospitalarias y el consumo de energía y proteínas (38)(39)(40) , los cuales se encuentra desglosados en la Tabla 1. En la Figura 1 se muestra el proceso de selección de artículos. Evaluar el estado nutricional de los pacientes hospitalizados en una sala geriátrica utilizando los recientes criterios de la Iniciativa Global de Liderazgo sobre la Desnutrición (GLIM) para determinar el equilibrio entre la ingesta energética con una dieta enriquecida y el requerimiento energético utilizando calorimetría indirecta. ...
... Mudge y colaboradores (2011) (22) Australia 134 pacientes, ≥ 65 años. Estudio de cohorte prospectivo. ...
... En este sentido, Mudge y colaboradores (22) , en un estudio con 134 pacientes de 65 años o más y que tuvieran una estancia hospitalaria de más de dos días, encontraron que las principales causas asociadas con una menor ingesta de energía y proteínas fueron la falta de apetito, delirio y diagnóstico de infección o cáncer; mientras que McCray y colaboradores (30) , en un estudio que incluyó 85 pacientes, fueron cirugía, malestar al comer, náuseas y cambios en el gusto. ...
Introducción: la desnutrición se asocia con una mayor estancia hospitalaria, tasas de reingreso y riesgo de mortalidad, especialmente en adultos mayores. Objetivo: identificar los factores que afectan la ingesta de alimentos en adultos mayores hospitalizados. Justificación: promover nuevas estrategias en la terapia nutricional hospitalaria en pacientes adultos mayores a través de la identificación de los factores que afectan la ingesta de alimentos de acuerdo con la revisión del presente estudio. Material y métodos: búsqueda sistemática de estudios publicados en las bases de datos de Springer Link, Medline y Scopus a través de la plataforma PubMed en mayo de 2022, con una temporalidad de 20 años. Se buscaron por términos controlados como: anciano, dieta, ingestión de alimentos, consumo de alimentos, deficiencia de proteína y hospitalización. Resultados: se encontraron 4508 artículos en inglés, de los cuales se seleccionaron 28 para el análisis del texto completo debido al cumplimiento de criterios de selección. Conclusiones: el estado nutricional en adultos mayores hospitalizados presenta afectaciones por factores como la enfermedad, la reducción de la actividad física, la fatiga, la depresión y la presencia de síntomas como náuseas y vómitos, la alteración en el proceso de masticación y deglución, y presentar un menor nivel educativo. Los factores dietéticos y de servicio que se relacionan con la baja ingesta son la temperatura de la dieta, la textura, el sabor y la apariencia, así como el mismo entorno hospitalario.
... Is it also with strong evidence how malnourishment among older adults increases the risk of morbidity, mortality, delayed wound healing [4,5], and raises societal costs [6]. The food intake of older adults is influenced by a wide range of individual factors (e.g., preferences, appetite, acute illness, oral issues, mood, dysphagia, confusion, isolation) and structural issues (e.g., meal context, mealtimes, difficulty accessing food and beverage packaging, variety, sensory properties) [7]. Further, risk of malnutrition is closely connected to functional capacity, well-being, and social factors [1,3,7]. ...
... The food intake of older adults is influenced by a wide range of individual factors (e.g., preferences, appetite, acute illness, oral issues, mood, dysphagia, confusion, isolation) and structural issues (e.g., meal context, mealtimes, difficulty accessing food and beverage packaging, variety, sensory properties) [7]. Further, risk of malnutrition is closely connected to functional capacity, well-being, and social factors [1,3,7]. Thus, early identification and treatment of nutrition problems can improve outcomes and quality of life for older adults [4]. ...
... There is common agreement about the importance to have appropriate tools for assessing food intake to investigate the effects of health initiatives targeting malnutrition among older adults [1,7,12]. Traditional dietary assessment methods (e.g., weighed food record, 24-h dietary recall, dietary record (DR) food frequency questionnaire [FFQ], food diaries) can provide detailed information on eating frequencies, energy intake, and nutritional value. ...
To be more successful in preventing malnutrition for older adults living at home, there is a need for better methods to characterize their food behavior, as well as there is a need for health-supporting technologies focusing more on individualized contextual preferences. This study reveals how photos can be used to characterize older adults’ food-related behavior and preferences, and how photo elicitation can be used to design an eating environment in mixed reality for older solitary adults. This study is based on a sample of 22 older adults, who took in total 153 pictures of their meals, and a workshop using photo elicitation with 16 older adults in a community center. The findings revealed how photos can be used as a self-monitoring process to create meaningful and rich in-depth information on food-related behavior of older adults living at home. Photo elicitation can be used as a supplement to characterize older adults’ food-related behavior and preferences in a mixed reality environment. Further, we outline both advantages and limitations of using photo elicitation in a context of human-computer interaction.KeywordsPhoto elicitationMalnutritionOlder adultsMixed reality
... Providing adequate and balanced nutrition in old age is important to protect and improve health and to increase the quality of life [24]. Nursing home food services are one of the factors affecting older adults' nutritional status [25]. In addition, since providing almost all of the residents' nutritional requirements from nursing home food services, menus should contain adequate energy, macro-, and micronutrients [25]. ...
... Nursing home food services are one of the factors affecting older adults' nutritional status [25]. In addition, since providing almost all of the residents' nutritional requirements from nursing home food services, menus should contain adequate energy, macro-, and micronutrients [25]. However, in previous studies, it was determined that nursing home menus could not meet the older adults' requirements for vitamin D, vitamin E, vitamin C, folate, vitamin B 6 , magnesium, calcium, potassium, and zinc [26,27]. ...
Background & Aims
There are studies in the literature that consider only the opinions of older adults about food service or only the status of meeting dietary needs to evaluate the quality of food services. However, evaluating both satisfaction (residents’ perspective) and nutritional adequacy (experts’ perspective) together is important for ensuring adequate food intake and meeting dietary requirements. This study aimed to evaluate the quality of nursing home food service from both perspectives and to detect its effects on older adults’ nutritional status.
Methods
A cross-sectional study was conducted on 101 older adults. Satisfaction with the food service and nutritional status was assessed using a questionnaire and the Mini Nutritional Assessment Short Form.
Results
The 28-days menu had higher energy for females, lower protein for males, higher fat and sodium for both genders, and inadequate micronutrient (vitamin B6, folic acid, vitamin B12, potassium, calcium, magnesium, etc.) contents than recommended. Older adults were 65.1% satisfied with food service, and dissatisfaction was associated with a decrease of 8.42%, 6.85%, and 6.25% in meeting their energy, protein, and fiber requirements, respectively, and an increase of almost 20 times in malnutrition risk.
Conclusion
Our findings shed light on the importance of food service quality in nursing homes and of evaluating the satisfaction of residents, as well as the nutritional adequacy of menus.
... Weight loss can be the result of multiple factors, including anorexia and poor intake, cachexia as a result of underlying illness and an inflammatory state, and sarcopenia or loss of muscle mass and function [9,13]. The latter is also frequently seen with decreased levels of testosterone or estrogen, and is also associated with increased insulin resistance. ...
... Older adults also experience specific nutritional deficiencies, including B, C, and D vitamins as well as calcium and folate [4••]. Patients who are most vulnerable from a nutritional standpoint thus include older adults, those with sepsis or malignancy, patients who require help feeding themselves and, perhaps counterintuitively, obese patients [13]. Weight loss and malnutrition is also often related to underlying pathology, such as cancer, endocrine disease, or organ failure, but it can also be seen in patients with dementia, polypharmacy, psychiatric disease, most commonly depression, and other socio-economic factors. ...
Purpose of Review
Poor nutritional status is common among inpatients, and particularly so among surgical patients. The problem is even more pronounced among elderly surgical patients, with age itself being an independent risk factor for malnutrition. With older adults representing a large proportion of patients undergoing emergency operations, and with malnutrition contributing to worse surgical outcomes, peri-operative nutritional optimization has garnered significant interest in the surgical literature. We sought to review the literature, specifically over the last five years, regarding the approach to nutritional evaluation and optimization in the pre- and post-operative settings in the elderly surgical patient.
Recent Findings
Recent research has focused on the pathophysiologic mechanisms that drive cachexia, including inflammatory and endocrine pathways and their interplay in patients subjected to the stress of surgery, as well as on the important differences between cachexia and sarcopenia. Emphasis has been placed on approaching nutritional status in a systematic fashion and on using context-specific validated screening tools in addition to biochemical and anthropometric parameters. In the elective setting, Enhanced Recovery After Surgery (ERAS) pathways have become the norm. With this, the concept of multimodal prehabilitation has been extensively studied and societal recommendations have been made.
Summary
Elderly surgical patients constitute a particularly vulnerable population who is at risk of poor post-operative outcomes by virtue of both advanced age and poor nutritional status. Serum albumin, BMI, and history of recent involuntary weight loss or poor intake should be supplemented with screening tools such as the Nutritional Risk Screening (NRS-2002) to evaluate each patient’s nutritional risk. Nutritional and physical activity interventions lead to better outcomes, and should be implemented well before surgery and continued in the post-operative setting. It will be interesting and useful in the future to evaluate how these strategies translate to patients undergoing emergency surgery and who therefore do not usually have the benefit of pre-operative optimization.
... In hospitalized older patients, the need for assistance with feeding was associated with inadequate energy intake. 47 Our finding that body weight decreased in patients with ADL dependency may thus be explained by lower nutritional intake in these patients. ...
... Por outro lado, em muitos serviços, a equipe da cozinha dietética não possui treinamento técnico suficiente. Isso, infelizmente, colabora para a baixa aceitabilidade com a ingestão alimentar inadequada [76][77][78][79][80][81][82] . ...
... Daily protein intake in our patients was 1.0 g$kg À1 $d À1 (Table 1), which is in line with earlier work in older community-dwelling individuals [28e30]. Following hospital admission, food intake typically declines [31,32]. Protein provision in the usual care group was in line with previous observations [3,4] and averaged 0.8 g$kg À1 $d À1 . ...
... In a meta-analysis conducted by Cereda et al. [14], the prevalence of undernutrition was estimated across six healthcare settings using the Mini Nutritional Assessment (MNA) tool: community (3.1%), outpatient (6.0%), home care services (8.7%), hospital (22.0%), nursing homes (17.5%), long-term care (28.7%), and rehabilitation units (29.4%). Despite its high prevalence, malnutrition has been reported as an under-diagnosed problem in older people [15,16]. ...
Background: Older adults are vulnerable to malnutrition due to physical, psychological, and social factors. Malnutrition, a prevalent and modifiable issue in this population, is associated with an elevated risk of adverse clinical outcomes. The purpose of the study is to assess the nutritional status of older adult individuals admitted to a general hospital and examine its correlation with socio-health and demographic variables. Methods: The study included 239 individuals aged 70 and above, employing a cross-sectional descriptive observational approach with a convenience sampling method. Sociodemographic information was gathered, and variables such as cognitive impairment, functional capacity, comorbidities, medication consumption, and nutritional status were evaluated. Statistical analysis involved descriptive calculations, bivariate analysis, and multi-variate analysis, utilizing binary logistic regression. Results: Approximately half of the sample were at risk of malnutrition, with a more notable prevalence among women. Factors such as age (OR = 1.04), cognitive impairment (OR = 1.06), functional dependence (OR = 0.96), and comorbidities (OR = 1.08) were linked to an elevated risk of malnutrition. In our regression model, age, cognitive impairment , and drug consumption emerged as significant predictors of malnutrition risk. Conclusions: Individuals aged 70 and above have a notably high prevalence of malnutrition risk, particularly among those experiencing functional dependence and cognitive impairment. In our sample, cognitive impairment in older adults, coupled with above-median drug consumption, emerges as the primary predictor for malnutrition risk.
... However, among medical patients, the effect of nutritional support may also depend on underlying disease. Mudge et al. identified diagnosis of infection or cancer to be associated with inadequate energy intake in patients aged 65 years or older [81]. A recent study by Bargetzi et al. found that kidney disease predicted response to nutritional treatment with lower eGFR showing stronger clinical benefit [45]. ...
... Nutritional status is often compromised in the elderly. Physiological and social changes resulting from advanced age, comorbidities, high consumption of drugs, degenerative loss of mobility, psychological and mental distress, and loss of appetite are just some of the factors that affect the nutritional status of this age group [1,2]. ...
Background
Elderly are one of the most heterogeneous and vulnerable groups who have a higher risk of nutritional problems. Malnutrition is prevalent among hospitalized elderly but underdiagnosed and almost undistinguishable from the changes in the aging process. The Geriatric Nutritional Risk Index (GNRI) is a tool created to predict nutrition-related complications in hospitalized patients. This study aims to measure the prevalence of nutritional risk using the GNRI among hospitalized elderly Egyptian inpatients and to determine the association between the GNRI and selected adverse clinical outcomes.
Methods
A hospital-based prospective cohort study was conducted among 334 elderly patients admitted to a tertiary specialized geriatric university hospital in Cairo, Egypt from August 2021 to June 2022. Within 48 hours after hospital admission, socio-demographic characteristics, blood biomarkers, anthropometric measurements, and nutritional risk assessment by the GNRI score were obtained. Patients were divided into three groups based on their GNRI: high, low, and no nutritional risk (GNRI<92, 92-98, and >98) respectively. Patients were followed up for the occurrence of adverse outcomes during hospital stay (bed sores, Healthcare-Associated Infections (HAIs), hospital Length of Stay (LOS), and hospital mortality) and three months after discharge (non-improvement medical status, appearance of new medical conditions, hospital readmission and 90-day mortality). Multivariable regression and survival analysis were conducted.
Results
The prevalence of high-nutritional risk was 45.5% (95% CI, 40%–51%). Patients with high risk had significantly longer LOS than those with no risk. The high-nutritional risk was significantly associated with the development of bed sores (Adjusted Odds Ratio (AOR) 4.89; 95% CI, 1.37–17.45), HAIs (AOR: 3.18; 95% CI, 1.48–6.83), and hospital mortality (AOR: 4.41; 95% CI, 1.04–18.59). The overall survival rate was significantly lower among patients with high-nutritional risk compared to those with no risk.
Conclusion
GNRI is a simple and easily applicable objective nutritional screening tool with high prognostic value in this Egyptian sample of patients. The findings of this study signal the initiation of the application of this tool to all geriatric hospitals in Egypt.
... Simple tasks such as delivering food trays to a patient in a respectful, calm and polite manner as well as taking time out to describe the meal content to the patient will positively enhance his or her satisfaction (o'Regan 2009). Poor appetite was a commonly reported reason for not consuming all the offered food and supports existing literature where a loss of appetite or "not hungry" was also reported as the main reason for reduced intake by hospital patients (Mudge, Ross, Young, Isenring, & Banks, 2011). ...
Nutrients are essential to support the growth and healing of sick individuals. Most hospital provides meals for admitted patients. Sometimes these meals are not taken by these patients due to one reason or the other. Patients' satisfaction with hospital meals could play a role in the quality of care rendered. Aim: This study aimed to assess patients' attitudes and satisfaction with meals served to inpatients at Aminu Kano Teaching Hospital. Methods: A cross-sectional descriptive design was used to collect data from one hundred and thirty-one respondents utilizing a self-structured questionnaire. Data analysis was analyzed using simple descriptive statistics and results were presented in frequency and percentages. Results: The mean age of respondents was 41.5±5years, the majority are female 53.4%, married 66.4%, Hausa/Fulani 78.6% and have no formal education 33.4%. The preferred meal was home 68.7% and 62.6% were never asked about their choice of meal. The majority of the respondents 72.5% were satisfied with the hospital meal. There was no significant relationship between the level of income and satisfaction with hospital meals (X2 = 5.934; p = 0.115). Conclusion: Most patients are satisfied with the hospital meal. There was no relationship between income and satisfaction with hospital meals. It is recommended that patients be involved with the choice of meal served as this will enhance the taking of hospital meals and also help in quick healing and quality of care.
... Simple tasks such as delivering food trays to a patient in a respectful, calm and polite manner as well as taking time out to describe the meal content to the patient will positively enhance his or her satisfaction (o'Regan 2009). Poor appetite was a commonly reported reason for not consuming all the offered food and supports existing literature where a loss of appetite or "not hungry" was also reported as the main reason for reduced intake by hospital patients (Mudge, Ross, Young, Isenring, & Banks, 2011). ...
Nutrients are essential to support the growth and healing of sick individuals. Most hospital provides meals for admitted patients. Sometimes these meals are not taken by these patients due to one reason or the other. Patients' satisfaction with hospital meals could play a role in the quality of care rendered. Aim: This study aimed to assess patients' attitudes and satisfaction with meals served to inpatients at Aminu Kano Teaching Hospital. Methods: A cross-sectional descriptive design was used to collect data from one hundred and thirty-one respondents utilizing a self-structured questionnaire. Data analysis was analyzed using simple descriptive statistics and results were presented in frequency and percentages. Results: The mean age of respondents was 41.5±5years, the majority are female 53.4%, married 66.4%, Hausa/Fulani 78.6% and have no formal education 33.4%. The preferred meal was home 68.7% and 62.6% were never asked about their choice of meal. The majority of the respondents 72.5% were satisfied with the hospital meal. There was no significant relationship between the level of income and satisfaction with hospital meals (X2 = 5.934; p = 0.115). Conclusion: Most patients are satisfied with the hospital meal. There was no relationship between income and satisfaction with hospital meals. It is recommended that patients be involved with the choice of meal served as this will enhance the taking of hospital meals and also help in quick healing and quality of care.
... Within both groups, the energy and protein targets and the intake showed poor agreement, with many patients in negative energy and protein balance, which is in line with other studies in geriatric patients (40,41). High prevalence of poor appetite, delirium, infection, cancer and assistance required for feeding in older patients have shown to be associated with inadequate energy intake (42). This could partly explain why patients were unable to meet energy targets in NEED. ...
Objectives
To assess if nutritional interventions informed by indirect calorimetry (IC), compared to predictive equations, show greater improvements in achieving weight goals, muscle mass, strength, physical and functional performance.
Design
Quasi-experimental study.
Setting and Participants
Geriatric rehabilitation inpatients referred to dietitian.
Intervention and Measurements
Patients were allocated based on admission ward to either the IC or equation (EQ) group. Measured resting metabolic rate (RMR) by IC was communicated to the treating dietitian for the IC group but concealed for the EQ group. Achieving weight goals was determined by comparing individualised weight goals with weight changes from inclusion to discharge (weight gain/loss: >2% change, maintenance: ≤2%). Muscle mass, strength, physical and functional performance were assessed at admission and discharge. Food intake was assessed twice over three-days at inclusion and before discharge using plate waste observation.
Results
Fifty-three patients were included (IC n=22; EQ n=31; age: 84.3±8.4 years). The measured RMR was lower than the estimated RMR within both groups [mean difference IC −282 (95%CI −490;−203), EQ −273 (−381;−42) kcal/day)] and comparable between-groups (median IC 1271 [interquartile range 1111;1446] versus EQ 1302 [1135;1397] kcal/day, p=0.800). Energy targets in the IC group were lower than the EQ group [mean difference −317 (95%CI −479;−155) kcal/day]. There were no between-group differences in energy intake, achieving weight goals, changes in muscle mass, strength, physical and functional performance.
Conclusions
In geriatric rehabilitation inpatients, nutritional interventions informed by IC compared to predictive equations showed no greater improvement in achieving weight goals, muscle mass, strength, physical and functional performance. IC facilitates more accurate determination of energy targets in this population. However, evidence for the potential benefits of its use in nutrition interventions was limited by a lack of agreement between patients’ energy intake and energy targets.
... The aging of the population is one of the factors influencing the increase in the prevalence of malnutrition, as the elderly are a group at risk due to their biological, psychological, and social characteristics. Malnutrition is underdiagnosed in geriatrics, and this was the origin of the development of the Mini Nutritional Assessment (MNA) scale [17,18]. It is a structured and validated nutritional assessment method for the population at the hospital, residential, or community level dedicated to obtaining an assessment of the nutritional status among malnourished elderly people or those at risk of malnutrition [19,20]. ...
Frailty is a biological syndrome that leads to a loss of physiological reserve, increasing susceptibility to adverse health events. In the Peruvian Amazon, the elderly live with hardly any economic resources, presenting a caloric deficit that is related to functional and cognitive deterioration. Our objective was to identify the health needs of elderly people living in extreme poverty in Requena (Peru) by means of a geriatric assessment of the nutritional and functional spheres to design, in the future, a cooperation project appropriate to the needs detected. This is an observational, descriptive, and cross-sectional study. Sixty participants were included, and sociodemographic and functional status variables were analyzed using the MNA and Barthel scales and the Get Up and Go test. The mean age of the participants was 79 ± 6.67 (women 55% and men 45%), where 60% had frailty. A statistically significant relationship was found between the MNA scores and Barthel test. Eighty-five percent were malnourished or at risk and thirteen percent had total or moderate dependence. We conclude that the nutritional status of the elderly was deficient. The high degree of living alone in which they live forces them to maintain their independence and their walking stability is normal. The situation of frailty exceeds the national average, a situation that has repercussions for their quality of life. We found a statistically significant association between nutritional status, dependence, and frailty. The better-nourished elderly are less frail and less dependent.
... Still, understanding the interplay of different chronic and acute diseases is challenging and needs further research. Mudge et al. identified diagnosis of infection or cancer to be associated with inadequate energy intake in patients aged 65 years or older [170] (Level of evidence: 2þþ). A recent study by Bargetzi et al. found that kidney disease predicted response to nutritional treatment with lower estimated glomerular filtration rates [eGFR] showing stronger clinical benefit [89] (Level of evidence: 1þþ). ...
Background:
Disease-related malnutrition in polymorbid medical inpatients is a highly prevalent syndrome associated with significantly increased morbidity, disability, short- and long-term mortality, impaired recovery from illness, and cost of care.
Aim:
As there are uncertainties in applying disease-specific guidelines to patients with multiple conditions, our aim was to provide evidence-based recommendations on nutritional support for the polymorbid patient population hospitalized in medical wards.
Methods:
This update adheres to the standard operating procedures for ESPEN guidelines. We did a systematic literature search for 15 clinical questions in three different databases (Medline, Embase and the Cochrane Library), as well as in secondary sources (e.g. published guidelines), until July 12th. Retrieved abstracts were screened to identify relevant studies that were used to develop recommendations (incl. SIGN grading), which was followed by submission to Delphi voting.
Results:
From a total of 3527 retrieved abstracts, 60 new relevant studies were analyzed and used to generate a guideline draft that proposed 32 recommendations (7x A, 11x B, 10x O and 4x GPP), which encompass different aspects of nutritional support including indication, route of feeding, energy and protein requirements, micronutrient requirements, disease-specific nutrients, timing, monitoring and procedure of intervention. The results of the first online voting showed a strong consensus (agreement of >90%) on 100% of the recommendations. Therefore, no final consensus conference was needed.
Conclusions:
Recent high-quality trials have provided increasing evidence that nutritional support can reduce morbidity and other complications associated with malnutrition in polymorbid patients. The timely screening of patients for risk of malnutrition at hospital admission followed by individualized nutritional support interventions for at-risk patients should be part of routine clinical care and multimodal treatment in hospitals worldwide. Use of this updated guideline offers an evidence-based nutritional approach to the polymorbid medical inpatients and may improve their outcomes.
... The inadequate fibre provided by the haemodialysis menu is also similar to results from a previous study for salt-restricted standard menus [25]. This should be of concern to dietitians as it is well known that oral intake is suboptimal among hospital patients and malnutrition can develop rapidly in vulnerable patients with prolonged hospital stays [11,27]. ...
Aim: To evaluate the nutritional adequacy of the hospital haemodialysis menu, quantify the dietary intake of hospitalised haemodialysis patients and explore patient perceptions of the menu. Methods: The menu analysis compared the default menu to reference standards using a one sample t-test via SPSS. Eight hospitalised haemodialysis patients were purposively interviewed using semi-structured interviews. Thematic analysis was used to identify the dominant themes. The participant’s actual dietary intake was calculated and compared to individual nutrients using evidence-based guidelines. Results: Compared to the reference standards, the default inpatient haemodialysis menu did not provide adequate energy (p < 0.001, mean = 8767 kJ/day ± 362), sodium (p < 0.001, mean = 72 mmol/day ± 9), potassium (p < 0.001, mean = 64 mmol/day ± 4), vitamin C (p ≤ 0.001, mean = 33 mg/day ± 10) and fibre (p < 0.001, mean = 26 g/day ± 3). Inadequate intake of energy and protein occurred in half of the participants. Passive acceptance of the menu, environmental and cultural considerations contributed to missed food opportunities impacting the patient experience and limited intake. Conclusions: The profile of the current default inpatient haemodialysis menu impacts the dietary intake and the experience of haemodialysis inpatients. It is recommended that the default menu is optimised in line with evidence-based guidelines for inpatients.
... Within both groups, the energy and protein targets and the intake showed poor agreement, with many patients in negative energy and protein balance, which is in line with other studies in geriatric patients (40,41). High prevalence of poor appetite, delirium, infection, cancer and assistance required for feeding in older patients have shown to be associated with inadequate energy intake (42). This could partly explain why patients were unable to meet energy targets in NEED. ...
Objectives: To assess if nutritional interventions informed by indirect calorimetry (IC), compared to predictive equations, show greater improvements in achieving weight goals, muscle mass, strength, physical and functional performance.
Design: Quasi-experimental study
Setting and participants: Geriatric rehabilitation inpatients referred to dietitian
Intervention and measurements: Patients were allocated based on admission ward to either the IC or equation (EQ) group. Measured resting metabolic rate (RMR) by IC was communicated to the treating dietitian for the IC group but concealed for the EQ group. Achieving weight goals was determined by comparing individualised weight goals with weight changes from inclusion to discharge (weight gain/loss: >2% change, maintenance: ≤2%). Muscle mass, strength, physical and functional performance were assessed at admission and discharge. Food intake was assessed twice over three-days at inclusion and before discharge using plate waste observation.
Results: Fifty-three patients were included (IC n=22; EQ n=31; age: 84.3±8.4 years). The measured RMR was lower than the estimated RMR within both groups [mean difference IC -282 (95%CI -490;-203), EQ -273 (-381;-42) kcal/day)] and comparable between-groups (median IC 1271 [interquartile range 1111;1446] versus EQ 1302 [1135;1397] kcal/day, p=0.800). Energy targets in the IC group were lower than the EQ group [mean difference -317 (95%CI -479;-155) kcal/day]. There were no between-group differences in energy intake, achieving weight goals, changes in muscle mass, strength, physical and functional performance.
Conclusions: In geriatric rehabilitation inpatients, nutritional interventions informed by IC compared to predictive equations showed no greater improvement in achieving weight goals, muscle mass, strength, physical and functional performance. IC facilitates more accurate determination of energy targets in this population. However, evidence for the potential benefits of its use in nutrition interventions was limited by a lack of agreement between patients’ energy intake and energy targets.
... Likewise, in this study, it was found that people living alone had a more poor appetite than those living with someone. Mudge et al. (47), stated that nutritional intake was assessed by measuring plate waste, and in a multivariate reported, poor appetite was the strongest predictor of inadequate nutritional intake. Poor appetite can lead to low dietary intake and malnutrition among elderly adults (13) and psychological factors such as depression and well-being are related to appetite (14). ...
... In elderly people with cognitive impairment, the phenomenon is also more serious, since malnutrition irreversibly worsens other health conditions [13]. At the same time, mental status significantly affects nutritional status; people with lower cognitive levels tend to face a higher risk of malnutrition, especially during hospitalization [14,15]. The relationships between nutritional status, cognitive decline, and performance are complex and reciprocal: the presence or the risk of malnutrition may influence cognitive performance, and the presence of cognitive decline may affect the activities of daily living (ADL), also affecting food intake [16]. ...
Cognitive impairment and dementia can negatively impact the nutritional capacities of older people. Malnutrition is common in hospitalized frail elderly people with cognitive impairment and negatively affects prognosis. Malnutrition worsens the quality of life and increases morbidity and mortality. This scoping review aimed to identify factors affecting the risk of malnutrition and preventive strategies in hospitalized patients with cognitive impairment, focusing on nursing interventions. The authors researched population, context, and concept in international databases of nursing interest. Full texts that met the inclusion criteria were selected and reviewed. The extracted data were subject to thematic analysis. A five-stage approach, already reported in the scientific literature, was utilized in the following scoping review. Of 638 articles yielded, 9 were included. Two focus areas were identified as follows: (1) prevalence and risk factors of malnutrition in older patients with cognitive decline; (2) nursing strategies used to enhance clinical outcomes. Nursing health interventions aim to recognize and reduce malnutrition risk, positively impacting this phenomenon. A multidisciplinary team is essential to meet the nutritional needs of these patients.
... Potential prognostic factors of nutritional intake were collected from the patients' electronic records, including age [14], sex [15], weight at admission [16], type of admission (elective or unplanned), American Society of Anesthesiologists Physical Status Classification (ASA PS Classification) [16], length of stay (LOS) [17] and type of surgery (colorectal, hepato-pancreato-biliary, esophageal, neuroendocrine, plastic and reconstructive or oral maxillofacial) [18]. Additionally, risk screening scores measured at the day of hospital admission were collected, i.e., the Short Nutritional Assessment Questionnaire (SNAQ) score [19], the Delirium Observation Scale (DOS) score [20], Amsterdam UMC Extension of the Johns Hopkins Highest Level of Mobility scale (AMEXO) score, and the Johns Hopkins Fall risk assessment score. Furthermore, Numeric Rating Scale (NRS) pain scores [21] measured at the day of admission and consequently every morning until the seventh day of admission were retrieved from the electronic patient records. ...
Background:
An early return to normal intake and early mobilization enhances postoperative recovery. However, one out of six surgical patients is undernourished during hospitalization and approximately half of the patients eat 50% or less of the food provided to them. We assessed the use of newly introduced breakfast buffets in two wards for gastrointestinal and oncological surgery and determined the impact on postoperative protein and energy intake.
Methods:
A prospective pilot cohort study was conducted to assess the impact of the introduction of breakfast buffets in two surgical wards. Adult patients had the opportunity to choose between an attractive breakfast buffet and regular bedside breakfast service. Primary outcomes were protein and energy intake during breakfast. We asked patients to report the type of breakfast service and breakfast intake in a diary over a seven-day period. Prognostic factors were used during multivariable regression analysis.
Results:
A total of 77 patients were included. The median percentage of buffet use per patient during the seven-day study period was 50% (IQR 0-83). Mean protein intake was 14.7 g (SD 8.4) and mean energy intake 332.3 kcal (SD 156.9). Predictors for higher protein intake included the use of the breakfast buffet (β = 0.06, p = 0.01) and patient weight (β = 0.13, p = 0.01). Both use of the breakfast buffet (β = 1.00, p = 0.02) and Delirium Observation Scale scores (β = -246.29, p = 0.02) were related to higher energy intake.
Conclusion:
Introduction of a breakfast buffet on a surgical ward was associated with higher protein and energy intake and it could be a promising approach to optimizing such intake in surgical patients. Large, prospective and preferably randomized studies should confirm these findings.
... A recent systematic review [28] highlighted evidence that dietitians may improve nutrition care and patient, healthcare and/or workforce outcomes across the Nutrition Care Process (NCP) domains, particularly for patients with or at risk of malnutrition. It is well established that malnutrition and its associated complications negatively impact cost and clinical and patient-centered outcomes, including mortality [29]. Several studies have suggested that a significant proportion of patients with COVID-19 are at high risk of malnutrition [30,31]. ...
The COVID-19 pandemic has brought about various restrictions around the world, and its impact on healthcare has been enormous: RDNs have had to shift from in-person interactions with clients to telenutrition consultations, encountering obstacles. We designed the first survey to investigate the changes in RDN practices related to telenutrition provision after the onset of the pandemic through an online survey in Italy. Four hundred and thirty-six responses were analyzed. Before the pandemic, only 16% of Italian RDNs provided telenutrition; this percentage increased significantly up to 63% (p < 0.001). Among patients, the lack of interest in accessing telenutrition (30.9%) and the Internet (16.7%) were the most frequently reported barriers. Among RDNs, one of the main obstacles was their inability to conduct nutritional evaluation or monitoring activities (24.4%). Our survey indicated that increased adoption of telenutrition can be a valid, safe alternative to face-to-face visits. Telenutrition was mainly used by young RDNs (20-39 years) with fewer years of professional experience (0-20 years) and master's degrees. Remote nutrition can enable RDNs to maintain normal workloads and provide patients with uninterrupted access to nutritional healthcare. It is important that RDNs using telemedicine resources possess the ability to provide high-quality, efficient, and secure services using evidence-based guidance.
... 28,30,31,36 These findings are consistent with those of a recent study in which 85% of patients with hospitalacquired malnutrition were found to have nutrition impact symptoms and protein and energy intakes less than 80% of prescribed requirements for longer than 2 weeks. 51 Where oral intake is negatively affected by condition-or treatment-related symptoms, as is often the case in hospitalised patients, 52 and particularly oncological patients undergoing chemotherapy or radiation therapy, it may be argued that appropriate pharmacological management of symptoms may result in optimised intakes. Lack of provision thereof can be considered to be a modifiable and preventable cause of malnutrition. ...
Background:
Malnutrition affects between 20% and 50% of hospital inpatients on admission, with further declines expected during hospitalisation. This review summarises the existing literature on hospital-acquired malnutrition that examines the magnitude of nutritional deterioration amongst adult inpatients and identifies preventable barriers to optimising nutrition support during episodes of care.
Methods:
A systematic review was conducted to answer the question: Among adult hospital inpatients, the presence of which modifiable factors contribute to hospital-acquired malnutrition? A database search was conducted between the 24 April and 30 June 2020 using CINAHL, MEDLINE, Scopus and PubMed databases according to a protocol registered with PROSPERO (CD42020182728). In addition, issues of the 10 top clinical nutrition journals published during the period of from 1 April 2015 to 30 March 2020 were hand-searched.
Results:
Fifteen articles were eligible for inclusion from a total of 5944 retrieved abstracts. A narrative synthesis of evidence was completed because of the high level of heterogeneity in methodologies. Nutritional deterioration is common among previously well-nourished and nutritionally compromised patients, with studies reporting that 10%-65% of patients experienced nutritional decline. Frequently reported barriers were mealtime interruptions, meal dissatisfaction, procedure-related fasting, effects of illness or treatment, chewing difficulties, poor appetite and malnutrition as a low clinical priority.
Conclusions:
The findings of this review support the need for routine nutritional risk screening throughout each hospital admission with hospital-acquired malnutrition affecting up to 65% of inpatients. Clear establishment of the roles and responsibilities of each member within multidisciplinary healthcare teams in the provision of nutrition care and cost-benefit analyses are recommended to demonstrate the effectiveness of changes to models of care.
... According to this methodology, 26.8% of the food served was wasted at AL-Khor hospital, with the side plate being the most often discarded dish. This rate is close to the highest rates identified by other studies, both recent and older, most of which reported rates ranging between 25% and 40% [54][55][56][57][58][59][60][61][62][63]. The overall prevalence of food waste (26.8 %) founded by the current study was inconsistence with Italian hospitals in several studies in the Piedmont region [64] reported that 31.2% of the food served was wasted. ...
Background: Food waste (FW) has been linked with nutrient intake, menu planned, food acceptability, costs, and environmental impacts. Objectives: This project aims to evaluate FW in the units of AL-Khor hospital-Hamad Medical Corporation (HMC) in the state of Qatar. Methods: The evaluation of the FW of main meals and nourishments was performed over six months (Jan-June) / 2019, For each client, the type of diet and FW were evaluated during the length of the study (covering 563 meals and 211 snacks). The FW of the dish was calculated by the physical method by weighing before and after distribution. Dietary Intake Monitoring System (DIMS) was used to record plate contents before and after consumption for the 563 patients at 3 main meals and 3 snacks. Results: The average waste rate was calculated as the weighted average of food remaining in the plate in all meals and snacks in relation to the weight of served food. The current study allowed us to estimate that (26.8%) of the food served in general hospital was wasted. Conclusion: establishing an efficient communication structure involving all actors along the food supply chain contributes to decreasing food waste is crucial.
... p = 0.023), which is consistent with the research results of Landi et al. and Li et al. [16] [17], providing a certain theoretical basis for the application and promotion of appetite assessment in the nutritional care of inpatients. Appetite directly affects food intake, so appetite is closely related to insufficient nutritional intake and weight loss, and is one of the important factors predicting nutritional risk [18]. Therefore, appetite assessment and intervention are very important to improve the nutritional status of hospitalized patients. ...
... Both malnutrition and dehydration have been recognised as risk factors for developing delirium [12,13], perhaps not surprisingly considering the high metabolic requirements of the brain and the need for reliable brain blood flow [14][15][16]. However, delirium also increases the risk of poor oral intake [17,18], potentially creating a vicious circle [19]. Malnutrition should be screened at admission using a validated tool (e.g. ...
Delirium is a common and serious complication in hospitalised older people. Poor nutrition and hydration are both risk factors for, and consequences of, delirium. This chapter will discuss the phenomenology of delirium and the role of nurses in recognising, preventing and managing this serious complication. It will also provide practical strategies to support nutrition and hydration in patients with, or at risk of, delirium.KeywordsDeliriumCognitive impairmentPrevention of deliriumMalnutritionMealtime care
... While supporting cultural food preferences can improve quality of life, it may also not be consistent with dietary recommendations. There are a variety of considerations and challenges when addressing this goal including medication and illness-based dietary restrictions, the need to adapt food viscosity and texture based on swallowing and dentition, age-related changes to appetite and taste, and the limited ability to independently access and prepare healthy foods (Locher et al., 2009;Mudge et al., 2011;Roberts et al., 2019). The diversity and complexity of potential obstacles requires an HBPC-WH approach that is broad and inclusive and incorporates the patient, caregiver, interdisciplinary care team, and community resources. ...
Through the integration of Whole Health for Life into the Department of Veterans Affairs (VA) health care system, the VA aims to transform health care delivery from a disease management approach to one that embraces person-centered care. The home-based primary care (HBPC) program is a care model that, within the VA, provides holistic primary care services to homebound veterans with multiple chronic medical conditions, mental health issues, and functional declines. These veterans may have limited access to VA programs delivered in a traditional outpatient format. This article describes adaptations to the whole health model of care that could improve its accessibility and applicability to HBPC veterans, caregivers, and the interdisciplinary teams that serve this population. These modifications are informed by whole-person geriatric and gerontological and family-systems theories and address population-based differences in the focus and approach to care. The focus on care is expanded to (a) reflect the importance of attending to caregiver needs and well-being and (b) shift from a preventative model to one that prioritizes resilience and maintenance. The approach to care emphasizes alternative modes of delivery, adaptations to interventions, and integration of geriatric-specific medical considerations into the self-care domains and more directly centers the collaboration between family, the VA, and community partners. This adapted model also addresses the unique needs of health care teams providing in-home services to medically complex veterans and offers suggestions for enhancing self-care and preventing burnout. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
... Total GOHAI, autonomy for oral care, access to the dentist and edentulism combined with 0 or 1 prosthesis were found to be statistically significant for malnutrition after adjustment for socio-demographic factors. 12.1% percent were considered "Low Risk of Bias," with a "Yes" for all nine criteria [39,45,47,49]. ...
Purpose: To evaluate whether poor oral health is associated with a higher risk of malnutrition based on the Mini Nutritional Assessment (MNA) or MNA-SF (short form) in older adults.
Study Selection: For this meta-analysis, cohort and cross-sectional studies with adults 65 years and older, reporting oral health outcomes (i.e. edentulism, number of teeth) and either the MNA or MNA-SF were selected. Four electronic databases were searched (Medline via PubMed, Web of Science, Cochrane Library and EMBASE) through June 2020. Risk of bias was assessed with the checklist by the Agency for Healthcare Research and Quality scale.
Results: A total of 928 abstracts were reviewed with 33 studies, comprising 27,559 participants, aged ≥65 being ultimately included. Meta-analyses showed that the lack of daily oral hygiene (teeth or denture cleaning), chewing problems and being partially/fully edentulous, put older adults at higher risk of malnutrition (p < 0.05). After adjustment for socio-demographic variables, the included studies reported lack of autonomy for oral care, poor/moderate oral health, no access to the dentist and being edentulous with either no dentures or only one denture were risk factors significantly associated with a higher risk of malnutrition (p < 0.05).
Conclusions: These findings may imply that once elders become dependent on others for assistance with oral care, have decreased access to oral healthcare, and lack efficient chewing capacity, there is increased risk of malnourishment. Limitations of the study include heterogeneity of oral health variables and the observational nature of the studies. Further studies are needed to validate our findings.
... In our study, the prevalence of risk for malnutrition increased among older persons living in short terms nursing homes. Since cognitive impairment, low mood, medications and poor oral health may occur due to acute illness requiring hospital admission [45] and because nutritional status is estimated to worsen during a hospital admission [46], older persons transferred to short term nursing homes (to recover) may already be frail [47]. Overall, this emphasizes the importance of the preventive work regarding malnutrition and pressure ulcers, which is highlighted by The European Society for Clinical Nutrition and Metabolism (ESPEN) [48]. ...
Background
Although pressure ulcers, malnutrition, poor oral health and falls are common among older persons, causing deteriorated health status, they have not been studied altogether among older persons receiving different types of municipal health care. The aim of this study was to determine the prevalence of risk for pressure ulcers, malnutrition, poor oral health and falls among older persons aged ≥65 years receiving municipal health care in southern Sweden.
Methods
A retrospective cross-sectional study ( n = 12,518 persons aged ≥65 years) using data from the national quality registry Senior Alert was conducted. The prevalence of risk for pressure ulcers, malnutrition, poor oral health and falls was calculated based on categorical data from the instruments available in Senior Alert. T-tests, chi-square test, the Mantel- Haenszel test and logistic regression models were performed.
Results
The prevalence of risk for pressure ulcers, malnutrition, poor oral health and falls was 27.9, 56.3, 34.2 and 74.5% respectively. Almost 90% of the older persons had at least one health risk. The prevalence of risk for pressure ulcers, poor oral health and falls was significantly higher in dementia care units compared to short term nursing care, home health care and nursing homes. The prevalence of risk for malnutrition was significantly higher among older persons staying in short term nursing care compared to other types of housing. The odds of having a risk for malnutrition were higher in short term nursing care compared to other types of housing. The oldest age group of 95–106 years had the highest odds of having a risk for falls. The presence of multiple health risks in one subject were more common in dementia homes compared to nursing homes and home health care but not compared to short term nursing care.
Conclusion
The prevalence of risk for pressure ulcers, malnutrition, poor oral health and falls was high, implying that these health risks are a great concern for older persons receiving municipal health care. A comprehensive supporting preventive process to prevent all the investigated health risks among older persons receiving municipal health care is recommended.
... По данным зарубежных исследований распространенность мальнутриции составляет 3% среди проживающих независимо пациентов и 8,7% среди получающих услуги по уходу на дому [5]. Среди госпитализированных пациентов 65 лет и старше 39% подвержены риску развития недостаточности питания [6] и у 60% отмечается ухудшение пищевого статуса во время госпитализации [7], что может быть связано как непосредственно с заболеванием, послужившим причиной для госпитализации, так и с имеющимися у пациента РОССИЙСКИЙ ЖУРНАЛ ГЕРИАТРИЧЕСКОЙ МЕДИЦИНЫ № 01'2021 Клинический разбор когнитивными нарушениями, депрессией, проблемами с зубами, дисфагией и побочными эффектами лекарственных препаратов [8][9][10]. Кроме того, на питание пациента в стационаре может повлиять множество внешних факторов, таких как пропуск приема пищи в связи с обследованиями и процедурами, наличие непривычных для пациента блюд, нехватка персонала для помощи при приеме пищи [11][12][13][14]. ...
Malnutrition is a common geriatric syndrome, which often undiagnosed, leads to impaired physical and mental functioning and patient prognosis. Geriatric patients admitted to hospital with acute and subacute conditions and pain syndrome are in an especial risk zone. The article presents a clinical case of the development and correction of malnutrition in an 84-year-old patient with aseptic necrosis of the femoral head. Risk factors and existing approaches to the management of patients with malnutrition are discussed.
... People suffering from DRM place a high economic burden on healthcare services (9,10). It is, however, possible to proactively counteract DRM through adequate food intakes, for example by using foods containing high amounts of high-quality proteins and energy (11)(12)(13). ...
Background: An adequate dietary intake, especially of protein and energy, is important for maintaining health
among elderly people, especially those in care homes. One strategy to ensure nutritional intake is to customise
attractive products through enrichment to match the needs of elderly people in care homes.
Objective: To evaluate liking and practical aspects of protein and energy enriched in-between meals designed
for elderly people in care homes through the use of quantitative and qualitative assessments.
Design: A broad range of energy and protein enriched in-between meals, including both savoury and sweet
products, were included. The products were evaluated by a consumer test and a focus group discussion with
elderly respondents. The products were also evaluated by a second focus group discussion with care staff.
Results: The most liked products were ice cream and cheesecake. All products achieved high scores for appearance,
taste/flavour and texture. No product included in the study was extremely disliked. However, the least
liked product was tomato soup, which scored above the middle of the scale except for texture. It was clear
from the focus group discussions that a colourful appearance, small portion size and texture were of primary
importance. The temperature had an impact on liking and swallowability.
Discussion: Most products were perceived by the elderly participants as appealing and tasting good, and possible
to include in a daily diet. It was clear that the colours of the foods were of primary importance. In line
with other studies, it was found that highly liked in-between meals were frozen, cold and sweet. These products
were also easy to swallow.
Conclusions: It is possible to produce highly liked energy and protein enriched in-between meal products
designed for elderly people. The temperature had a great impact on the liking of texture, taste and flavour.
In-between meals should preferably be colourful and have a small portion size.
Aims
This scoping review aimed to identify and map the available information on the nutrition care process in older adults with delirium to analyse and summarise key concepts, and gaps, including the barriers and enablers to providing nutrition care for this group.
Design
Scoping review.
Methods
This review was conducted in accordance with the JBI methodology for scoping reviews. Published and grey sources in English were considered.
Data sources
Databases searched were CINAHL, Medline, Embase, JBI Evidence‐based Practice, Scopus, ProQuest and Google. The initial search was conducted from October 2021 to March 2022 and repeated in October 2023.
Results
The database search identified 1561 articles, 186 underwent full‐text review and 17 articles were included. The grey literature search identified eight articles. Malnutrition and delirium were identified as mutually reinforcing, and nutrition strategies were included as part of multicomponent interventions for delirium management. There was no mention of barriers or enablers to nutrition care and minimal descriptive or empirical data available to guide nutrition care processes in this group.
Conclusion
This scoping review revealed a need for further research into nutrition care processes in older patients with delirium, in particular the barriers and enablers, to inform appropriate management strategies in this vulnerable group.
Implications for the profession and patient care
Providing nutrition care for older patients with delirium is important and further practical guidance could help patients, healthcare staff and families.
Impact
This scoping review yielded instructive data suggesting that delirium is an important risk factor for malnutrition and vice versa, which leads to poor patient and health service outcomes.
Reporting method
This scoping review adhered to relevant EQUATOR guidelines and used the Preferred Reporting Items For Systematic Reviews and Meta‐Analyses Extension for Scoping Reviews (PRISMA‐ScR).
Patient of public contribution
No patient or public contribution.
Quantification of oral intake within the hospital setting is required to guide nutrition care. Multiple dietary assessment methods are available, yet details regarding their application in the acute care setting are scarce. This scoping review, conducted in accordance with JBI methodology, describes dietary assessment methods used to measure oral intake in acute and critical care hospital patients. The search was run across four databases to identify primary research conducted in adult acute or critical care from 1 st January 2000-15 th March 2023 which quantified oral diet with any dietary assessment method. In total, 155 articles were included, predominantly from the acute care setting (n=153, 99%). Studies were mainly single-center (n=138, 88%) and of observational design (n=135, 87%). Estimated plate waste (n=59, 38%) and food records (n=42, 27%) were the most frequent assessment methods with energy and protein the main nutrients quantified (n=81, 52%). Validation was completed in 23 (15%) studies, with the majority of these using a reference method reliant on estimation (n=17, 74%). A quarter of studies (n=39) quantified completion (either as complete versus incomplete or degree of completeness) and four studies (2.5%) explored factors influencing completion. Findings indicate a lack of high-quality evidence to guide selection and application of existing dietary assessment methods to quantify oral intake with a particular absence of evidence in the critical care setting. Further validation of existing tools and identification of factors influencing completion is needed to guide the optimal approach to quantification of oral intake in both research and clinical contexts.
Objective: to search in the current literature the elements that exert an influence on feeding and nutrition in hospitalized aged people. Method: the following strategies were used for the integrative review stages: research question (Population or Patients; Exposure; Outcomes); analysis flowchart (Preferred Reporting Items for Systematic Reviews and Meta-analyses); and levels of evidence corresponding to the studies (Oxford Centre for Evidence-Based Medicine). The searches were conducted in the MEDLINE/PubMed, Biblioteca Virtual em Saúde, Embase, CINAHL and Scopus databases. Results: the initial search yielded 1808 studies, of which 34 comprised the analysis corpus after applying the inclusion/exclusion criteria. The assessments corresponding to nutritional status and to the risk factors for hospitalized aged people are fundamental in defining the diet. An association was found between inadequate energy intake, lack of appetite, infections, malignity, delirium and need for assistance in feeding. Dysphagia affected nutritional status and was associated with multimorbidities, cognitive impairment, malnutrition, higher dependence for the activities of daily living, and greater care need. Nutritional support improved the perioperative nutritional status, in addition to reducing the hospitalization times and the number of infectious complications. Conclusion: the main disorder that hinders meeting the nutritional needs is dysphagia, and is associated with aged people’s multimorbidity and dependence. The results provide geriatric and gerontological knowledge about elderly nutrition, in addition to targeting preventive and intervention treatments and care during hospitalization.
Older individuals face an elevated risk of developing geriatric syndromes when confronted with acute stressors like COVID-19. We assessed the connection between in-hospital delirium, malnutrition, and frailty in a cohort of COVID-19 survivors. Patients aged ≥65, hospitalized in a tertiary hospital in Milan for SARS-CoV-2 pneumonia, were enrolled and screened for in-hospital delirium with the 4 ‘A’s Test (4AT) performed twice daily (morning and evening) during hospital stay. Malnutrition was assessed with the malnutrition universal screening tool (MUST) at hospital admission and with the mini-nutritional assessment short-form (MNA-SF) one month after hospital discharge. Frailty was computed with the frailty index one month after hospital discharge. Fifty patients (median age 78.5, 56% male) were enrolled. At hospital admission, 10% were malnourished. The 13 patients (26%) who developed delirium were frailer (7 vs. 4), experienced a higher in-hospital mortality (5 vs. 3), and were more malnourished one month after discharge (3 of the 4 patients with delirium vs. 6 of the 28 patients without delirium who presented at follow up). The 4AT scores correlated with the MNA-SF scores (r = −0.55, p = 0.006) and frailty (r = 0.35, p = 0.001). Frailty also correlated with MUST (r = 0.3, p = 0.04), MNA-SF (r = −0.42, p = 0.02), and hospitalization length (r = 0.44, p = 0.001). Delirium, malnutrition, and frailty are correlated in COVID-19 survivors. Screening for these geriatric syndromes should be incorporated in routine clinical practice.
Aims:
Improving hospital nutrition and mealtime care is complex and often requires multifaceted interventions and implementation strategies to change how staff, wards and systems operate. This study aimed to develop and validate a staff questionnaire to identify multilevel barriers and enablers to optimal nutrition and mealtime care on hospital wards, to inform and evaluate local quality improvement.
Methods:
Literature review, multidisciplinary focus groups and end-user testing informed questionnaire development and establishment of content and face validity. To determine the construct validity, the questionnaire was administered to ward staff working in five wards across two facilities (acute hospital, rehabilitation unit). Exploratory factor analysis was used to estimate the number of factors and to guide decisions about whether to retain or reject individual items. Scale reliability was assessed using Cronbach's alpha.
Results:
The questionnaire was completed by 138 staff, with most respondents being nurses (57%) and working in the acute care facility (76%). Exploratory factor analysis supported construct validity of four of the original seven subscales. The final questionnaire consisted of 17 items and 4 sub sub-scales related to (1) Personal Staff Role; (2) Food Service; (3) Organisational Support, and (4) Family Involvement; each sub-scale demonstrated good reliability with Cronbach's alpha values all >0.70.
Conclusion:
This novel and brief questionnaire shows good reliability and preliminary evidence of construct validity in this small sample. It provides a potentially useful instrument to identify barriers and enablers to nutrition and mealtime care from the staff perspective and inform where improvement efforts should be focused.
Objectives:
Malnutrition risk can be recognized by nurses using screening tools and food intake monitoring. We measured the prevalence of food intake reporting and its association with malnutrition screening scores or other patient characteristics.
Methods:
This retrospective cohort study collected hospital database information regarding patients aged ≥18 y who were hospitalized for ≥ 7 consecutive days and were orally fed or had medical records that no tube feeding or parenteral nutrition had been administered. Data were collected and statistically analyzed focusing on food intake reporting, Malnutrition Universal Screening Tool (MUST) scores, oral nutritional intervention, and other secondary characteristics.
Results:
Out of 5155 patients admitted to two internal medicine departments over 1 y (July 1, 2018, through August 31, 2019), 1087 fulfilled the inclusion criteria with a mean age of 72.4 ± 14.6 y; of these, 74.6% had sufficient food intake reports. No food intake was reported for one-third of patients with MUST scores ≥ 2. There were no differences between the groups of patients with and without reported food intake with regard to MUST scores, sex, mean albumin level, comorbidity, length of stay, all-cause in-hospital mortality, hospital-acquired pressure injury, or the rate of oral nutritional intervention. MUST scores ≥ 2 were not significantly associated with intake reporting. Increased probability of having food intake reported was found in patients ages ≥70 y (adjusted odds ratio = 1.36; P = 0.036 [95% CI, 1.02-1.82]) and those who had Norton scores ≤ 13 (adjusted odds ratio = 1.60; P = 0.013 [95% CI, 1.10-2.31]). However, the model had a weak predictive efficacy (area under the curve = 0.577; P < 0.0001 [95% CI, 0.538-0.616]).
Conclusions:
More adherence to food intake monitoring guidelines is needed.
Amaç: Bu çalışmanın amacı yoğun bakım ünitelerinde yatan hastaların bası yarası insidanslarını ve bası yaralarının ilişkili olabileceği risk faktörlerini araştırmaktır. Bireyler ve Yöntem: Mersin Şehir Hastanesi Hastanesi Yoğun bakım ünitelerinde yatan hastalarda yapılan bu çalışmada 18-65 yaş arası, albümin değeri > 2.5 g/dL ve BKI değeri 18.5-24.9 Kg/m2 olan 200 hasta değerlendirilmiştir. Çalışmada hastaların tanımlayıcı özellikleri ve antropometrik ölçümleri sorgulanırken, hastaların hastalık ciddiyetlerini değerlendirmek için APACHE II, bası yarası risklerini değerlendirmek için Norton Bası Yarası ölçeği, malnutrisyon durumlarını saptamak için ise NRS2002 tarama testleri hastalara uygulanmıştır. Ayrıca hastaların beslenme durumları ve serum albümin değerleri diyetisyen tarafından günlük vizitelerle 30 gün boyunca izlenmiş ve kayıt altına alınmıştır.Bulgular: Hastaların bası yarası durumlarına göre APACHE II (p<0.001), NRS-2002 skorları (p<0.001), takip sonu hedeflenen enerji (p<0.001) ve protein (p<0.001) gereksinimlerini karşılama yüzdeleri arasındaki farkın istatistiksel olarak anlamlı olduğu görülmüştür. Yapılan ileri analizlerde; bası yarası olmayan hastalara göre; bası yarası yatışta olan (p<0.001) ve hastanede gelişen hastaların (p<0.001) APACHE II ve NRS-2002 skorlarının daha yüksek, takip sonunda hedeflenen enerji ve protein gereksinimlerini karşılama yüzdelerinin ise daha düşük olduğu bulunmuştur. Yatışında bası yarası olan hastaların başlangıç serum albümin değerlerinin <3 g/dL olduğu ve bu grupla birlikte hastanede bası yarası gelişen hastaların da takip sonu serum albümin değerlerinin yatış değerlerine göre istatistiksel olarak azaldığı görülmüştür (p<0.001).Sonuç: Yoğun bakım ünitesinde yatan hastalarda yüksek malnutrisyon riski olanların, yatışları sırasında değerlendirilen düşük serum albümin değerlerinin, uygulanan beslenme destek tedavisinin etkinliğinin ve yüksek APACHE II skorlarının hastalarda bası yarası durumu ile ilişkilendirilebileceği düşünülmektedir
The relationship between low physical function (LPF) at discharge and food intake percentage (FIP) during hospitalization is unclear. We aimed to clarify the relationship between LPF at discharge and FIP and the change in nutritional status during hospitalization in elderly patients with heart failure (HF), and determine cutoff values for FIP and change in nutritional status during hospitalization. We included 431 consecutive patients aged ≥ 65 years who were hospitalized for HF and underwent cardiac rehabilitation (CR) from 2017 to 2019. Physical function at discharge was classified into two groups according to the Short Performance Physical Battery (SPPB): low physical function (LPF) (SPPB ≤ 9) and high physical function (HPF) (SPPB > 9). We compared background, clinical parameters, pre-hospital walking level, CR progress, nutritional factors during hospitalization including FIP of the main dish and side dish, and changes in nutritional status using the Geriatric Nutritional Risk Index (ΔGNRI) at admission and discharge. Multiple logistic regression analysis was also performed. The final analysis included 213 patients (age, 81.6 years) divided into the LPF (n = 136) and HPF groups (n = 77). The LPF group showed low FIP and a high ΔGNRI value. Multivariate analysis showed FIP main dish, ΔGNRI, worsening renal function, pre-hospital walking level, and days to start of walking to be factors influencing LPF at discharge. Respective cutoff values for FIP main dish and ΔGNRI predicting LPF at discharge were 82.2% and 4.24. FIP main dish during hospitalization and ΔGNRI were associated with LPF at discharge.
O objetivo do presente trabalho foi identificar nas publicações nacionais e internacionais indexadas nas principais bases de dados, as características adotadas no desenvolvimento dos aplicativos móveis de saúde e nutrição. Realizou-se uma revisão integrativa da literatura pesquisando nas bases de dados PubMed, Scielo, Lilacs e Periódicos Capes, artigos publicados no período de 2010 a 2020 abrangendo textos em inglês, espanhol ou português. Os resultados demonstram que a maioria dos aplicativos foram direcionados a pacientes e objetivavam educar/informar ou buscar informações quanto à alimentação e estilo de vida saudável se relacionando intimamente com a área da nutrição. Os artigos tratavam de desenvolvimento e teste do aplicativo. Quanto às características técnicas, verificou-se que as mais importantes se referiram à personalização de acordo com os usuários, linguagem de fácil compreensão, interface de fácil manuseio, arquitetura adequada de fácil identificação do que deve ser clicado e utilizando-se poucos cliques. O que facilitou o uso dos aplicativos foi a acessibilidade/clareza, simplicidade e motivação que ele apresenta ao usuário. Como principal dificuldade, percebeu-se a disponibilidade heterogênea de acesso à internet. Tais características são consideradas importantes, pois podem promover melhorias e adequações na aplicação móvel em saúde e nutrição, de modo com que o sistema apresente o foco no usuário e satisfaça suas necessidades.
Background: Most elderly age groups in Indonesia experience vitamin D deficiency. Increasing age and decreasing food intake of vitamin D will trigger an increase in metabolic diseases. One of the most common effects of metabolic diseases is obesity. Unhealthy diet can reduce consumption of foods that contain sources of vitamin D. The suitability of diet in preventing vitamin D deficiency is influenced by the level of knowledge about the type of food, benefits and needs about vitamin D. Objectives: To analyze the relationship of vitamin D diet in older people with obesity to the level of knowledge of vitamin D.Methods: This was analytic observational study with case control design. Data collection technique was using purposive sampling. The sample in this research were geriatric with obesity and non-obesity. Subjects in each group were 88 elderly people according to inclusion and exclusion criteria. Instruments in this research were Food Frequency Questionnaire (FFQ) and questionnaire knowledge of vitamin D amounted to 11 questions that have been done validity (r> 0.361) and reliability (Cronbach's Alpha> 0.6). Chi Square test was used to compare age factor with food intake and vitamin D knowledge. Results: There was significant relationship between the level of knowledge and the pattern of vitamin D intake in old age (r = 0.293; p = 0.000). However there was no difference between intake patterns and level of knowledge on vitamin D in elderly obese and non-obese (p> 0.05).Conclusion: increased in vitamin D knowledge can improve food intake patterns in geriatric.ABSTRAKLatar Belakang: Kelompok usia lanjut di indonesia sebagian besar mengalami defisiensi vitamin D. Pertambahan usia dan penurunan asupan makanan vitamin D akan memicu peningkatan penyakit metabolik. Salah satu dampak penyakit metabolik yang paling sering terjadi adalah obesitas. Pola makan yang tidak sesuai dapat menurunkan konsumsi makanan yang mengandung sumber vitamin D. Kesesuaian pola makan dalam mencegah defisiensi vitamin D salah satunya dipengaruhi oleh tingkat pengetahuan mengenai jenis makanan, manfaat dan kebutuhan tubuh akan vitamin D.Tujuan: Melihat hubungan pola makan dan pengetahuan vitamin D pada usia lanjut dengan obesitas.Metode: Penelitian ini adalah observational dengan desain case control. Teknik pengumpulan data menggunakan purposive sampling. Sampel pada penelitian ini adalah masyarakat pada usia lanjut dengan obesitas dan non-obesitas. Subjek penelitian pada tiap kelompok berjumlah 88 orang yang memenuhi kriteria inklusi dan eksklusi. Instrumen pada penelitian ini adalah Food Frequency Questionnaire (FFQ) dan kuisioner pengetahun vitamin D berjumlah 11 soal yang telah dilakukan validitas (r>0,361) dan reliabilitas (Cronbach’s Alpha > 0,6). Uji Chi Square digunakan untuk melihat hubungan pola makan vitamin D dan tingkat pengetahuan pada usia lanjut dengan obesitas dan non-obesitas.Hasil: Adanya hubungan tingkat pengetahuan dan pola asupan vitamin D pada usia lanjut (r=0,293; p=0,000). Namun tidak terdapat perbedaan antara pola asupan dan tingkat pengetahuan terhadap vitamin D pada lansia obesitas dan non obesitas (p>0,05).Kesimpulan: Peningkatan pengetahuan tentang vitamin D dapat memperbaiki pola asupan makanan pada usia lanjut.
This open access book aims to primarily support nurses as leaders and champions of multimodal, Interdisciplinary nutrition care for older adults. A structured approach to fundamentals of nutrition care across Interdisciplinary settings is combined with additional short chapters about special topics in geriatric nutrition. The book is designed to provide highly accessible information on evidence-based management and care for older adults, with a focus on practical guidance and advice across acute, rehabilitation, and primary and secondary malnutrition prevention settings.The cost of malnutrition in England alone has been estimated to be £19.6 billion per year, or more than 15% of the total public expenditure on health and social care. ^65 years). The importance and benefit of specialised nutrition care, delivered by experts in field, is well established for those with complex nutrition care needs. However, despite the substantial adverse impact of malnutrition on patient and healthcare outcomes, specialised management of this condition is often under-resourced, overlooked and under-prioritised by both older adults and their treating teams.
As an alternative, timely, efficient, and effective supportive nutrition care opportunities may be appropriately implemented by nurses and non-specialist Interdisciplinary healthcare team members, working together with nutrition specialists and the older adults they care for. Practical, low-risk opportunities should be considered across nutrition screening, assessment, intervention, and monitoring domains for many patients with, or at risk of malnutrition. Whilst a variety of team members may contribute to supportive nutrition care, the nursing profession provide a clear focal point. Nurses across diverse settings provide the backbone for Interdisciplinary teamwork and essential patient care. The nursing profession should consequently be considered best placed to administer Interdisciplinary, multimodal nutrition care, wherever specialist nutrition care referrals are unlikely to add value or are simply not available. As such, the book is a valuable resource for all healthcare providers dedicated to working with older patients to improve nutrition care.
Previous chapters have described how to implement and improve nutrition care with an emphasis on interdisciplinary approaches. The focus of this chapter is on the link between malnutrition and pressure injuries (PIs), focussing on nutritional screening, assessment and interdisciplinary interventions in preventing and managing PIs.
Eating habits are inseparably linked with people’s physical and psychological health and well-being. Many factors impact on eating behavior and nutritional status in older adults. Motivational and multidisciplinary interventions have been shown to be highly effective in promoting healthy eating, especially in hospitalized patients, but are often overlooked or not considered. The aim of this chapter is to discuss how to overcome the psychological barriers that lead older patients away from an appropriate nutritional intake and the importance of motivational interventions for adherence to nutritional care, providing useful evidence and direction for further research.
Dysphagia in older adults can have a profound adverse influence nutrition and hydration status, quality of life, morbidity, mortality and healthcare costs in adults. Identification and management of dysphagia in older adults are most effective when implemented by a team, including a nurse, physician, speech-language pathologist, dietitian and occupational therapist. However, each professional’s role may vary according to the standards, responsibilities and resources available in local settings.KeywordsDysphagiaMalnutritionAspirationDeglutition disorderOropharyngeal
The purpose of this chapter is to describe the nutritional recommendations for older adults and change in requirements with age and disease. Key factors influencing nutritional requirements, dietary intake, and nutritional status in old adults will be described, including specific nuances for geriatric and orthogeriatric patients.
Previous chapters have described nutritional care in geriatrics and orthogeriatrics in detail, including special focus on malnutrition and best practice in nursing care. This chapter will focus on recommendations and guidelines for hydration, fluid intake and intravenous fluid therapy in geriatrics and orthogeriatrics.
Malnutrition, sarcopenia, frailty and cachexia are different conditions but have overlapping characteristics and consequences for older adults. These conditions are especially prevalent in hospitalised patients affecting almost two thirds of older adults. They can often be hidden conditions; hence multidisciplinary awareness is needed for optimal identification and management. This chapter provides an overview of the definitions of each of these syndromes, its detrimental impact on health outcomes of older adults and tips for clinical practice implementation.
Background
Little is known about the nutritional care provided to patients who develop hospital acquired malnutrition (HAM). The present study aimed to describe the quality of nutritional care provided to patients who developed HAM and determine whether this differed by length of stay (LOS).
Methods
A retrospective medical records audit was conducted on adults with LOS > 14 days across five Australian public hospitals from July 2015 to January 2019 who were clinically assessed to have HAM. Descriptors and nutrition‐related care data were sourced. Descriptive statistics were conducted. Chi‐squared and t‐tests were used to compare patient data by LOS ≤ or > 50 days.
Results
Eligible patients (n = 208) were 64% male, with median (range) LOS of 51 (15–354) days, body mass index = 26.8 ± 6.2 kg m⁻² and mean ± SD age of 65 ± 17 years. Malnutrition screening was first completed a median (range) of 0 (0–31) days after admission, with weekly screening conducted on 29% of patients. Mean (range) time to initial dietitian assessment was 9 (0–87) days and 27 (2–173) days until malnutrition diagnosis. Thirty‐seven percent of patients were weighed within 24 h of a dietitian requesting it, and 51% had fluid retention that may have masked further weight loss. Most (91%) patients consumed < 80% of nutrition requirements for > 2 weeks. However, 54% did not receive additional nutrition support (e.g., enteral nutrition), which was not considered by the dietitian in 28% (n = 31/112) of these patients. Only 40% consumed adequate intake prior to discharge. Those with LOS > 50 days (50%, n = 104/208) took 24 days longer to be diagnosed with malnutrition and lost 2.4 kg more body weight during admission (p < 0.010).
Conclusions
Opportunities exist to optimise nutritional care to facilitate the prevention and management of hospital acquired malnutrition in long‐stay patients.
The association between malnutrition and poor clinical outcome is well-established, yet most research has focussed on the role of artificial nutritional support in its management. More recently, emphasis has been placed on the provision of adequate nutritional care, including nutritional screening and the routine provision of food and drink. The aim of this literature review is to establish the evidence for the efficacy of interventions that might result in improvements in nutritional and clinical outcomes and costs.
A structured literature review was conducted investigating the role of nutritional care interventions in adults, and their effects on nutritional and clinical outcomes and costs, in all healthcare settings. Ten databases were searched electronically using keywords relating to nutritional care, patient outcomes and healthcare costs. High quality trials were included where available.
Two hundred and ninety-seven papers were identified and reviewed. Of these, only two randomised, controlled trials and six other trials were identified that addressed the major issues. A further 99 addressed some aspects of the provision of nutritional care, although very few formally evaluated nutritional or clinical outcomes and costs.
This review reveals a serious lack of evidence to support interventions designed to improve nutritional care, in particular with reference to their effects on nutritional and clinical outcomes and costs. The review suggests that screening alone may be insufficient to achieve beneficial effects and thus more research is required to determine the most cost-effective interventions in each part of the nutritional care pathway, in a variety of healthcare settings and across all age ranges, to impact upon nutritional and clinical outcomes.
Studies on hospitalized elderly subjects have demonstrated that negative energy balance is common during hospitalization, but have concentrated primarily on long-stay and psychogeriatric patients. There is little information on energy balance in elderly patients admitted with acute illness from the community, despite the importance of this patient group and the presence of a number of factors likely to predispose such patients to negative energy balance. In the present study energy balance was quantified in twenty patients (eight males, mean age 82 (SD 5) years; twelve females, mean age 84 (SD 6) years) admitted from the community with acute illness, and predicted basal metabolic rate (BMR) was compared with measured resting metabolic rate (RMR). Most patients were in negative energy balance during hospitalization, and median measured energy intake (EI): measured RMR ratio was 1.0 (range 0.7-1.8). The mean difference between measured EI and estimated total energy expenditure was -1.3 MJ/d (range -3.4 to +2.5 MJ/d). Estimated total energy expenditure exceeded measured EI in fifteen of the patients and there was a significant decline in mid-arm muscle circumference (paired t, P < 0.05) during hospitalization. We conclude that moderate negative energy balance is common in this patient group, and that these patients are at risk of undernutrition during their hospital stay.
Short-stay hospitalization in older patients is frequently associated with a loss of function, which can lead to a need for postdischarge assistance and longer-term institutionalization. Because little is known about this adverse outcome of hospitalization, this study was conducted to (1) determine the discharge and 3-month postdischarge functional outcomes for a large cohort of older persons hospitalized for medical illness, (2) determine the extent to which patients were able to recover to preadmission levels of functioning after hospital discharge, and (3) identify the patient factors associated with an increased risk of developing disability associated with acute illness and hospitalization.
A total of 1279 community-dwelling patients, aged 70 years and older, hospitalized for acute medical illness were enrolled in this multicenter, prospective cohort study. Functional measurements obtained at discharge (Activities of Daily Living) and at 3 months after discharge (Activities of Daily Living and Instrumental Activities of Daily Living) were compared with a preadmission baseline level of functioning to document loss and recovery of functioning.
At discharge, 59% of the study population reported no change, 10% improved, and 31% declined in Activities of Daily Living when compared with the preadmission baseline. At the 3-month follow-up, 51% of the original study population, for whom postdischarge data were available (n=1206), were found to have died (11%) or to report new Activities of Daily Living and/or Instrumental Activities of Daily Living disabilities (40%) when compared with the preadmission baseline. Among survivors, 19% reported a new Activities of Daily Living and 40% reported a new Instrumental Activities of Daily Living disability at follow-up. The 3-month outcomes were the result of the loss of function during the index hospitalization, the failure of many patients to recover after discharge, and the development of new postdischarge disabilities. Patients at greatest risk of adverse functional outcomes at follow-up were older, had preadmission Instrumental Activities of Daily Living disabilities and lower mental status scores on admission, and had been rehospitalized.
This study documents a high incidence of functional decline after hospitalization for acute medial illness. Although there are several potential explanations for these findings, this study suggests a need to reexamine current inpatient and postdischarge practices that might influence the functioning of older patients.
Numerous studies have identified strong correlations between the severity of nutritional deficits and an increased risk of subsequent morbid events among the hospitalized elderly, but whether inadequate nutrient intake during hospitalization contributes to such nutritional deficits or the risk of adverse outcomes is not known.
To identify the distribution of average daily nutrient intake among the nonterminally ill hospitalized elderly, ascertain what factors contribute to persistently low intakes, and determine whether the adequacy of nutrient intake correlates with the risk of mortality.
Prospective cohort study conducted from 1994 to 1997.
University-affiliated Department of Veterans Affairs hospital.
A total of 497 patients 65 years or older (mean [SD] age, 74 [6] years; 97% male; 86% white) with a length of stay of 4 days or more.
Daily in-hospital nutrient intake, in-hospital mortality, and 90-day mortality.
A total of 102 patients (21%) had an average daily in-hospital nutrient intake of less than 50% of their calculated maintenance energy requirements. Admission illness severity, average length of stay, and admission albumin and prealbumin levels for this low nutrient group did not differ significantly from those of the remaining patients. However, the low nutrient group had lower mean (SD) discharge serum total cholesterol (154 [44] mg/dL [4 [1.1] mmol/L] vs 173 [42] mg/dL [4.5 [1.1] mmol/L]; P=.001), albumin (29.1 [6.7] vs 33.2 [6.1] g/L, P=.001), and prealbumin (162 [69] vs 205 [68] mg/L; P=.001) concentrations and a higher rate of in-hospital mortality (relative risk, 8.0; 95% confidence interval, 2.8-22.6) and 90-day mortality (relative risk, 2.9; 95% confidence interval, 1.4-6.1). Contributing to the problem of inadequate nutrient intake, patients were frequently ordered to have nothing by mouth and were not fed by another route. Neither canned supplements nor nutritional support were used effectively.
Throughout their hospitalization, many elderly patients were maintained on nutrient intakes far less than their estimated maintenance energy requirements, which may contribute to an increased risk of mortality. Given the difficulties reversing established nutritional deficits in the elderly, greater efforts should be made to prevent the development of such deficits during hospitalization.
Impaired nutritional status has been frequently reported in surveys estimating its prevalence amongst patients in hospital. While there is no doubt that protein-energy undernutrition has serious implications for health, recovery from illness or surgery and hospital costs, lack of nationally or internationally accepted cut-off points and guidelines for most nutrition-related variables make nutritional assessment difficult and proper comparisons between studies impossible. In reviewing published work in which the prevalence of undernutrition has been assessed, it can be seen that each study defined undernutrition, or nutritional risk, using different methodology. This present review aims to highlight the problems which arise when deciphering these studies, and the resulting difficulty in determining the true prevalence of undernutrition and nutritional risk, amongst both general and specific groups of hospital in-patients. It is widely agreed that routine hospital practices can further adversely affect the nutritional status of sick patients in hospital. How this occurs, and the potential effects of impaired nutritional status on clinical outcome are examined. The methods currently available to assess nutritional status are evaluated in the knowledge that such assessments are difficult in clinical practice. The review concludes by proposing that if we want the medical and nursing professions to consider the nutritional status of hospital patients seriously, definitions of undernutrition and nutritional risk, and cut-off values for the nutritional variables measured must be agreed to allow evidence-based practice. Outcome measures which allow clear comparisons between groups and treatments must be used in studies assessing the effects of nutritional interventions.
Malnutrition, considered for the purpose of the present data set as undernutrition, is a major risk factor of mortality in elderly people. Such protein-energy malnutrition should be detected as soon as possible. Once established, this malnutrition state must be corrected by appropriate diet, supplementation, artificial nutrition, or therapeutic treatment. If carried out well, these interventions should reduce the risk of mortality and, for some diseases such as degenerative diseases, may postpone morbidity and dependence. The efficiency of nutritional interventions has already been evaluated by different means including the measurement of anthropometric and laboratory parameters. However, in the absence of a consensus on the use of these parameters, comparison between studies and even effectiveness of the proposed treatment are frequently unconvincing. The relevance of the most common markers used in epidemiologic studies on malnutrition and nutritional interventions in elderly persons was studied for establishing a minimum data set. The aim of this task force was to provide investigators and operators in the field of clinical nutrition with clear and expert validated clinical outcomes allowing them to design and set up conclusive trials.
Anorexia-related weight loss can have devastating consequences on quality-of-life, morbidity, and mortality. Without a simple tool to evaluate appetite, health care providers often use inaccurate surrogates, such as measurement of energy consumption and nutritional risk, to reflect appetite.
We aimed to validate a simple tool for assessing appetite and predicting weight loss.
This was a cross-sectional measurement study conducted on long-term care residents and community-dwelling adults. Construct validity of the 8-item Council on Nutrition appetite questionnaire (CNAQ) and its 4-item derivative, the simplified nutritional appetite questionnaire (SNAQ), were examined through correlation with a previously validated research tool: the appetite hunger and sensory perception questionnaire (AHSP). The length and complexity of the AHSP render it inefficient for clinical use. The sensitivity and specificity of the CNAQ and SNAQ to predict significant weight loss were calculated.
Cronbach's alpha coefficients for the CNAQ were 0.47 (long-term care group) and 0.72 (community-dwelling group). In the long-term care group, the CNAQ correlated with the AHSP (r = 0.60, P < 0.001) and with the AHSP domains of taste (r = 0.47, P < 0.0001), hunger (r = 0.51, P < 0.0001), and smell (r = 0.53, P < 0.0001). The CNAQ showed sensitivities and specificities for 5% and 10% weight losses of 80.2 and 80.3 and 82.4 and 81.9, respectively. The SNAQ had sensitivities and specificities for 5% and 10% weight losses of 81.3 and 76.4 and 88.2 and 83.5, respectively.
The SNAQ and CNAQ are short, simple appetite assessment tools that predict weight loss in community-dwelling adults and long-term care residents. The SNAQ is a 4-item derivative of the CNAQ and thus is clinically more efficient.
To avoid any negative outcomes associated with under- or overfeeding it is essential to estimate nutrient requirements before commencing nutrition support. The energy requirements of an individual vary with current and past nutritional status, clinical condition, physical activity and the goals and likely duration of treatment. The evidence-base for prediction methods in current use, however, is poor and the equations are thus open to misinterpretation. In addition, most methods require an accurate measurement of current weight, which is problematic in some clinical situations. The estimation of energy requirements is so challenging in some conditions, e.g. critical illness, obesity and liver disease, that it is recommended that expenditure be measured on an individual basis by indirect calorimetry. Not only is this technique relatively expensive, but in the clinical setting there are several obstacles that may complicate, and thus affect the accuracy of, any such measurements. A review of relevant disease-specific literature may assist in the determination of energy requirements for some patient groups, but the energy requirements for a number of clinical conditions have yet to be established. Regardless of the method used, estimated energy requirements should be interpreted with care and only used as a starting point. Practitioners should regularly review the patient and reassess requirements to take account of any major changes in clinical condition, nutritional status, activity level and goals of treatment. There is a need for large randomised controlled trials that compare the effects of different levels of feeding on clinical outcomes in different disease states and care settings.
Background:
Short-stay hospitalization in older patients is frequently associated with a loss of function, which can lead to a need for postdischarge assistance and longer-term institutionalization. Because little is known about this adverse outcome of hospitalization, this study was conducted to (1) determine the discharge and 3-month postdischarge functional outcomes for a large cohort of older persons hospitalized for medical illness, (2) determine the extent to which patients were able to recover to preadmission levels of functioning after hospital discharge, and (3) identify the patient factors associated with an increased risk of developing disability associated with acute illness and hospitalization.Methods:
A total of 1279 community-dwelling patients, aged 70 years and older, hospitalized for acute medical illness were enrolled in this multicenter, prospective cohort study. Functional measurements obtained at discharge (Activities of Daily Living) and at 3 months after discharge (Activities of Daily Living and Instrumental Activities of Daily Living) were compared with a preadmission baseline level of functioning to document loss and recovery of functioning.Results:
At discharge, 59% of the study population reported no change, 10% improved, and 31% declined in Activities of Daily Living when compared with the preadmission baseline. At the 3-month follow-up, 51% of the original study population, for whom postdischarge data were available (n=1206), were found to have died (11%) or to report new Activities of Daily Living and/or Instrumental Activities of Daily Living disabilities (40%) when compared with the preadmission baseline. Among survivors, 19% reported a new Activities of Daily Living and 40% reported a new Instrumental Activities of Daily Living disability at follow-up. The 3-month outcomes were the result of the loss of function during the index hospitalization, the failure of many patients to recover after discharge, and the development of new postdischarge disabilities. Patients at greatest risk of adverse functional outcomes at follow-up were older, had preadmission Instrumental Activities of Daily Living disabilities and lower mental status scores on admission, and had been rehospitalized.Conclusions:
This study documents a high incidence of functional decline after hospitalization for acute medical illness. Although there are several potential explanations for these findings, this study suggests a need to reexamine current inpatient and postdischarge practices that might influence the functioning of older patients.(Arch Intern Med. 1996;156:645-652)
Background Malnutrition among elderly hospitalised patients is widespread and has been shown to lead to adverse health outcomes. The effectiveness of interventions to minimise undernutrition in elderly inpatients is not well documented.
Objectives To identify the best available practices, in the hospital setting, that minimise undernutrition or the risk of undernutrition, in the acute care patient especially for the older patient. The review will assesses the effectiveness of a range of interventions designed to promote adequate nutritional intake in the acute care setting, with the aim of determining what practices minimise malnutrition in the elderly inpatients.
Search strategy English language articles from 1980 onwards were sought using Medline, Premedline, Cinahl, Austrom-Australasian Medical Index and AustHealth, Embase and Science Citations Index.
Selection criteria For inclusion the study had to include an intervention aiming to minimise undernutrition in hospitalised elderly patients aged 65 years or older. All study designs were included.
Data collection and analysis Two independent reviewers assessed the eligibility of each study for inclusion into the review, critically appraised the study quality and extracted data using standardised tools. For each outcome measure results were tabulated by intervention type and discussed in a narrative summary. Results from randomised controlled trials were pooled in meta-analyses where appropriate.
Main results Twenty-nine studies met the inclusion criteria, with a total of 4021 participants. The focus of 15 interventions was the supplying of oral supplements to the participants, six focused on enteral nutrition therapy, four interventions made changes to the foods provided as part of the hospital diet, one included the services of an additional staff member and three incorporated the implementation of evidence-based guidelines. Ten meta-analyses were conducted from which the main findings were: significant improvements in weight status and arm muscle circumferences with an oral supplement intervention, P < 0.05.
Reviewers’ conclusions The findings of the review support the use of oral supplements to minimise undernutrition in elderly inpatients. The results also emphasise the need for more high-quality research using appropriate outcome measures in the area of minimisation of undernutrition, particularly interventions that make alterations to the hospital diet and address support for feeding patients at the ward level.
The Barthel Index is considered to be the best of the ADL measurement scales. However, there are some scales that are more sensitive to small changes in functional independence than the Barthel Index. The sensitivity of the Barthel Index can be improved by expanding the number of categories used to record improvement in each ADL function. Suggested changes to the scoring of the Barthel Index, and guidelines for determining the level of independence are presented. These modifications and guidelines were applied in the assessment of 258 first stroke patients referred for inpatient comprehensive rehabilitation in Brisbane, Australia during 1984 calendar year. The modified scoring of the Barthel Index achieved greater sensitivity and improved reliability than the original version, without causing additional difficulty or affecting the implementation time. The internal consistency reliability coefficient for the modified scoring of the Barthel Index was 0.90, compared to 0.87 for the original scoring.
Background Malnutrition among elderly hospitalised patients is widespread and has been shown to lead to adverse health outcomes. The effectiveness of interventions to minimise undernutrition in elderly inpatients is not well documented. Objectives To identify the best available practices, in the hospital setting, that minimise undernutrition or the risk of undernutrition, in the acute care patient especially for the older patient. The review will assesses the effectiveness of a range of interventions designed to promote adequate nutritional intake in the acute care setting, with the aim of determining what practices minimise malnutrition in the elderly inpatients. Search strategy English language articles from 1980 onwards were sought using Medline, Premedline, Cinahl, Austrom-Australasian Medical Index and AustHealth, Embase and Science Citations Index. Selection criteria For inclusion the study had to include an intervention aiming to minimise undernutrition in hospitalised elderly patients aged 65 years or older. All study designs were included. Data collection and analysis Two independent reviewers assessed the eligibility of each study for inclusion into the review, critically appraised the study quality and extracted data using standardised tools. For each outcome measure results were tabulated by intervention type and discussed in a narrative summary. Results from randomised controlled trials were pooled in meta-analyses where appropriate. Main results Twenty-nine studies met the inclusion criteria, with a total of 4021 participants. The focus of 15 interventions was the supplying of oral supplements to the participants, six focused on enteral nutrition therapy, four interventions made changes to the foods provided as part of the hospital diet, one included the services of an additional staff member and three incorporated the implementation of evidence-based guidelines. Ten meta-analyses were conducted from which the main findings were: significant improvements in weight status and arm muscle circumferences with an oral supplement intervention, P < 0.05. Reviewers' conclusions The findings of the review support the use of oral supplements to minimise undernutrition in elderly inpatients. The results also emphasise the need for more high-quality research using appropriate outcome measures in the area of minimisation of undernutrition, particularly interventions that make alterations to the hospital diet and address support for feeding patients at the ward level.
A food quality control and improvement permanent process was initiated in 1999. To evaluate the food service evolution, protein-energy needs coverage were compared in 1999 and 2008 with the same structure survey in all hospitalized patients receiving 3 meals/day.
Nutritional values of food provided, consumed and wasted over 24h including non-exclusive nutritional support were calculated individually. Nutritional needs were estimated as 110% of Harris-Benedict formula for energy and 1.2 or 1.0 g protein/kg/day for patients <65 or ≥65 years old, respectively. Multivariate analysis identified factors associated with low nutritional intake in both populations standardized to body mass index (BMI) of 1999's patients.
Out of 1677 patients, 1291 were included. Mean BMI was higher in 2008 than 1999 (P<0.001). The proportion of underfed patients was unchanged (69 vs. 70%, NS). The consumption of ≥1 oral nutritional supplements (ONS) daily increased the protein needs coverage from 80% to 115% (P<0.001). The year 1999, high BMI, 1st week of hospital stay, specific diet, ONS absence and low meal quality were associated with low nutritional intakes.
The nutritional needs coverage could have improved in 2008 if BMI was similar to 1999's. ONS consumption is associated with a lower risk of underfeeding in hospitalized patients.
To (1) develop a dysphagia screening tool to triage all patients at risk of aspiration/dysphagia on admission to acute hospital wards, (2) evaluate tool reliability, (3) evaluate nursing compliance and (4) develop a robust dysphagia training programme.
Failure to diagnose dysphagia has significant medical and economic costs. Dysphagia screening reduces pneumonia threefold. Most nurse-screening tools have focused on stroke. However, many other conditions are associated with dysphagia. A multidisciplinary team developed a nurse-administered, evidence-based swallow screening tool for generic acute hospital use.
Prospective, quasi-experimental.
Nurses were assessed for knowledge pre- and post-training. All patients were nurse-screened for dysphagia on admission. All patients were reviewed by speech pathologists to determine screening accuracy. Results were not blinded. The one page tool encompassed (1) diagnostic categories, (2) patient/carer interview, (3) dysphagia indicators and (4) if applicable, water swallow test.
Thirty-eight nurses participated in a seven-week study; 442 patients were screened on two general medical wards. Three speech pathologists counter-assessed each patient by clinical examination or chart review. Sensitivity was 95%; specificity was 97%. Positive predictive value was 92%; negative predictive value was 98%. 3.4% of clinical screening decisions were incorrect. Compliance rate was 85%.
Caution is advised in interpretation of the results due to lack of blinding. Initial results suggest that the dysphagia screening tool is a quick and robust tool for triaging individuals with dysphagia. Training is critical to successful screening.
Twenty-five to 30% of acute hospitalised individuals have dysphagia. All adult acute patients are screened for dysphagia using the Royal Brisbane and Women's Hospital dysphagia screening tool. Patients are triaged into categories of 'those requiring additional specialist intervention' and 'those who can proceed directly to regular diets and liquids'. Improved quality of care and cost savings is likely.
Prediction of metabolic rate is an important part of the nutrition assessment of critically ill patients, yet there are limited data regarding the best equation to use to make this prediction.
Standardized indirect calorimetry measurements were made in 202 ventilated, adult critical care patients, and resting metabolic rate was calculated using the following equations: Penn State equation, Faisy, Brandi, Swinamer, Ireton-Jones, Mifflin, Mifflinx1.25, Harris Benedict, Harris Benedictx1.25, Harris Benedict using adjusted weight for obesity, and each of the adjusted weight versions of Harris Benedictx1.25. The subjects were subgrouped by age and obesity status (young nonobese, young obese, elderly nonobese, elderly obese). Performance of each equation was assessed using bias, precision, and accuracy rate statistics.
Accuracy rates in the study population ranged from 67% for the Penn State equation to 18% for the weight-adjusted Harris Benedict equation (without multiplication). Within subgroups, the highest accuracy rate was 77% in the elderly nonobese using the Penn State equation and the lowest was 0% for the weight-adjusted Harris Benedict equation. The Penn State equation was the only equation that was unbiased and precise across all subgroups. The obese elderly group was the most difficult to predict. Therefore, a separate regression was computed for this group: Mifflin(0.71)+Tmax(85)+Ve(64)-3085.
The Penn State equation provides the most accurate assessment of metabolic rate in critically ill patients if indirect calorimetry is unavailable. An alternate form of this equation for elderly obese patients is presented, but has yet to be validated.
In the early 1990s, the Mini Nutritional Assessment (MNA; Nestle Nutrition, Vevey, Switzerland) was developed for nutrition screening in the elderly. Since then, it became the most established and widespread screening tool for older persons and has been translated into many different languages. The MNA shows prognostic relevance with regard to functionality, morbidity, and mortality of the elderly in different settings. This article recalls the development of the MNA with its short form (MNA-SF) and reviews the literature, focusing on the most recent publications. Specific features of the application of the MNA in different settings (community, nursing home, hospital) are considered. Minor shortcomings of the tool, such as the resources and the cooperation necessary for completion of the MNA, are discussed. Future options for the adaptation of this valuable tool are briefly characterized.
In an anthropometric nutritional assessment, elderly individuals are frequently unable to assume the positions needed for many measurements. This is especially true for stature, which is affected by mobility and skeletal deformities, and as a result measurements may be unreliable and inaccurate. An alternative is to use a surrogate value of stature. We developed predictive equations using data from elderly subjects in Cycle I of the National Health Examination Survey (NHES). The developed equations were cross-validated using two separate independent and more contemporary samples of elderly White men and women. The possible predictor variables were knee height and buttocks-knee length in the men and knee height and age in the women. For both the men and the women, the majority of the variance in stature was accounted for by knee height. Selected equation models were cross-validated, and a single equation was recommended for each elderly group that included knee height rather than buttocks-knee length as predictor variables. This selection was based upon the performance of the equations, and also upon the practical ease of collecting the possible predictor variables. Included with the recommended equations are the RMSEs and the standard error for predicting stature for an individual (SEI). The successful application of the recommended equations with two recent sets of elderly persons indicates the current utility of the recommended equations in White elderly Americans.
To develop and validate a new standardized confusion assessment method (CAM) that enables nonpsychiatric clinicians to detect delirium quickly in high-risk settings.
Prospective validation study.
Conducted in general medicine wards and in an outpatient geriatric assessment center at Yale University (site 1) and in general medicine wards at the University of Chicago (site 2).
The study included 56 subjects, ranging in age from 65 to 98 years. At site 1, 10 patients with and 20 without delirium participated; at site 2, 16 patients with and 10 without delirium participated.
An expert panel developed the CAM through a consensus building process. The CAM instrument, which can be completed in less than 5 minutes, consists of nine operationalized criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R). An a priori hypothesis was established for the diagnostic value of four criteria: acute onset and fluctuating course, inattention, disorganized thinking, and altered level of consciousness. The CAM algorithm for diagnosis of delirium required the presence of both the first and the second criteria and of either the third or the fourth criterion. At both sites, the diagnoses made by the CAM were concurrently validated against the diagnoses made by psychiatrists. At sites 1 and 2 values for sensitivity were 100% and 94%, respectively; values for specificity were 95% and 90%; values for positive predictive accuracy were 91% and 94%; and values for negative predictive accuracy were 100% and 90%. The CAM algorithm had the highest predictive accuracy for all possible combinations of the nine features of delirium. The CAM was shown to have convergent agreement with four other mental status tests, including the Mini-Mental State Examination. The interobserver reliability of the CAM was high (kappa = 0.81 - 1.0).
The CAM is sensitive, specific, reliable, and easy to use for identification of delirium.
A prospective study was done in 21 hospitalized medical patients to determine the effects of age and gender on food intake. From precise weighing of food served and uneaten, macronutrients and micronutrients ingested during the hospital stay were determined. Even though the hospital diet served was adequate in energy and protein, 38% of the patients ingested less than 65% of their nutritional requirements, with a higher percentage of those with inadequate intake among the elderly than among the young (28% vs. 10%). Patients over 65 years of age ingested less energy and protein than those under 65 years of age (1,167 vs. 1,967 kcal, p less than .01; 47 vs. 78 gm, p less than .05). The gender of the patients had no influence on food intake. More than 60% of the medical patients, especially the elderly, had an inadequate intake of micronutrients: folate, 100% of the elderly vs. 93% of the young; zinc, 90% vs. 64%; magnesium, 90% vs. 36%; and vitamin B-6, 90% vs. 64%. Multiple stepwise regression analysis showed that age and body weight on admission were of predictive value in terms of subsequent nutrient intakes during the hospitalization. Patients who were over 65 years old and weighted less than 80% of their ideal body weight consumed significantly less energy and fewer macronutrients and micronutrients.
Malnutrition is a common finding in the acute-care hospital.
To assess the adequacy of nutritional intake to individual needs and the effects of the hospitalization on nutritional status and to identify the reasons for inadequate energy intake.
A total of 286 patients with a mean ( +/- SD) age of 79 +/- 6 years (range, 70 to 99 years), consecutively admitted to the geriatrics and internal medicine wards of an acute-care university hospital, underwent multidisciplinary assessment on admission and at discharge and daily dietary data collection. The needed, prescribed, and actual daily energy intake for each individual was measured. Nutritional depletion was diagnosed if midarm circumference decreased by 3.6% or more from admission to discharge.
Nutritional depletion occurred in 27% of the patients and correlated with anorexia (86.4% vs 65.5% and 40% in patients whose midarm circumference was unchanged and increased, respectively; P < .001), Mini-Mental State Examination score (21.6 +/- 8.3 vs 23 +/- 6.9 and 26.5 +/- 3.6; P < .05), simplified premorbid Activities of Daily Living score (4.4 +/- 2.2 vs 5.1 +/- 1.8 and 5.0 +/- 1.8; P < .03), lymphocyte count (1.32 +/- 0.63 x 10(9)/L vs 1.62 +/- 0.88 x 10(9)/L and 1.47 +/- 0.50 x 10(9)/L; P < .03), serum albumin level (38 +/- 5g/L vs 40 +/- 4 g/L and 39 +/- 8 g/L; P < .002), ratio of actual to needed energy intake (56.9% +/- 22.1% vs 69.3% +/- 30.4% and 60.0% +/- 14.1%; P < .01), ratio of actual to prescribed energy intake (50.5% +/- 16.9% vs 60.5% +/- 20.%% and 65.5% +/- 15.7%; P < .001). Patients who consumed less than 40% of the prescribed food complained of anorexia and masticatory inefficiency and were unsatisfied with quality and timing of meals compared with other patients.
In-hospital starvation affects mainly patients with baseline nutritional, functional, and cognitive deficits and is strongly related to the inadequate energy intake.
It was hypothesized that energy intake in hospitalized elderly patients could be improved by increasing the density of energy of the food and that the volume of food actually consumed, even with a higher energy content than the normal, would not change with servings of high energy-dense hospital food.
Thirty-six elderly patients (52 to 96 years) of both sexes, long-term treated at two comparable wards, participated in this study. The patients were given 6 weeks of regular hospital food (RHF, 1670 kcal/d, 7.0 MJ) and 6 weeks of high-energy food (HE, 2520 kcal/d, 10.5 MJ). The volume of food was kept constant. A crossover study design was used. Food intake, energy intake, body weight, and modified functional condition (Norton scale) were measured.
Regardless of type of food (RHF or HE) and time of day (lunch or dinner), he food portion size (volume of food) intake was the same, approximately 80% of the portions consumed. HE led to a 40% increase in energy intake (from 25 +/- 1 during RHF to 35 +/- 2 kcal/kg/d, p < .0001), which resulted in a 3.4% increase in body weight (p < .001) after 3 weeks of HE. Only minimal changes in functional condition were found. The cost of HE was substantially lower (-85%) than any other mean available for improvement of energy intake.
A significant increase in energy intake can be achieved by higher energy density in regular hospital food and that HE does not cause a decrease in the volume of the food consumed. These findings suggest that it is the volume of food rather than the energy that limits voluntary energy intake of hospital food in elderly hospitalized patients.
Logistic regression is used frequently in cohort studies and clinical trials. When the incidence of an outcome of interest is common in the study population (>10%), the adjusted odds ratio derived from the logistic regression can no longer approximate the risk ratio. The more frequent the outcome, the more the odds ratio overestimates the risk ratio when it is more than 1 or underestimates it when it is less than 1. We propose a simple method to approximate a risk ratio from the adjusted odds ratio and derive an estimate of an association or treatment effect that better represents the true relative risk.
Malnutrition is common in hospitalized older people and may predict adverse outcomes. Previous studies of the relationship between nutritional status and hospital outcomes are limited by inadequate accounting for other potential predictors of adverse outcomes, the failure to consider functional outcomes, and the omission of clinical assessments of nutritional status.
To measure the relationship between a clinical assessment of nutritional status on hospital admission and subsequent mortality, functional dependence, and nursing home use.
Prospective cohort study
A tertiary care hospital
A total of 369 patients at least 70 years old (mean age 80.3, 62% women) admitted to a general medical service
Nutritional status was measured with the Subjective Global Assessment, a validated measure of nutritional status based on historical and physical exam findings. Patients were classified as severely malnourished (generally at least a 10% weight loss over the previous 6 months and marked physical signs of malnutrition), moderately malnourished (generally a 5 to 10% weight loss and moderate physical signs), or well nourished. Vital status, independence in activities of daily living, and nursing home use were determined through patient or surrogate interview at admission and 90 days and 1 year after discharge. Indices of comorbidity and illness severity were determined from chart review.
219 patients (59.3%) were well nourished, 90 (24.4%) were moderately malnourished, and 60 (16.3%) were severely malnourished. Severely malnourished patients were more likely than moderately malnourished or well nourished patients to die by 90 days (31.7%, 23.3%, and 12.3%, respectively, P < .001) and 1 year (55.0%, 35.6%, and 27.9%, P < .001) after discharge. In logistic regression models controlling for acute illness severity, comorbidity, and functional status on admission, severely malnourished patients were more likely than well nourished patients to die within 1 year of discharge (OR = 2.83, 95% CI, 1.47-5.45), to be dependent in activities of daily living 3 months after discharge (OR = 2.81, 1.06-7.46), and to spend time in a nursing home during the year after discharge (OR = 3.22, 1.05-9.87).
Malnutrition was common in hospitalized patients with medical illness and was associated with greater mortality, delayed functional recovery, and higher rates of nursing home use. These adverse outcomes were not explained by greater acute illness severity, comorbidity, or functional dependence in malnourished patients on hospital admission.
Protein-energy undernutrition, or the possibility of its development, has been documented to occur frequently in patients on admission to hospital. Deterioration in nutritional status is known to occur in hospital. In a prospective study of 594 sequential hospital admissions, we aimed to assess the prevalence of undernutrition among patients on admission to two acute teaching hospitals in Dublin, Republic of Ireland using the widely-accepted anthropometric criteria applied in a large study from Dundee, Scotland, UK (McWhirter & Pennington, 1994) and to determine changes in nutritional status in hospital. The mean prevalence of undernutrition (11 %) was considerably lower than was reported from Dundee (40 %). Unintentional weight loss before admission and functional impairment on admission occurred to a similar extent in both centres. Weight loss in hospital occurred in the same proportion of patients, but less frequently among those undernourished on admission to hospital, in Dublin compared with Dundee. The patients found to be undernourished on admission in this study had a mortality rate in hospital (6.5 %) over three times that of the adequately nourished group (2 %). The magnitude of the difference in prevalence of undernutrition between the two centres cannot be explained by ethnicity, case-mix or age distribution. With the secular increase in BMI in the population, the thresholds for classifying patients as undernourished or at risk of nutritional deterioration may need to be reviewed. For clinical use, recent weight loss and functional status may be more appropriate variables to use in the evaluation of nutritional status on admission to hospital.
The aim of this study was to investigate the cause of continuing weight-loss in hospitalized patients. We determined 1. whether the hospital menu was able to meet the patients' minimum nutritional requirements, 2. the proportion of food being wasted and 3. the mean nutritional intakes of patients.
This study was carried out in a University hospital (1200 beds). All the food supplied and wasted was measured over a 28 day period on one ward in each of 4 different specialties. Average food intake per patient was calculated and checked against individual food intake measurements.
The hospital menu provided over 2000 kcal/day and could meet patients' nutritional requirements. However, high wastage rates of greater than 40% resulted in energy and protein intakes within all specialties being less than 80% of that recommended. The cost of this waste was 139,655 pounds sterling in these four specialties.
More than 40% of hospital food was wasted. Energy and protein intakes were low and patients did not, therefore, meet their recommended intakes. This helps to explain continuing weight-loss in hospital patients and represents a large waste of resources. Hospital feeding policies therefore need reviewing and made more appropriate to the needs of the sick.
Many patients in hospitals are undernourished and nutritional care is inadequate in most hospitals. The aim of this investigation was to gain insight into how this situation could be improved.
Seven hundred and fifty randomly selected patients were screened at admission in three hospitals and surveyed during their entire hospitalization. Each time a patient was not treated according to a clearly defined nutritional standard, the nurse responsible for the patient was interviewed about possible reasons according to preformed questionnaires.
The investigators found that 22% of the patients were nutritionally at-risk, and that only 25% of these patients received an adequate amount of energy and protein. The departments had only screened for nutritional problems in 60% of the cases. Only 47% of the patients, who the departments judged to be at-risk patients, had a nutrition plan worked out, and only about 30% of the at-risk patients were monitored by the departments by recording of dietary intake and/or body weight. The main causes for inadequate nutritional care were lack of instructions to deal with these problems, and lack of basic knowledge with respect to dietary requirements and practical aspects of the hospital's food provision. Patient-related aspects and the system of food provision also contributed, but only to a small degree.
These findings form the basis of the strategy to improve nutritional care in these hospitals.
This study aimed to assess the ability of the hospital meal service to meet patients' nutritional needs.
All hospitalised patients who received 3 meals/day without artificial nutritional support were included. The nutritional values of food served, consumed and wasted during a 24 h period were compared to patients' needs estimated as energy: 110% Harris-Benedict formula; protein: 1.2 or 1.0 g/kg bodyweight/day for patients < or = or > 65 years old, respectively. A structured interview recorded patients' evaluation of the meal quality, their reasons for non-consumption of food and the relationship between food intake and disease.
Out of 1707 patients included, 1416 were fully assessable (59% women; 68+/-21 years; body mass index: 24.3+/-5.1 kg/m(2)). Daily meals provided 2007+/-479 kcal and 78+/-21 g of protein and exceeded patients' needs by 41% and 15%, respectively. However, 975 patients did not eat enough. Plate waste was 471+/-372 kcal and 21+/-17 g of protein/day/patient. Moreover, the food intake of 572 (59%) of these underfed patients was not predominantly affected by disease. Logistic regression analyses identified as other risk factors: elevated BMI, male gender, modified diet prescription, length of stay <8 or > or = 90 days and inadequate supper.
Despite sufficient food provision, most of the hospitalised patients did not cover their estimated needs. Since insufficient food intake was often attributed to causes other than disease, there should be potential to improve the hospital meal service.
Protein undernutrition enhances frailty and aggravates intercurrent diseases generally observed in elderly patients. Undernutrition results from insufficient food intake and catabolic status. Daily nutrient intakes were explored for hospitalized geriatric patients. Nutrient intake (carbohydrates, lipids, proteins, and calcium) was determined in randomly selected geriatric patients (n=49) over five consecutive days by weighting food in the plate before and after meals. For each geriatric patient, catabolic status and risk factors of undernutrition were considered. Results were compared between patients in a steady status or catabolic status. In steady status patients, protein, lipid and carbohydrate intake but not calcium intake, met recommended dietary allowances (total caloric intake:1535 +/- 370 Cal/day ; protein:1+/- 0.4 g/kg/day ; carbohydrates:55 +/- 7.7 % ; lipids: 30 +/- 6.3 % ; calcium:918 +/- 341 mg/day) . Patients in catabolic status (cardiopulmonary deficiency , neurologic disease , inflammatory process) had lower total caloric intake, lower protein intake and dramatically lower calcium intake (total caloric intake : 1375 +/- 500 Cal/day ; protein :0.9 +/- 0.4 g/kg/day ; carbohydrates : 54 +/- 8.3 % ; lipids : 31 +/-6.2 % ; calcium : 866 +/- 379 mg/day). Nutrient intake was lower in elderly patients hospitalized in short stay care units, perhaps due to failure to recognize suitable nutrient requirements. Protein-caloric undernutrition should be diagnosed early during hospitalization in order to allow appropriate dietary supplementation. However the incidence of protein undernutrition among elderly patients as a cause or a consequence of adverse pathophysiological processes remains a cause of debate.
Acute hospital general medicine services care for ageing complex patients, using the skills of a range of health-care providers. Evidence suggests that comprehensive early assessment and discharge planning may improve efficiency and outcomes of care in older medical patients.
To enhance assessment, communication, care and discharge planning by restructuring consistent, patient-centred multidisciplinary teams in a general medicine service.
Prospective controlled trial enrolling 1538 consecutive medical inpatients. Intervention units with additional allied health staff formed consistent multidisciplinary teams aligned with inpatient admitting units rather than wards; implemented improved communication processes for early information collection and sharing between disciplines; and specified shared explicit discharge goals. Control units continued traditional, referral-based multidisciplinary models with existing staffing levels.
Access to allied health services was significantly enhanced. There was a trend to reduced index length of stay in the intervention units (7.3 days vs 7.8 days in control units, P = 0.18), with no change in 6-month readmissions. In-hospital mortality was reduced from 6.4 to 3.9% (P = 0.03); less patients experienced functional decline in hospital (P = 0.04) and patients' ratings of health status improved (P = 0.02). Additional staffing costs were balanced by potential bed-day savings.
This model of enhanced multidisciplinary inpatient care has provided sustainable efficiency gains for the hospital and improved patient outcomes.
To evaluate the accuracy of seven predictive equations, including the Harris-Benedict and the Mifflin equations, against measured resting energy expenditure (REE) in hospitalized patients, including patients with obesity and critical illness.
A retrospective evaluation using the nutrition support service database of a patient cohort from a similar timeframe as those used to develop the Mifflin equations.
All patients with an ordered nutrition assessment who underwent indirect calorimetry at our institution over a 1-year period were included.
Available data was applied to REE predictive equations, and results were compared to REE measurements.
Accuracy was defined as predictions within 90% to 110% of the measured REE. Differences >10% or 250 kcal from REE were considered clinically unacceptable.
Regression analysis was performed to identify variables that may predict accuracy. Limits-of-agreement analysis was carried out to describe the level of bias for each equation.
A total of 395 patients, mostly white (61%) and African American (36%), were included in this analysis. Mean age+/-standard deviation was 56+/-18 years (range 16 to 92 years) in this group, and mean body mass index was 24+/-5.6 (range 13 to 53). Measured REE was 1,617+/-355 kcal/day for the entire group, 1,790+/-397 kcal/day in the obese group (n=51), and 1,730+/-402 kcal/day in the critically ill group (n=141). The most accurate prediction was the Harris-Benedict equation when a factor of 1.1 was multiplied to the equation (Harris-Benedict 1.1), but only in 61% of all the patients, with significant under- and over-predictions. In the patients with obesity, the Harris-Benedict equation using actual weight was most accurate, but only in 62% of patients; and in the critically ill patients the Harris-Benedict 1.1 was most accurate, but only in 55% of patients. The bias was also lowest with Harris-Benedict 1.1 (mean error -9 kcal/day, range +403 to -421 kcal/day); but errors across all equations were clinically unacceptable.
No equation accurately predicted REE in most hospitalized patients. Without a reliable predictive equation, only indirect calorimetry will provide accurate assessment of energy needs. Although indirect calorimetry is considered the standard for assessing REE in hospitalized patients, several predictive equations are commonly used in practice. Their accuracy in hospitalized patients has been questioned. This study evaluated several of these equations, and found that even the most accurate equation (the Harris-Benedict 1.1) was inaccurate in 39% of patients and had an unacceptably high error. Without knowing which patient's REE is being accurately predicted, indirect calorimetry may still be necessary in difficult to manage hospitalized patients.
To estimate energy intake and energy expenditure (EE) in elderly hospitalized patients recovering from an acute illness.
Cross-sectional evaluation of the disparity between energy intake and expenditure.
Ninety geriatric patients (mean age+/-standard deviation 79.7+/-7.5) admitted to acute care or rehabilitation units.
Patients' energy intake and resting EE (REE) were measured over a 3-day period. Blood samples were taken to determine C-reactive protein (CRP), creatinine, and albumin concentrations and to check renal function.
Energy intake was higher than REE by a factor of 1.29, but it was lower than the energy requirement. Energy intake, adjusted for differences in body weight, was independent of sex, highest in those who were malnourished (defined as a body mass index (BMI) <21), and lowest in patients who scored poorly on the Mini-Mental State Examination. Energy intake and REE were independent of plasma CRP, creatinine, and albumin concentrations, as well as the initial diagnosis. REE was similar in men and women, at 18.8 kcal/kg per day. REE was 21.4 kcal/kg per day in patients with a BMI of 21 or less and 18.4 kcal/kg per day in those with a BMI greater than 21 kg/m2. The Harris-Benedict equation accurately predicted mean REE.
The mean REE of the geriatric patients studied was 18.8 kcal/kg per day, whereas energy intake was just sufficient to cover minimal requirements. Thus, hospitalized elderly patients are likely to benefit from higher calorie intake.
Background: Malnutrition is common among older hospital patients and contributes to poor clinical outcomes. Poor intake among this group of patients could be due to a variety of factors.
To better understand the causes and consequences of inadequate food intake among hospitalised elderly patients, specifically: to determine (i) the prevalence of factors contributory to inadequate food intake, (ii) the relationship of these factors to nutritional status and course of hospital stay.
A longitudinal observational study of a convenience sample.
Inpatients of an inner city elderly care unit in the UK.
One hundred patients (mean 81.7 years (sd 7.2);27 male,73 female) were observed twice weekly, from admission to discharge/maximum of 4 weeks. Anthropometric assessments of nutritional status were made on admission and discharge. At each visit, adequacy of intake in the preceding 24-hour period, and reasons for inadequate intake, were determined using nurse observations, food-charts, case-notes, and interviews of patients/carers. With all available information, adequacy was estimated whether the subject had consumed at least three-quarters of their standard diet along with any prescribed food supplements. Inadequate nutritional intake was defined as completing less than this amount.
On admission, 21 patients were malnourished [below the 10th percentile for demiquet (weight/demispan2) for males or mindex (weight/demispan) for females. Three patients became malnourished during their stay. At 285/425 assessments (67%), patients were judged to be eating inadequately. Acute illness, anorexia, catering limitations and oral problems were the most prevalent reasons for inadequate intake during the earlier part of patients' hospital stay. Confusion, low mood and dysphagia remained prevalent throughout. Compared to well-nourished patients (n=67), malnourished patients (n=24) had higher prevalence of oral problems (22%v6%;p<0.001), mood/anxiety disturbances (33% v 19%;p=0.02), anorexia (38% v 23%;p=0.02) and catering limitations (34% v 12%;p<0.001), but lower prevalence of dysphagia (4% v 13%,p=0.015). Of 51 patients in hospital for less than 10 days, 36 were eating inadequately.
Reasons for inadequate intake vary according to stage of hospital stay and nutritional status. Inadequate intake in the early stage after admission is mainly due to self-limiting temporary factors associated with acute illness.
To determine the protein requirements of elderly hospitalized patients.
Cross-sectional evaluation of nitrogen balance.
Short-stay geriatric ward or rehabilitation care unit.
Thirty-six elderly hospitalized patients (aged 65-99) admitted to short-stay and rehabilitation care units.
Resting energy expenditure and nitrogen balance were determined under usual and spontaneous energy and protein intake after subjects were clinically stable (3-5 days after admission). All items consumed over a 3-day period were weighed to determine energy and protein intake.
Energy (23.5+/-6.3 kcal/kg per day) and protein (0.99+/-0.24 g/kg per day) intake were similar in men and women, and nitrogen balance was neutral (0.37+/-2.6 g/day; P=.41 vs a neutral nitrogen balance, i.e., 0 g/d). Half of the patients had a positive nitrogen balance. Plasma C-reactive protein, renal function, nutritional status, and initial diagnosis had no influence on nitrogen balance. In contrast, energy and protein intakes correlated positively with nitrogen balance. Linear regression analysis suggested that an elderly hospitalized patient with an energy intake of 1.31 times resting energy expenditure or greater appears to require a minimum protein intake of 1.06+/-0.28 g/kg per day.
Mean protein intake to reach a neutral nitrogen balance in elderly hospitalized patients is 1.06+/-0.28 g/kg per day, which is higher than current recommendations for healthy elderly people. Safe protein intake (that would be adequate to ensure that 95% of patients remain in positive nitrogen balance) is difficult to establish.
Analysis of estimation methods for resting metabolic rate in critically ill adults
- D C Frankenfeld
- A Coleman
- S Alam
- R N Cooney
Frankenfeld DC, Coleman A, Alam S, Cooney RN. Analysis of estimation
methods for resting metabolic rate in critically ill adults. J Parenter Enteral Nutr
2009;33:27e36.
Protein-energy under nutrition among elderly hospitalized patients: a prospective study
- Sullivan
Analysis of estimation methods for resting metabolic rate in critically ill adults
- Frankenfeld