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Position of the Academy of Nutrition and Dietetics: Individualized Nutrition Approaches for Older Adults: Long-Term Care, Post-Acute Care, and Other Settings
Abstract
It is the position of the Academy of Nutrition and Dietetics that the quality of life and nutritional status of older adults in long-term care, post-acute care, and other settings can be enhanced by individualized nutrition approaches. The Academy advocates that as part of the interprofessional team, registered dietitian nutritionists assess, evaluate, and recommend appropriate nutrition interventions according to each individual's medical condition, desires, and rights to make health care choices. Nutrition and dietetic technicians, registered assist registered dietitian nutritionists in the implementation of individualized nutrition care, including the use of least restrictive diets. Health care practitioners must assess risks vs benefits of therapeutic diets, especially for frail older adults. Food is an essential component of quality of life; an unpalatable or unacceptable diet can lead to poor food and fluid intake, resulting in malnutrition and related negative health effects. Including older individuals in decisions about food can increase the desire to eat and improve quality of life.
... Physiological changes in the cardiovascular, neurological, respiratory, and musculoskeletal systems are a natural part of biological aging and are a primary factor of agerelated chronic illness [7]. These age-related conditions increase an older adult's risk for poor nutritional status [8]. Age-related changes in appetite, ability to taste and smell, and level of food involvement [9] can further worsen nutrition status, chronic diseases, disabilities, and QOL [10]. ...
... Several studies focused on webinars and "live" nutrition counseling [57,76,83,88] as ways to provide nutrition information. Two papers used telephone sessions with an RDN [8,80]. One study trained long-term care staff to enhance their knowledge around nutrition related topics [73]. ...
... Electronic health records (EHRs) include medical history, medications, treatment plans, etc., and are not as common in day-to-day use today. Nutrition assessment, monitoring, and evaluation are essential components of the nutrition care process to detect and treat poor nutritional status among older adults and understand intervention efficacy [8]. ...
The technological developments in healthcare may help facilitate older adult nutritional care. This scoping review includes research in technology and nutrition to (1) explain how technology is used to manage nutrition needs and (2) describe the forms of technology used to manage nutrition. Five major databases were the foundation for papers published from January 2000 to December 2020. The most common type of technology used is software to (1) “track, plan, and execute” nutrition management and for (2) “assessing” technology use. “Track, plan, and execute” includes tracking food intake, planning for changes, and executing a plan. “Assessing” technology use is collecting nutrition data from a provider’s or an older adult’s self-use of technology to understand dietary intake. Hardware is the second most type of technology used, with tablet computers for software and internet access. The findings reveal that software for older adults lacks standardization, the Internet of Things is a promising area, the current device emphasis is the tablet computer, and broadband internet access is essential for nutrition care. Only 38 studies were published in the last five years, indicating that nutrition management for older adults with hardware or software has not reached a significant research mass.
... Physiological changes associated with aging are a primary factor in chronic illness, including cardiovascular, respiratory, neurological, and musculoskeletal disease (Granic et al., 2019). These physiological conditions place older adults at nutritional risk (Dorner & Friedrich, 2018). Age-related changes in taste, smell, and appetite (Somers et al., 2014) can compromise nutrition status and worsen chronic diseases, disabilities, and QOL (Sahyoun, 2017). ...
... Several studies focused on nutrition education through webinars and counseling with an RDN (e.g., Beasley et al., 2019). Two papers used telephone sessions with an RDN (Dorner & Friedrich, 2018;Scott et al., 2018). One study educated long-term care staff to enhance their knowledge (Ploeg et al., 2019). ...
... Nutrition areas of focus included assessment, monitoring/tracking, education/counseling, and dietary intake and quality. Nutrition assessment, monitoring, and evaluation are essential components of the NCP to detect and treat poor nutritional status and understand intervention effectiveness (Dorner & Friedrich, 2018). ...
Technology improvements for health care may enable nutritional health management for older adults. Research has yet to map the types of technology utilized to manage nutrition. This scoping review includes research in technology and nutrition to: (1) explain how technology is used to manage the nutrition needs of older adults; (2) describe the types of technology used to manage nutrition. The literature period was 21 years, but 86 percent of the papers retained were published within the past five years. The most common type of technology used is software, which is used to: (1) track, plan, and execute nutrition management and (2) assess technology use. The findings show that software for older adults lacks standardization. The internet of things is a promising area for research, and personal devices emphasize the tablet computer. The results suggest that managing older adult nutrition through technology is not yet a formable research area.
... La anorexia del envejecimiento es un síndrome geriátrico altamente prevalente, que describe los cambios relacionados con la edad que reducen el consumo de energía y aumentan la probabilidad de desnutrición, sarcopenia y fragilidad en el adulto mayor, convirtiéndose también en un predictor de morbilidad y mortalidad (7,53,54). Además, una disminución de las hormonas gastrointestinales (p. ej. ...
... La Encuesta de Salud de España en 2017, reveló que el 27,3 % de los adultos mayores usan 5 o más medicamentos al día, y 0,9 % utilizan 10 o más medicamentos (68). Se ha descrito interacción entre medicamentos y nutrientes o los efectos secundarios de estos, como la anorexia, las náuseas, el vómito y las pérdidas sensoriale que afectan la ingesta de alimentos con posterior efecto deletéreo sobre el estado nutricional (53,69). En la tabla 3 se describen los efectos secundarios de medicamentos sobre algunos aspectos del estado nutricional. ...
... el objetivo de mejorar la salud, pueden tener el efecto contrario, ya que tienen poca variedad y palatabilidad, que reduce el placer de comer y genera una disminución en la ingesta de alimentos (53). ...
Durante el envejecimiento se presentan una serie de cambios biológicos y psicológicos que tienen un impacto social y económico en la población a medida que avanza su edad. Uno de los sistemas con cambios fisiológicos que guarda una estrecha relación con el estado nutricional es el tracto gastrointestinal. Cada una de sus secciones presenta modificaciones que alteran, en una u otra medida, la motilidad, la digestión o la absorción de la energía y nutrientes, con efectos deletéreos como la pérdida de la masa musculoesquelética, la disminución en la funcionalidad y la alteración en la calidad de vida, que finalmente contribuye al aumento de la incidencia de desnutrición proteico calórica y sarcopenia. La vejez es una etapa en la que la presencia de enfermedades crónicas incrementa los problemas nutricionales debido al impacto propio de las patologías, sus efectos gastrointestinales, el uso de medicamentos y la inadecuada indicación de dietas restrictivas, que sin la apropiada orientación de un profesional en nutrición y dietética, pueden favorecer y exacerbar la desnutrición. Esta revisión describe los cambios en la función gastrointestinal que ocurren durante el envejecimiento y los efectos sobre el estado nutricional, y expone las consecuencias de las modificaciones en términos del perfil, contenido de nutrientes y consistencia de la alimentación del adulto mayor.
... It is not surprising then that measurement and documentation of malnutrition can help account for differences in the risk for adverse events and the resulting financial implications for SNFs [15]. Malnutrition is also linked to increased hospital readmissions [16], which is significant for SNFs because one in four patients discharged to a SNF is readmitted to the hospital within 30 days [17] and two-thirds of readmissions may be preventable [18]. Further, readmission rate is an important CMS quality measure that is tied to SNF Medicare reimbursement [19]. ...
... In addition, interventions that may be suitable in other care settings, such as patient nutrition education, may have less of a role and other considerations such as addressing medications that can impact appetite, and avoiding needlessly restrictive diets may become primary areas of focus. Indeed, it is the position of the Academy of Nutrition and Dietetics that in post-acute care settings, older adults who prioritize quality of life/personal choice receive the least restrictive diet appropriate to meet their nutrition needs [16]. In addition, despite recognized needs, implementing nutrition-focused QIPs in nursing homes can be challenging due to constraints on time and staffing [56]. ...
... The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) requires development of quality measures [16]. Screening, assessment, diagnosis, and intervention for malnutrition are notably missing from current CMS SNF quality measures, even though malnutrition is common among residents and associated with increased risk for infections, readmissions, falls, impaired wound healing, pressure injuries, physical limitations and disabilities, and even death [10]. ...
As skilled nursing in the United States moves to a value-based model, malnutrition care remains a critical gap area that is associated with multiple poor health outcomes, including hospital readmissions and declines in functional status, psychosocial well-being, and quality of life. Malnutrition is often undiagnosed/untreated, even though it impacts up to half of skilled nursing facility (SNF) residents, and COVID-19 infections/related symptoms have likely further increased this risk. In acute care, malnutrition quality measures have been both developed/tested, and nutrition-focused quality improvement programs (QIPs) have been shown to reduce costs and effectively improve care processes and patient outcomes. Less is known about such quality initiatives in SNF care. This perspective paper reviewed malnutrition-related quality measures and nutrition-focused QIPs in SNFs and nursing home care. It identified that although the Centers for Medicare & Medicaid Services (CMS) has had a nursing home Quality Assurance and Performance Improvement (QAPI) program for 10 years and has had SNF quality measures for nearly 20 years, there are no malnutrition-specific quality measures for SNFs and very few published nutrition-focused QIPs in SNFs. This represents an important care gap that should be addressed to improve resident health outcomes as SNFs more fully move to a value-based care model.
... 5 The Academy of Nutrition and Dietetics published its position that individualized nutritional care for the OA population, including those with dementia, can improve this patient population's nutritional status and quality of life. 6 Registered Dietitian Nutritionists (RDNs) are the leading nutrition experts who are specially trained to assess nutritional status, design and implement a nutrition care plan, and coordinate care with the interdisciplinary team. 6 In providing nutritional care for OAs with dementia, the role of the RDN may differ across practice settings based on the level of care required for their patients. ...
... 6 Registered Dietitian Nutritionists (RDNs) are the leading nutrition experts who are specially trained to assess nutritional status, design and implement a nutrition care plan, and coordinate care with the interdisciplinary team. 6 In providing nutritional care for OAs with dementia, the role of the RDN may differ across practice settings based on the level of care required for their patients. For instance, RDNs who work in the community are more involved in counseling their community-dwelling patients and caregivers compared to RDNs in long-term care settings, who routinely focus on providing individualized diets and assistance for their patients. ...
... For instance, RDNs who work in the community are more involved in counseling their community-dwelling patients and caregivers compared to RDNs in long-term care settings, who routinely focus on providing individualized diets and assistance for their patients. 6,7 Regardless of setting, training clinicians to provide care to this patient population is essential. Geriatric and dementia-specific curricula in dietetics programs can vary, and program directors have stated that it is challenging to find space to include this content. ...
Background: With the increasing prevalence of older adults with dementia, there is a need for healthcare providers, including Registered Dietitian Nutritionists (RDNs), skilled in geriatric and dementia care
Objective: This qualitative study aimed to explore what dementia care training RDNs have received, investigate if this training is adequate to meet the needs of clinicians, and determine their preferred training modalities for providing nutritional care to older adults with dementia.
Methods: RDNs who work with older adults in Alabama participated in three focus groups (n=20). Participants described the dementia care training they have received, including training as part of their education to become an RDN, and continuing professional education opportunities they have completed since becoming an RDN. They also discussed their ideal professional training modes, including frequency and duration of training sessions. Focus groups were audio recorded, transcribed verbatim, and data were analyzed using thematic analysis.
Results: Dementia-specific training provided during academic coursework varied but was limited overall. Since becoming an RDN, participants reported that training opportunities on dementia care are often designed for other healthcare professions and are not specific to nutrition. Many RDNs resort to learning from other healthcare professionals at work and seeking out dementia-specific information on their own. When describing their preferred training modalities, RDNs favored trainings that were in-person, include a variety of formats, can be completed in one day, and include text-based materials that can be used as a reference when on the job.
Conclusions: Dementia-specific training for RDNs is currently limited, and academic training should incorporate more focus on this patient population. RDNs in this study indicated that they prefer training that is one full day, is in-person, provides a variety of information and interactive activities, and incorporates interdisciplinary team members. They also desire text-based resources to take back to the workplace with them.
... 5 The Academy of Nutrition and Dietetics published its position that individualized nutritional care for the OA population, including those with dementia, can improve this patient population's nutritional status and quality of life. 6 Registered Dietitian Nutritionists (RDNs) are the leading nutrition experts who are specially trained to assess nutritional status, design and implement a nutrition care plan, and coordinate care with the interdisciplinary team. 6 In providing nutritional care for OAs with dementia, the role of the RDN may differ across practice settings based on the level of care required for their patients. ...
... 6 Registered Dietitian Nutritionists (RDNs) are the leading nutrition experts who are specially trained to assess nutritional status, design and implement a nutrition care plan, and coordinate care with the interdisciplinary team. 6 In providing nutritional care for OAs with dementia, the role of the RDN may differ across practice settings based on the level of care required for their patients. For instance, RDNs who work in the community are more involved in counseling their community-dwelling patients and caregivers compared to RDNs in long-term care settings, who routinely focus on providing individualized diets and assistance for their patients. ...
... For instance, RDNs who work in the community are more involved in counseling their community-dwelling patients and caregivers compared to RDNs in long-term care settings, who routinely focus on providing individualized diets and assistance for their patients. 6,7 Regardless of setting, training clinicians to provide care to this patient population is essential. Geriatric and dementia-specific curricula in dietetics programs can vary, and program directors have stated that it is challenging to find space to include this content. ...
Research Snapshot Purpose: This study aimed to explore Registered Dietitian Nutritionists' (RDNs) perceptions of the dementia care training they have received and determine their preferred training modalities for future dementia care training. Key Findings: Overall, dementia care training for RDNs is limited, both in terms of academic curricula and continuing education opportunities. More dementia care training opportunities are needed for RDNs who work with older adults. RDNs may prefer training sessions that can be completed in-person, in one day, with a variety of delivery styles while incorporating text-based resources to take back to the workplace with them.
... Specifically, there are few reports on how care is currently delivered and on the challenges that arise in delivering that care. 15,16 This is also the case for the United States. Thus, global literature has been used to describe the current situation. ...
... 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 Dietetics confirmed this diversity in practice; amount of time allocated to the dietitian varies by state. 16 In Ontario, Canada, the dietitian is mandated as part of the allied health care team at 30 minutes per resident per month, 19 yet this resource allocation is insufficient for proactive identification of challenges that impair food intake, as well as other clinical tasks (eg, assessment, evaluation, determining need for modified textures). 19,20 Lack of monitoring around nutrition and hydration was also a common official complaint in a Finnish LTC database. ...
... 4 Increasing dietitian time to 45 to 60 minutes per resident per month 20 is recommended to meet this clinical mandate and take a lead role for developing policy and training staff on malnutrition, its causes, impacts, and screening. 16,18 Dietitian time (9-month intervention: 533 minutes per resident, 27% maintained or gained weight vs control; 18 minutes per resident, 7% maintained or gained weight; P < .001) promoted nutrition status in high-risk residents with dementia, 45 and more dietitian (1 additional/ 100 residents; OR 0.955, P < .01) ...
Poor food and fluid intake and subsequent malnutrition and dehydration of residents are common, longstanding challenges in long-term care (LTC; eg, nursing homes, care homes, skilled nursing facilities). Institutional factors like inadequate nutrition care processes, food quality, eating assistance, and mealtime experiences, such as staff and resident interactions (ie, relationship-centered care) are partially responsible and are all modifiable. Evidence-based guidelines on nutrition and hydration for older adults, including those living with dementia, outline best practices. However, these guidelines are not sector-specific, and implementation in LTC requires consideration of feasibility in this setting, including the impact of government, LTC home characteristics, and other systems and structures that affect how care is delivered. It is increasingly acknowledged that interconnected relationships among residents, family members, and staff influence care activities and can offer opportunities for improving resident nutrition. In this special article, we reimagine LTC nutrition by reframing the evidence-based recommendations into relationship-centered care practices for nutrition care processes, food and menus, eating assistance, and mealtime experience. We then expand this evidence into actions for implementation, rating these on their feasibility and identifying the entities that are accountable. A few of the recommended activities were rated as highly feasible (6 of 27), whereas almost half were rated moderate (12/27) and the remainder low (9/27) owing to the need for additional staff and/or expert staff (including funding), or infrastructure or material (eg, food ingredients) investment. Government funding, policy, and standards are needed to improve nutrition care. LTC home leadership needs to designate roles, initiate training, and support best practices. Accountability will result from enforcement of policies through auditing of practice. Further evidence on these desirable nutrition care and mealtime actions and their benefit to residents’ nutrition and well-being is required.
... Household money spent within the last 7 days on food to be prepared and eaten at home, or prepared outside the home, were recorded as amount between USD 0-900 or USD 0-500, respectively. The HPS did not include questions on household spending in weeks [35][36][37][38][39][40][41][42][43][44][45]. Thus, like the SNAP data, these were only used in the descriptive analysis. ...
... When the definition of food insecurity to include undesirable changes to types of food was expanded in some other HPS-based studies [37,38], increases in levels of food insecurity among adults aged ≥60 years mirrored that of younger adults in the HPS [37]. Those findings underscore the complexities of food insecurity among older adults, as unpalatable foods or difficulty in eating certain foods (e.g., due to dentition) can lead to restricted dietary intake and malnutrition [39]. This variability in food insecurity definition, measure, and application presents challenges in generalizing the interpretation of findings and making comparisons across studies. ...
Food insecurity increased during the COVID-19 pandemic, but the impact varied across different age groups during the prolonged public health emergency. This study sought to describe national food insecurity prevalence by adult age group at multiple stages of the pandemic and explore differences by demographic characteristics. Data were from the nationally representative US Census Bureau’s Household Pulse Survey from April 2020 to May 2023 (N = 4,153,462). Locally weighted scatterplot smoothing (LOESS) regression analysis identified change points in food insecurity trends, segmenting the timeline into three periods: (1) April 2020–March 2021, (2) April 2021–May 2022, and (3) June 2022–May 2023. Logistic regression models examined associations between age, time period, and self-reported household food insecurity; covariates included demographics, socioeconomic status, household structure, and food support program usage. Overall, 9.3% of respondents experienced food insecurity, ranging from 3.5% among those aged ≥75 to 12.2% for ages 35–44 years. Significant interaction between age group and time period indicated inconsistency in the age-food insecurity association during the pandemic (p < 0.001). From Period 1 to 3, the proportion of food-insecure adults aged ≥65 rose from 9.2% to 13.9%. Across all age groups, higher odds of food insecurity were found among Black, Hispanic/Latino, or Other/Multiracial respondents; those with less than a Bachelor’s degree; those with incomes below USD 35,000; those unemployed for reasons other than retirement; and non-homeowners (p < 0.001). The results show that trends and characteristics associated with food insecurity varied across age groups and time periods. Continuous monitoring of food insecurity during emergencies is critical to identify vulnerable populations and timely interventions.
... Malnutrition in old people is basically addressed through periodic assessment and individualized treatment plans [16]. Moreover, individualized dietary counseling, a method by which people are guided and helped to put healthy foods and lifestyles into practice, is more effective than similar advice given for all old people, as they greatly vary in terms of biological age, disease conditions, functional frailty, and nutritional status [17]. According to studies, nutritional counseling is a crucial tool for maintaining good health and is a recognized component of the treatment of eating disorders [17,18]. ...
... Moreover, individualized dietary counseling, a method by which people are guided and helped to put healthy foods and lifestyles into practice, is more effective than similar advice given for all old people, as they greatly vary in terms of biological age, disease conditions, functional frailty, and nutritional status [17]. According to studies, nutritional counseling is a crucial tool for maintaining good health and is a recognized component of the treatment of eating disorders [17,18]. A recent review study showed nutritional counseling for malnourished older people had a positive impact on their body composition, weight, and grip strength [19]. ...
Background
Physiological, pathological, and socioeconomic changes occurring in older people negatively influence food intake, utilization, nutritional status, and health. These problems are deeply rooted in low socio-economic settings and could partly be addressed through systematic behavioral change approaches. Hence, this study was to evaluate the effect of behavioral model-guided nutritional counseling on the dietary intake and nutritional status of elders.
Methods
A one-armed pre- and post-test quasi-experimental design was conducted on 293 community-dwelling older adults aged above 60 years from January to May 2022. A health education tool was developed and validated using health beliefs and the theory of behavioral change. The sessions were delivered by trained nurses through home-to-home visits every week lasting 45–60 min for up to two months. Data on nutritional knowledge, dietary intake, and body weight were captured using standardized questionnaires and measurements. The primary outcome was captured using the validated mini-nutritional assessment (MNA) tool and classified accordingly. The data was analyzed using Stata software, where it is presented in tables, graphs, and summary statistics. A paired t-test and the p-value were used to identify statistically significant effects of the intervention.
Results
A total of 263 elders were involved in the experiment, and modeled nutritional counseling significantly improved the knowledge score from 7.58 (± 1.05) to 11.6 (± 1.37) (P < 0.001) at the pre- and post-intervention periods. A significant improvement has been shown in the consumption of dairy products, fruits, and animal-source foods and, importantly, in the mean dietary diversity score (p < 0.001). As a result, the burden of malnutrition was significantly lower in the post-intervention period (9.6%: 7.9–11.3) compared to baseline (12.5%: 11.4–13.8). There is a significant increase in the mini-nutrition assessment score (MD = 0.30; p = 0.007). The mean body weight and the body mass index did not change significantly after the intervention (p > 0.05).
Conclusion
Targeted behavioral model-guided nutritional counseling could help promote perception, diversify dietary consumption, and reduce the risk of undernutrition among elders. Particular attention to older people with the use of participant-centered nutritional behavioral change interventions coupled with livelihood support could help reduce undernutrition among older people.
Trial registration
Clinical Trial Registration-URL: www.clinicaltrials.gov, identifier number: NCT04746664, first released 10/02/2021.
... people as they greatly vary in terms of biological age, disease conditions, functional frailty, and nutritional status (4). ...
... According to studies, nutritional counselling is a crucial tool for maintaining good health and is a recognized component of the treatment of eating disorders (4,5). A recent review study showed nutritional counselling for malnourished older people had a positive impact on their body composition, weight, and grip strength (6). ...
Background: Physiological, pathological, and socioeconomic changes occur in older people that could influence their dietary intake, efficiency of nutrient utilization, and nutritional status. Impaired nutritional status aggravates existing disease conditions and worsens their health problems. Appropriate nutrition assessment followed by timely intervention and regular follow-up improves the nutritional status and health outcomes of older people, which are lacking in Ethiopia. Therefore, this study was aimed to estimate the effect of behavioural model-guided nutritional counselling on older people’s nutritional status in Bahir Dar City, Northwest Ethiopia.
Methods: A single-group pretest-posttest quasi-experimental design was conducted on 293 community-dwelling older adults aged 60 and above from January 28 to May 26, 2022. Trained nurses provided nutritional counseling guided by the health belief model and the theory of the behavioural model. The intervention was through home-to-home visits once a week for one month, with a two-month follow-up. Nutritional status, nutritional knowledge, dietary intake, body weight, and body mass index were measured. All measurements were recorded on a pre-post schedule, and the changes in outcomes were measured using a paired T-test.
Results: About 34(12.5%) and 21(9.6%) of the study participants were malnourished, while only 87(32.1%) and 76 (34.7%) were normal before and after the intervention, respectively. The mean score of nutritional status significantly increased from 21.55 ± 3.72 before the nutritional intervention to 21.64 ± 4.12 after the intervention (x̄ = -0.30, t218 = -2.72, 95% CI: -0.52- (-0.83), p = 0.007). While, mean body weight and the body mass index did not change after the intervention’s adoption.
The mean nutrition knowledge score rose from 7.58 ± 1.05 to 11.61 ± 1.37 (x̄ = 3.98, t218 = -32.79, 95% CI: -4.21-(-3.73), p < 0.001). Furthermore, the consumption of dairy products, fruits, and meat or egg intake increased after the intervention (p < 0.001).
Conclusion: Behavioural model-guided nutritional counseling improved the nutritional status of community-dwelling older people. A participant-centered nutritional programme recommended improving the health of community-dwelling older people.
Trial Registration: Clinical Trial Registration-URL: www.clinicaltrials.gov, identifier number: NCT04746664, first released 10/02/2021.
... There are multiple factors influencing nutritional intake like lifelong habits, clinical, sociodemographic and lifestyle components [100]. A patient-based approach is certainly time consuming but is also effective to improve nutritional compliance [15,101]. A qualified dietician should be involved in the supervision of nutritional compliance and follow-up [101]. ...
... A patient-based approach is certainly time consuming but is also effective to improve nutritional compliance [15,101]. A qualified dietician should be involved in the supervision of nutritional compliance and follow-up [101]. ...
Background & aims :
Acute illness can lead to disability and reduced quality of life in older patients. The aim of this systematic review was to evaluate the effect of nutritional rehabilitation provided during and after hospitalisation for an acute event on functional status, muscle mass, discharge destination and quality of life of older patients.
Methods :
The protocol for this systematic review was registered in PROSPERO (CRD42021264971). Articles were searched using Scopus, Medline, Google Scholar and Clinical.trials.gov. For studies included in the meta-analysis, Hedges'g standardized mean difference effect size was calculated and transformed in odds ratios.
Results :
We identified 7383 articles, of which 45 publications (41 trials, n = 8538 participants, mean age 80.35 ± 7.01 years.) were eligible for the systematic review. Patients were hospitalized for acute medical diseases (n = 6925) and fractures (n = 1063). The interventions included supplementation with a fixed amount of oral nutritional supplements (ONS, n = 17 trials), individualized diet plan (n = 3), combination of physical exercise with nutrition therapy (n = 14 trials), combination of anabolic agents with nutrition therapy (n = 5 trials). Overall nutritional rehabilitation improved functional status (Odds ratio 1.63 [1.15; 2.3], p = 0.003) and muscle mass (Odds ratio 2.61 [1.22; 5.5], p = 0.01), but not the quality of life or the discharge destination.
Conclusion :
Nutritional rehabilitation was found to improve functional status and muscle mass. There is a need for larger studies involving older hospitalized patients.
... 29 Additionally, food-based approaches are recommended for the management of undernutrition in older persons. [30][31][32] However, clinical research, as summarized in Table 3, has focused on the efficacy of supplementing with ONS for preventing and treating malnutrition in older adults, with unintentional weight loss being a primary outcome indicator. 38 Summary recommendations from an umbrella review suggest some benefits of ONS for increasing lean mass and body weight in older adults residing in the community. ...
... 100 Similarly, implementing individualized food and nutrition approaches can enhance the quality of life and nutrition status of older adults in a variety of settings, including relaxing food restrictions and emphasizing food preferences vs resorting to supplementation. 32 Research is needed to explore client and patient perceptions of ONS and their experiences related to consumption and expected compliance vs a self-selected diet of a variety of healthful and perhaps traditional, preferred foods. ...
Oral nutrition supplements (ONS) are widely recommended for the management of unintentional weight loss in patient populations, long-term care residents, and community-dwelling older adults. Most marketed ONS are ultra-processed, with precision nutrition and aseptic composition, as well as convenience and availability, driving their selection. However, therapeutic effectiveness is mixed and the potential health risks of consuming ultra-processed ONS long-term in lieu of less-processed foods have received little attention. A diverse and balanced microbiota supporting immunity and wellness is maintained by a diet rich in plant-sourced foods. The implications of ultra-processed ONS displacing plant-sourced foods, and specifically the potential for undesirable impacts on the gut microbiota, require consideration. Most ONS are either devoid of fiber or are supplemented with isolated or purified fibers that may contribute to adverse gastrointestinal symptoms and appetite suppression. In contrast, the diversity of microbial-available, nondigestible carbohydrates, together with the array of phytochemicals found in plant-sourced foods, support microbial diversity and its resiliency. This review outlines the clinical dilemma of recommending commercial ultra-processed ONS vs nutritionally adequate (eg, high-energy/high-protein) foods and beverages that contribute to diet quality, maintenance of a diverse and stable gut microbiota composition, and support nutrition status and health. Ultra-processed ONS may fall short of expected health benefits, and overreliance may potentially contribute to the risk for patient and older adult populations because of the displacement of a variety of healthful foods.
... • Tailor nutritional care to pandemic capacity using an algorithm for initiating early enteral tube feeding in lower-nutritional-risk patients and individualised care for high-nutritional-risk patients where capacity allows [20][21][22]25,35,36]; consideration of patient goals in cancer patients [22,33] and inpatients receiving EN or PN, although it was not clear if these were patient goals or goals as identified by a HCP [25,26]; individual assessment or adjustment of nutritional requirements (energy and protein) [21,27,30,35] and INC plans or nutrition intervention [21,23,26,29,30]. In certain topics, such as the nutritional care of older people and patients with cancer, the descriptions of INC are broader and incorporate inter-or multidisciplinary, multi-modal approaches where the patient's personal goals are also considered [32][33][34][35][36]. Singer et al. (2019) in the ESPEN guideline on clinical nutrition in the intensive care unit acknowledge the value of recommendations whilst highlighting that, due to the large heterogeneity of the ICU population, they can only serve as a basis to support decisions made for each patient on an individual basis [28]. ...
... • Tailor nutritional care to pandemic capacity using an algorithm for initiating early enteral tube feeding in lower-nutritional-risk patients and individualised care for high-nutritional-risk patients where capacity allows [20][21][22]25,35,36]; consideration of patient goals in cancer patients [22,33] and inpatients receiving EN or PN, although it was not clear if these were patient goals or goals as identified by a HCP [25,26]; individual assessment or adjustment of nutritional requirements (energy and protein) [21,27,30,35] and INC plans or nutrition intervention [21,23,26,29,30]. In certain topics, such as the nutritional care of older people and patients with cancer, the descriptions of INC are broader and incorporate inter-or multidisciplinary, multi-modal approaches where the patient's personal goals are also considered [32][33][34][35][36]. Singer et al. (2019) in the ESPEN guideline on clinical nutrition in the intensive care unit acknowledge the value of recommendations whilst highlighting that, due to the large heterogeneity of the ICU population, they can only serve as a basis to support decisions made for each patient on an individual basis [28]. ...
Delivering care that meets patients’ preferences, needs and values, and that is safe and effective is key to good-quality healthcare. Disease-related malnutrition (DRM) has profound effects on patients and families, but often what matters to patients is not captured in the research, where the focus is often on measuring the adverse clinical and economic consequences of DRM. Differences in the terminology used to describe care that meets patients’ preferences, needs and values confounds the problem. Individualised nutritional care (INC) is nutritional care that is tailored to a patient’s specific needs, preferences, values and goals. Four key pillars underpin INC: what matters to patients, shared decision making, evidence informed multi-modal nutritional care and effective monitoring of outcomes. Although INC is incorporated in nutrition guidelines and studies of oral nutritional intervention for DRM in adults, the descriptions and the degree to which it is included varies. Studies in specific patient groups show that INC improves health outcomes. The nutrition care process (NCP) offers a practical model to help healthcare professionals individualise nutritional care. The model can be used by all healthcare disciplines across all healthcare settings. Interdisciplinary team approaches provide nutritional care that delivers on what matters to patients, without increased resources and can be adapted to include INC. This review is of relevance to all involved in the design, delivery and evaluation of nutritional care for all patients, regardless of whether they need first-line nutritional care or complex, highly specialised nutritional care.
... A food-first approach should be the preferred method for treating sarcopenia and protein malnutrition in older adults. 11,41 For example, 3-5 ounces of animal and meat products can provide the 3-5 g of leucine needed for MPS. 42 However, as discussed above, older adults are at risk for dietary protein malnutrition, 26 which is exacerbated under COVID-19 pandemic conditions. ...
... [28][29][30] Enteral nutritional supplements are often used in long-term care settings due to poor food intake and to prevent protein malnutrition. 14,41 These products, such as Nestle Beneprotein Ò , 43 typically use either milk protein concentrate or whey protein isolate as a whey-source, which both contain between *10% and 15% leucine per gram of protein. 12,44 Data show that, when compared with a mixture of isonitrogenous equivalent constituent amino acids, casein, or soy protein isolate, whey protein stimulates greater MPS in older adults. ...
Sarcopenia and muscle wasting have many negative impacts on health and well-being. Evidence suggests that high rates of COVID-19 hospitalizations and lockdown conditions will lead to a marked increase in musculoskeletal disorders associated with sarcopenia in older adults. The molecular etiology of sarcopenia is complex, but physical inactivity, poor diet, and age diminished ability to stimulate muscle protein synthesis (MPS) remain important drivers. A body of evidence shows that, acting through the highly conserved nutrient sensor pathway mTORc1, the branch chain amino acid leucine can trigger and enhance MPS in older adults, and thus has a role in the medical management of sarcopenia. Whey protein-enriched enteral supplements are a low cost, easily accessible source of highly bioavailable leucine used clinically in older adults for preservation of lean body mass in long-term care setting. Therefore, given the evidence of leucine's ability to stimulate MPS in older adults, we argue that meal supplementation with whey-enriched enteral products, which can provide the 3-5 g of leucine necessary to trigger MPS in older adults, should be given serious consideration by medical and nutrition professionals to potentially mitigate muscle wasting and sarcopenia risk associated with prolonged COVID-19 lockdown measures.
... The use of technology encompassed three domains: (1) monitoring and management, (2) intervention, and (3) education. Nutritional monitoring and assessment are essential components of the nutritional process, allowing for the detection and treatment of poor nutritional status, as well as understanding the effectiveness of interventions [36]. ...
Background/objectives:
The Internet of Things (IoT) technology connects objects to the internet, and its applications are increasingly used in healthcare to improve the quality of care. However, the use of IoT for the nutritional management of patients with chronic neurological cognitive impairment is still in development. This scoping review aims to describe the integration of IoT and its applications to support monitoring, interventions, and nutritional education for patients with chronic neurological cognitive impairment.
Methods:
A scoping review was conducted using the Cochrane, PubMed/Medline, CINAHL, Embase, Scopus, and Web of Science databases following the Arksey and O'Malley framework.
Results:
Of the 1424 records identified, 10 were included in the review. Most of the articles were peer-reviewed proceedings from technology conferences or publications in scientific and technology journals. IoT-based innovations in nutritional management were discussed in methodological articles, case studies, or project descriptions. Innovations were identified across three key areas: monitoring, intervention, and education.
Conclusions:
IoT technology offers promising innovations for the nutritional management of patients with chronic neurological cognitive impairment. However, IoT capabilities in this field are still in the early stages of development and are not yet highly specific.
... As because there is great variation among them in terms of biological age, nutritional status and disease conditions. 25 Its all due to Physiological, pathological and socioeconomic changes that occurs in old age. 26 Hence, promoting optimal nutritional status is a key to improving longevity and quality of life among elders. ...
... Dietary restrictions e defined as any limitation on the type, quantity or consistency of certain foods or food groups e may limit food choice and pleasure to eat and thus bear the risk of limiting dietary intake. They are one potential cause of malnutrition and therefore generally not recommended for persons with malnutrition or at risk of malnutrition [52,93,106]. In addition, the benefits of special diets in old age and particularly in persons with dementia are uncertain [107]. ...
... The following were the requirements for inclusion: A person over 65 who is the primary or secondary outcome;2) intervention studies that compare pre-and post-trial changes with a quantitative measure;3) English language proficiency; as well as5) people residing in long-term care (LTC) facilities, such as assisted living, nursing homes, or hospices. (Dorner, B., 2018) [32] The Academy of Dietetics and Nutrition holds that customized nutrition techniques can improve the nutritional status and quality of life of older persons in post-acute care, long-term care, and other settings. The Academy supports the use of registered dietitian nutritionists in interprofessional teams to assess, evaluate, and prescribe suitable dietary interventions based on the unique medical needs, preferences, and rights of each patient to make decisions about their care. ...
Purpose: The traditional paradigm of home care in China is not up to the challenges posed by the country's increasing population's advancing age and lack of available resources. Digital monitoring technology solutions are thought to be advantageous for managing caregivers' workloads while also improving resident safety and care quality in assisted living facilities. To effectively provide the best possible services, teamwork is crucial in New Hampshire. Due to several issues such staffing shortages, rising resident expectations, and increased demands, NH are consequently embracing the use of Knowledge Management (KM) activities more and more to facilitate knowledge development, storage, transfer, and application. Method: In China, the lack of an established system for caring for the elderly is having a significant impact on society as a whole, making it imperative to establish one. The researcher examined the real impacts of their quality management system and KM efforts on service quality, as well as the KM adjustments made by two China state NH that adopted the E-Qalin management of quality model, in the qualitative research. Additionally, the researchers looked at the approaches used by two China private NH that address service quality from a knowledge management standpoint but have not implemented a certified management of quality program. There were eighty nursing professionals in the sample. Teamwork is crucial in every NH included in this study, and each participant in the researcher’s poll is a member of a team. In this work, the researchers used linear regression to analyse connections between individual variables. Results: Between the development, transmission, and application of knowledge in the state of New Hampshire regardless of the E-Qalin certificate, the researchers discovered a strong and favourable correlation. The researchers found a statistically significant and favourable association between knowledge storage and service quality, but only in New Hampshire with an E-Qalin certificate. Thus, the researcher’s study's findings highlight the necessity of learning more about quality control and knowledge management in the context of New Hampshire. Conclusion: The government, tech companies, and nursing homes need to further restructure the current system before more elderly people adopt sophisticated technology in home care settings. The study's findings, which centre on the transmission of tacit knowledge, substantially advance the field of knowledge management research in New Hampshire.
... Furthermore, likelihood of receiving a comfort-focused nutrition order was greater with more care plan modifications and with discontinued interventions. Such renegotiation and withdrawal of care orders may imply individualisation of care plans consistent with a palliative philosophy even in the absence of, or prior to, a formalised order (Niedert and American Dietetic Association 2005;Dorner and Friedrich 2018). The question remains whether there is an additional benefit to formalising comfort-focused nutrition care. ...
Background: Comfort-focused nutrition orders are recommended to manage eating changes among long-term care (LTC) residents nearing the end of life, though little is known about their current use. This investigation aims to describe current practices and identify resident-level and time-dependent factors associated with comfort-focused nutrition orders in this context.
Methods: Data were retrospectively extracted from resident charts of decedents (≥65 years at death, admitted ≥6 months) in 18 LTC homes from two sampling frames across southern Ontario, Canada. Observations occurred at 6 months (baseline), 3 months, 1 month and 2 weeks prior to death. Extracted data included functional measures (e.g. cognitive performance, health instability) at baseline, formalised restorative and comfort-focused nutrition care interventions at each timepoint and eating changes reported in the progress notes in 2 weeks following each timepoint. Logistic regression and time-varying logistic regression models determined resident-level (e.g. functional characteristics) and time-dependent factors (e.g. eating changes) associated with receiving a comfort-focused nutrition order.
Results: Less than one-third (30.5%; n = 50) of 164 participants (61.0% female; mean age = 88.3 ± 7.5 years) received a comfort-focused nutrition order, whereas most (99%) received at least one restorative nutrition intervention to support oral food intake. Discontinuation of nutrition interventions was rare (8.5%). Comfort orders were more likely with health instability (OR [95% CI] = 4.35 [1.49, 13.76]), within 2 weeks of death (OR = 5.50 [1.70, 17.11]), when an end-of-life conversation had occurred since the previous timepoint (OR = 5.66 [2.83, 11.33]), with discontinued nutrition interventions (OR = 6.31 [1.75, 22.72]), with co-occurrence of other care plan modifications (OR = 1.48 [1.10, 1.98]) and with a greater number of eating changes (OR = 1.19 [1.02, 1.38]), especially dysphagia (OR = 2.59 [1.09, 6.17]), at the preceding timepoint.
Conclusions: Comfort-focused nutrition orders were initiated for less than one-third of decedents and most often in the end stages of life, possibly representing missed opportunities to support the quality of life for this vulnerable population. An increase in eating changes, including new dysphagia, may signal a need for proactive end-of-life conversations involving comfort nutrition care options.
Implications for Practice: Early and open conversations with residents and family about potential eating changes and comfort-focused nutrition care options should be encouraged and planned for among geriatric nursing teams working in LTC. These conversations may be beneficial even as early as resident admission to the home.
... Since malnutrition and weight loss are prevalent in residents, and associated with functional decline, increased hospitalizations, and more dependence on activities of daily living [69], it is to be expected that interventions will seek results in improving food intake. Food and liquid intake have been recognized as an important interventional target for improving nutritional status of residents, being a concern for the development of interventions [70]. ...
The decrease in cognitive and physical ability among people with dementia can significantly affect eating performance, resulting in mealtime support needs that could lead to inadequate oral intake, weight loss, malnutrition, and reduced functionality in activities of daily living. This scoping review aimed to identify and summarize available research literature on mealtime interventions for people with dementia, and their impact on older people with dementia living in a residential care setting, care staff, and care context/environment. A scoping review of available research published in English, French, Portuguese, or Spanish, was conducted according to the methodology established by The Joanna Briggs Institute. The search was conducted between November 2022 and February 2023 in the following databases: MEDLINE, Web of Science, Scopus, CINAHL Complete, and SciELO. A total of 275 articles were retrieved, of which 33 studies were selected according to inclusion criteria. The interventions were classified into four general categories: environmental, mealtime assistance, staff training, and multicomponent. Most studies demonstrated effectiveness in increasing oral intake and improving behaviors such as agitation and aggression in people with dementia. The impact of interventions on care staff was linked to greater knowledge and attitudes towards mealtime support needs. There is a lack of reporting on the impact of interventions on the care context/environment. Most interventions examined the effects exclusively on residents, focusing on their oral intake and behavioral patterns, particularly agitation among individuals with dementia. However, it is crucial to conduct studies that evaluate the impact on administrators, to comprehend the viewpoints of various hierarchical levels within an organization regarding challenges associated with mealtime. The findings of this scoping review can support the development of new supportive programs, or strategies to improve mealtime experience with positive impact according to the reality and needs of each person or institution.
... 7 Furthermore, eating challenges can be detrimental to the psychosocial well-being of residents and their care partners because of the deeper symbolic and cultural meaning of food and mealtimes. [8][9][10] Dietitians are well positioned to develop individualised nutrition care plans that support the quality of life of LTC residents with complex nutritional needs, 8,11,12 including at the end of life. ...
Background
Dietitians are central members of the multidisciplinary long‐term care (LTC) healthcare team. The overall aim of this current investigation is to gain a better understanding of dietitian involvement in LTC resident's end‐of‐life care via referrals.
Methods
Retrospective chart reviews for 164 deceased residents (mean age = 88.3 ± 7.3; 61% female) in 18 LTC homes in Ontario, Canada, identified dietitian referrals and documented eating challenges recorded over 2‐week periods at four time points (i.e., 6 months, 3 months, 1 month and 2 weeks) prior to death. Nutrition care plans at the beginning of these time points were also noted. Logistic mixed effects regression models identified time‐varying predictors of dietitian referrals. Bivariate tests identified associations between nutrition orders and dietitian referrals that occurred in the last month of life.
Results
Nearly three‐quarters (73%) of participants had at least one dietitian referral across the four observations. Referrals increased significantly with proximity to death; 45% of residents had a referral documented in the last 2 weeks of life. Dietitian referrals were associated with the number of eating challenges (odds ratio [OR] = 1.42, 95% confidence interval [CI] = 1.27, 1.58). Comfort‐focused nutrition care orders were significantly more common when a dietitian was referred (25%) compared with when a dietitian was not referred (12%) in the final month of life ( p = 0.04).
Conclusions
Our findings suggest that dietitians are involved in end‐of‐life and comfort‐focused nutrition care initiatives, yet they are not engaged consistently for this purpose. This presents a significant opportunity for dietitians to upskill and champion palliative approaches to nutrition care within the multidisciplinary LTC team.
... While technology has shown promise in managingroutine tasks, it remains a challenge to provide personalized and precise dietary recommendations at the patient level. Each patient has unique requirements based on his/her medical history, dietary restrictions, and personal preferences [7]. Thus, the expertise and judgment of healthcare professionals in evaluating and prescribing appropriate interventions are currently indispensable. ...
Background: In the rapidly evolving domain of healthcare technology, the integration of advanced computational models has opened up new possibilities for personalized nutrition guidance. The emergence of sophisticated language models, such as Chat Generative Pre-training Transformer (ChatGPT), offers potential in providing interactive and tailored dietary advice. However, concerns remain about the applicability and appropriateness of ChatGPT's recommendations, especially for those with distinct health conditions. Objectives: This study aimed to evaluate the reliability of ChatGPT as a source of nutritional advice. Methods: Three hypothetical scenarios representing various health conditions were presented alongside precise dietary requirements. ChatGPT was tasked to generate personalized dietary programs, encompassing meal timing, specific caloric portions (measured in grams and spoons), as well as alternative meal options for each scenario. Following this, ChatGPT’s generated dietary programs underwent a thorough review by a multidisciplinary team of nutritionist, specialist physicians and clinical researchers. The evaluation focused on the programs' suitability, alignment with dietary standards, consideration of individual health factors, and additional guidance Safety. Results: ChatGPT demonstrated its ability to generate various options of meal plans in accordance with basic nutrition principles. However, there are apparent issues with the recommended individual macronutrient distribution, handling health conditions, drug interactions, and setting realistic weight loss goals. Conclusions: While ChatGPT exhibits promise as a dietary program generator, its application for intervention should be restricted to certified nutrition professionals. Until July 2023, it is not advisable for patients to engage in self-prescription using ChatGPT version 3.5, owing to its inability to provide professional knowledge and acceptable guidance, particularly for individuals with co-existing conditions. The prevailing absence of clinical reasoning highlights the importance of employing ChatGPT solely as a tool, rather than relying on it as an autonomous decision-maker. Its lack of clinical reasoning highlighted the need for human intervention and expert collaboration for precise personalized evaluations.
... The Academy of Nutrition and Dietetics recommends the use of the least restrictive diet for older adults to prioritize quality of life and their right to make choices over improving their health or increasing their longevity [19]. Another condition that often benefits from diet liberalization is diabetes; risk of hypoglycemia is one of the most important factors to consider when determining the treatment plan for older adults with diabetes [20]. ...
In the next two decades, the population aged 65 and older will increase from 1.7 million to 2.7 million in North Carolina. Food-insecure older adults are more likely to have an increase in negative health outcomes, be frequent utilizers of health care, and have more high-cost health care needs.
... Furthermore, holiday benefits , sanitary conditions (Parker 2020, Lee 2020), community regulation , and complaint and suggestion services (Lee and Severt 2018), are four fundamental aspects to be factored into community management and operations. Lee and Severt (2018), Dorner and Friedrich (2018), Ayalon (2018), and Lu et al (2021), agree that the key factors of community daily life include: information dissemination service, food and beverage service, daily life service, and shuttle service. Lee and Severt (2018), and Jester et al (2021) stress the role of health service and emergency service within the community, to enable appealing living environments for residents. ...
Purpose
The application of integrated project delivery (IPD) in conjunction with building information modeling (BIM) and Lean Construction (LC) as the efficient method for improving collaboration and delivering construction projects has been acknowledged by construction academics and professionals. Once organizations have fully embraced BIM, IPD and LC integration, a measurement tool such as a maturity model (MM) for benchmarking their progress and setting realistic goals for continuous improvement will be required. In the context of MMs literature, however, no comprehensive analysis of these three construction management methods has been published to reveal the current trends and common themes in which the models have approached each other.
Design/methodology/approach
Therefore, this study integrates systematic literature review (SLR) and thematic analysis techniques to review and categorize the related MMs; the key themes in which the interrelationship between BIM, IPD and LC MMs has been discussed and conceptualized in the attributes; the shared characteristics of the existing BIM, IPD and LC MMs, as well as their strengths and limitations. The Preferred Reporting Items for Systematic Reviews (PRISMA) method has been used as the primary procedure for article screening and reviewing published papers between 2007 and 2022.
Findings
Despite the growth of BIM, IPD and LC integration publications and acknowledgment in the literature, no MM has been established that holistically measures BIM, IPD and LC integration in an organization. This study identifies five interrelated and overlapping themes indicative of the collaboration of BIM, IPD and LC in existing MMs' structure, including customer satisfaction, waste minimization, Lean practices and cultural and legal aspects. Furthermore, the MMs' common characteristics, strengths and limitations are evaluated to provide a foundation for developing future BIM, IPD and LC-related MMs.
Practical implications
This paper examines the current status of research and the knowledge gaps around BIM, IPD and LC MMs. In addition, the highlighted major themes serve as a foundation for academics who intend to develop integrated BIM, IPD, and LC MMs. This will enable researchers to build upon these themes and establish a comprehensive list of maturity attributes fulfilling the BIM, IPD and LC requirements and principles. In addition, the MMs' BIM, IPD and LC compatibility themes, which go beyond themes' intended characteristics in silos, increase industry practitioners' awareness of the underlying factors of BIM, IPD and LC integration.
Originality/value
This review article is the first of a kind to analyze the interaction of IPD, BIM and LC in the context of MMs in current AEC literature. This study concludes that BIM, IPD and LC share several joint cornerstones according to the existing MMs.
... Individualized nutrition approaches according to personalized phenotype, genotype, food preferences, and health status can reduce the prevalence and risk of diseaserelated malnutrition and improve patients' Qol even in inhome care settings (28,32). On the other hand, the intuitive operation of enteral feeding pumps, their anti-free-flow protection, automatic priming, adjustable rate, and volume according to the patient's condition, and alarm conditions during any blockage, have enabled their handling more convenient for patients' home caregivers and made them easier to prescribe PN with commercial or homemade nutrition. ...
: Initiating early nutritional feeding in hospitalized patients will decline patients’ complications, shorten hospital length of stay and costs, and improve health outcomes. Over the years, with the emergence of the enteral feeding pumps, the process of enteral feeding has become easier with higher accuracy and safety. Enteral feeding pumps provide the ability to combine methods like continuous feeding during the overnight and bolus feeding during the day to make the feeding process more adaptable to patients’ status. Nowadays, prescriber’s knowledge regarding individualized nutrition for each patient according to their specific needs has been increased, and enteral feeding had shifted to home care settings. The need for precision enteral nutrition programs according to differences in human phenotype, genotype, food preferences, and health status becomes more apparent. Personalized nutrition programs can reduce the prevalence and risk of disease-related malnutrition and improve patients’ quality of life in home care settings. In this way, feeding pumps facilitate the personalized feeding process by making it unique and improved.
... Unfortunately, no formal guidance exists on how to optimally provide education and use patient education materials (PEMs) with older adults. Several position statements on care to older adults exist [2,3]. Guidance on the health literacy demands of patient education materials does exist [4]. ...
Objective:
To provide an overview of studies that describe the preferred mode and format of delivery of patient education materials to older adults.
Methods:
A scoping review was used to identify relevant literature published between January 2010 and June 2021, with specific attention given to studies conducted in high income countries with similar health systems.
Results:
A total of 3245 titles were identified, and 20 met the inclusion criteria and were included in this scoping review. Older adults preferred written information that could be accessed via health professionals or downloaded online. Other key features were identified including logical layout, signposted information, larger text size, labelled visual aids, and use of images appropriate and relevant to the target group were preferred. Audio visual resources were also considered valuable when well designed. Formats for patient education such as apps, group classes and online courses were less popular with older adults.
Conclusions:
Patient education materials for older adults should be carefully designed, with attention to layout and content. Older adults indicated a preference for hard copy handouts or in a format that can be downloaded.
Practice implications:
Regular engagement with older consumers about their preferences is important as technology for delivery of patient education materials evolve. Key features for specific attention during the design process include a logical layout (tested with consumers), signposted information, text size, labelled visual aids and appropriate images. The perspectives of other key groups of older adults such as those from minority populations or other disadvantaged groups are largely unexplored.
... The two main exclusions for this measure are a LOS <24 hours because those patients are not in the hospital long enough to receive proper assessment, and intervention care plan for malnutrition. Patients who are transferred or discharged to hospice 16,17 have significantly different requirements for nutrition support 18, 19 and those treatment plans are highly dependent on patient preferences. ...
... Um die vielfältigen Ernährungsprobleme von Personen mit (Risiko für) Mangelernährung adäquat zu adressieren, empfehlen internationale Leitlinien eine Individualisierung von 8 Ernährungsinterventionen (5). In einem Positionspapier plädiert die "Academy of Nutrition and Dietetics" für individualisierte Ernährungskonzepte in der Langzeitpflege und anderen Settings, um Lebensqualität und Ernährungszustand von älteren Erwachsenen zu verbessern (80). ...
Hintergrund und Ziele Mangelernährung ist im Pflegeheimbereich hoch prävalent und negative Folgen können von funktionellen Einschränkungen über eine verminderte Lebensqualität bis hin zu vorzeitigem Versterben reichen. Daher ist eine adäquate Ernährungstherapie wichtig, um das Fortschreiten und negative Folgen zu vermindern oder gar zu vermeiden. Insbesondere auf eine ausreichende Proteinzufuhr ist für die Erhaltung von Muskelmasse zu achten. Da Mangelernährung ein multifaktoriell bedingtes Problem ist und Ernährungsbedürfnisse von Person zu Person sehr unterschiedlich sein können, empfehlen internationale Leitlinien eine Individualisierung der Ernährungstherapie. Jedoch werden individualisierte Ernährungskonzepte im Pflegeheimbereich bisher kaum angewandt. Daher wurde im zugrundeliegenden Projekt dieser Dissertation ein individualisiertes Ernährungsinterventionskonzept für Bewohner*innen mit (Risiko für) Mangelernährung entwickelt. Ziele der Dissertation waren folglich 1) dieses Konzept sowie dessen Anwendung und Akzeptanz zu beschreiben, 2) die Effekte der Intervention auf Nahrungszufuhr, Körpergewicht, Handkraft und Lebensqualität zu untersuchen und 3) die übliche Proteinzufuhr zu beschreiben sowie Auswirkungen der Intervention auf die Proteinzufuhrmenge und -quellen zu analysieren. Methoden In einer Prä-Post-Studie erhielten Pflegeheimbewohner*innen mit (Risiko für) Mangelernährung aus zwei Nürnberger Pflegeheimen sechs Wochen die übliche Versorgung (Phase 1), gefolgt von sechs Wochen individualisierter Intervention (Phase 2). Während der Interventionsphase wurden drei Anreicherungsmodule - ein Protein-Energie-Getränk (250 mL, 220 kcal, 22 g Protein) sowie süße und herzhafte Proteinsahnen (je 40 g, 125 kcal, 10 g Protein) - einzeln oder kombiniert in fünf Anreicherungsstufen (von 0, keine Anreicherung, bis 4‚ alle drei Anreicherungsmodule) angeboten, um individuelle Energie- und Proteindefizite auszugleichen. Bewohner*innen mit Kau- und/oder Schluckstörungen erhielten zusätzlich optisch optimierte, wieder in Form gebrachte texturmodifizierte Kost (TMK). Die Akzeptanz dieses Interventionskonzepts seitens Bewohner*innen wurde durch Compliance und seitens der Mitarbeitenden der Pflegeheime durch eine schriftliche Befragung zur wahrgenommenen Nützlichkeit und Praktikabilität nach Ende der Interventionsphase erfasst. In den Wochen (w) 1, 6, 7 und 12 wurden Energie- und Proteinzufuhr (3-Tage-Wiege¬protokolle), in w1, w6 und w12 Körpergewicht, Handkraft (Martin-Vigorimeter) und Lebensqualität (3 Subskalen und 2 Items des "Quality of Life in Dementia“-Fragebogens) ermittelt. Die Effekte der Intervention wurden mittels Varianzanalyse (ANOVA) mit Messwiederholung analysiert. Für eine Sekundäranalyse wurde die Proteinzufuhr aus w1 und w6 (Phase 1) sowie w7 und w12 (Phase 2) vier Mahlzeiten sowie zwölf Proteinquellen zugeordnet und gemittelt. Unterschiede zwischen Phase 1 und 2 wurden mit dem t-Test für gepaarte Stichproben (Proteinzufuhr-menge) und dem Wilcoxon-Vorzeichen-Rang-Test (Proteinzufuhr aus verschiedenen Quellen) getestet. Ergebnisse und Beobachtungen Von 306 gescreenten Bewohner*innen wurden 55 mit einem (Risiko für) Mangelernährung in die Studie einbezogen und 50 schlossen diese ab. Das Durchschnittsalter der 50 Bewohner*innen betrug 84±8 Jahre, 74% waren weiblich und 26% mangelernährt. Zehn Teilnehmer*innen hatten kein Energie- oder Proteindefizit und erhielten somit keine Anreicherung (Anreicherungsstufe 0). Anreicherungsstufe 1 wurde 8%, Stufe 2 28%, Stufe 3 20% und Stufe 4 24% der Bewohner*innen zugewiesen, 32% (n=16) erhielten TMK. Die mediane Verzehrmenge der Anreicherungsmodule (basierend auf dem durchschnittlichen Anteil der konsumierten im Verhältnis zur angebotenen Menge aus drei Erhebungs-tagen) veränderte sich zwischen der ersten und der letzten Woche der Intervention nicht und reichte von 44% (herzhafte Proteinsahne, w6) bis 96% (Protein-Energie-Getränk, w1). Etwa die Hälfte der 36 befragten Mitarbeitenden (47% bei Proteinsahnen, 56% bei Protein-Energie-Getränk, 56% bei TMK) gaben an, die Interventionsmodule gut in ihre tägliche Routine integrieren zu können und 44% würden eine langfristige Implementierung des Konzepts unterstützen. In w1 lag die mittlere Energiezufuhr bei 1505±440 kcal/Tag und die mittlere Proteinzufuhr bei 47±19 g/Tag. Während der Interventionsphase wurden zusätzlich 258±167 kcal/Tag und 23±15 g Protein/Tag angeboten. Bewohner*innen mit TMK erhielten eine leicht höhere Anreicherung als solche mit regulären Mahlzeiten (287±191 kcal/Tag vs. 244±155 kcal/Tag, p=0.09; 26±17 g Protein/Tag vs. 22±14 g Protein/Tag, p=0.11). Die durchschnittliche tägliche Energie- (+207 (95%CI 47-368) kcal, p=0,005) und Proteinzufuhr (+14 (7-21) g, p<0,001) war während der Interventionsphase signifikant höher als in der Phase der üblichen Versorgung (w12 vs. w1), sowohl bei Personen mit TMK als auch bei denen mit regulären Mahlzeiten. Während der Interventionsphase verbesserte sich auch die Lebensqualität in der Subskala „Pflegebeziehung" (+9 (3-15) Punkte, p=0,002, w12 vs. w6). Die Sekundäranalyse bei Personen, die Anreicherungen erhielten (n=40), zeigte, dass bei diesen die Proteinzufuhr (59±11 g/d vs. 41±10 g/d, p<0,001) gesteigert werden konnten, ohne den Verzehr von Protein aus üblichen Lebensmitteln zu beeinflussen (42±11 g/d vs. 41±10 g/d, p=0,434). Hauptprotein-quellen waren Milch/Milchprodukte (29±14%), stärkehaltige Lebensmittel (18±7%) und Fleisch/Fleischprodukte (17±11%). Schlussfolgerungen Das individualisierte, multimodale Interventionskonzept wurde erfolgreich in zwei Nürnberger Pflegeheimen implementiert und zeigte insgesamt eine hohe Akzeptanz seitens der Bewohner*innen. Die modulare Intervention und möglicherweise eine verstärkte Aufmerksamkeit des Pflegeheimpersonals hinsichtlich Ernährungsproblemen konnten die Energie- und Proteinzufuhr sowie die Lebensqualität in der Subskala Pflegebeziehung bei Pflegeheimbewohner*innen mit (Risiko für) Mangelernährung verbessern. Nach-folgend sind Studien mit randomisiert kontrolliertem Design empfehlenswert, um die vor-liegenden Ergebnisse zu verifizieren sowie die Überlegenheit individualisierter Interventionen gegenüber standardisierten Konzepten (z.B. orale Trinknahrung) zu überprüfen.
... Furthermore, holiday benefits , sanitary conditions (Parker 2020, Lee 2020), community regulation , and complaint and suggestion services (Lee and Severt 2018), are four fundamental aspects to be factored into community management and operations. Lee and Severt (2018), Dorner and Friedrich (2018), Ayalon (2018), and Lu et al (2021), agree that the key factors of community daily life include: information dissemination service, food and beverage service, daily life service, and shuttle service. Lee and Severt (2018), and Jester et al (2021) stress the role of health service and emergency service within the community, to enable appealing living environments for residents. ...
Building Information Modelling (BIM) implementation in the design and construction phases of road projects has increased significantly during the last decade, while the application of BIM for the operation and maintenance phase of roads is less developed. BIM can offer an integrated and unified asset management process based on all phases of a road project, leading to significant savings in time and cost. COBie (Construction Operation Building information exchange) is the data handover solution applicable for vertical infrastructure (buildings). Australian and New Zealand Road Authorities are working on an adaptation of COBie, called CONie (Construction Operation Network information exchange), that considers linear infrastructure requirements for asset management. One of the challenges required to support the development of this data handover framework is the lack of a harmonised data schema for asset management in terms of asset name, definition, and categorisation.
The purpose of this paper is to argue that developing and utilising a harmonised and synthesised object model of road assets will assist Australasian road organisations to increase efficiency in asset management, especially through collaboration. This paper describes the procedure followed to harmonise road asset databases that has been used as a basis for developing CONie. The described aim was achieved through collecting relevant data from Road Authorities and the developers of road standards in Australia and New Zealand. The collected data was harmonised and synthesised. The harmonised database was then mapped to the building Smart ifcRoads project.
Regarding the existing road assets, a categorisation system is suggested by authors. It introduces the main categories including relevant subcategories and asset types. The developed database of road assets provides a basis for asset management, operation and maintenance purposes by road organisations beside being used for CONie development.
... The foodservice managers reported the menu had been audited by dietitians annually. All facilities failed to meet all nutritional requirements recommended by the guidelines [39][40][41][42]. Food fortification has been implemented in all facilities except one (Facility 4). ...
Dysphagia has become more prevalent with age. Thus, the demand for texture-modified diets (TMDs) has increased. While the nutritional perspectives have been studied, the provision of TMDs and mealtime practice has received less attention. This study aimed to explore the TMD provision and mealtime challenges of residents requiring TMDs in aged care facilities. The study was conducted across five aged care facilities using a mixed methods design involving 14 TMD menu audits by a foodservice dietitian, 15 mealtime observations, and semi-structured interviews with residents and staff (n = 18). TMD menus failed to meet all nutrition requirements and foodservice and clinical standards based on the dietitian NZ foodservice and nutrition audit tool. A content analysis offered three main themes: (1) Foodservice production. Inconsistent quality and meal portions were observed. The variety, choice, and portion size of TMDs required improvement based on the residents’ preferences; (2) Serving procedures. There was a lack of standardisation of meal distribution and feeding assistance; and (3) Dining environment. The dining room set-up varied across facilities, and residents expressed different preferences towards the dining environment. There is a need to improve staff awareness of mealtime consistency and optimise feeding assistance. The dining environment should be individualised to accommodate residents’ psychosocial needs. Standardised policies and continuous training can facilitate quality mealtime implementation.
... Furthermore, holiday benefits , sanitary conditions (Parker 2020, Lee 2020), community regulation , and complaint and suggestion services (Lee and Severt 2018), are four fundamental aspects to be factored into community management and operations. Lee and Severt (2018), Dorner and Friedrich (2018), Ayalon (2018), and Lu et al (2021), agree that the key factors of community daily life include: information dissemination service, food and beverage service, daily life service, and shuttle service. Lee and Severt (2018), and Jester et al (2021) stress the role of health service and emergency service within the community, to enable appealing living environments for residents. ...
The COP21 Paris Agreement and the Glasgow Climate Pact require urgent abatement of the current fossil-based energy consumption. In 2021, the Global Status for Buildings and
Construction Report pinpointed buildings as responsible for 36% of the global energy
consumption; 36% of this energy consumption by end-use of commercial buildings
corresponds to space heating. Heating loads in commercial buildings can be reduced by
building envelope retrofits, efficiency upgrades of heating equipment, energy management, and influencing energy users' behaviour. Traditional engineering assessment methods use capacity metrics such as the building load coefficient (BLC) for the building infrastructure or the coefficient of performance (COP) for heating and cooling equipment to measure how far the improvements can go. In-office buildings, one way to optimize operation systems for space heating is to modify set points, but the set parameters constrain the associated savings; for example, changes to the indoor temperature are limited, to maintain a safe indoor environmental quality (IEQ). However, these capacity metrics and constraints do not reflect the interaction between building occupants and the heating system, nor the resultant capacity for energy reductions. This paper reviews the literature on energy assessment tools focused on occupant heating behaviour. The findings suggest the need for a standard method to assess occupants' behavioural aspects related to the final energy use in commercial buildings and the consequent potential for energy conservation.
... Although international dietetic organizations recommend that all older people, regardless of age, can benefit from routine assessments of nutritional risk and careful attention to nutritional adequacy and balance [4,28,29], older adults, particularly the old-old, may be at a higher risk from consuming food of poor quality, especially when the consumption of food and its access and preparation present difficulties for them, due to physical and/or cognitive decline, and/or the lack of a caregiver. Some evidence exists regarding the health benefits of nutritional strategies targeting this population in the United States and European countries, through the provision of assisted meal services or packed foods, or the mobilization of social or community resources to support the nutritional care of older adults [30][31][32]. These nutritional support strategies can be considered for adoption in the Western Pacific region, especially as populations in the region continue to age. ...
The population in the Western Pacific region is aging rapidly. Nutritional deficiency is prevalent in older adults; however, information regarding nutritional deficiency in this population is scarce. Using the 2019 Global Burden of Disease (GBD) results, the age-standardized disability-adjusted life years (DALYs) and years of healthy life lost due to disability (YLDs) from nutritional deficiency were estimated between 1990 and 2019 for this population. Average annual percentage change (AAPC) was used to assess temporal trends, and linear mixed-effects models were used to examine socioeconomic and sex inequalities. From 1990 to 2019, the age-standardized DALYs of nutritional deficiency in this population decreased from 697.95 to 290.95 per 100,000, and their age-standardized YLDs decreased from 459.03 to 195.65 per 100,000, with the greatest declines seen in South Korea (AAPCs < −5.0). Tonga had the least decline in DALYs (AAPC = −0.8), whereas Fiji experienced an increase in YLDs (AAPC = 0.1). Being female and having a lower sociodemographic index score was significantly associated with higher age-standardized DALYs and YLDs. The magnitude and temporal trends of the nutritional deficiency burden among older adults varied across countries and sex in the region, indicating that health policies on nutritional deficiency among older adults must be crafted to local conditions.
Background
Health policies promote optimal care, yet policies that address disease-related malnutrition (DRM) are lacking. The purpose of this study was to conduct a scoping review to identify literature on existing and planned policy to address DRM in children or adults and explore the settings, contexts and actors of DRM policy.
Methods
A search strategy comprising DRM and policy keywords was applied to eight databases on 24 February 2023. Articles that addressed DRM and policy were selected for inclusion after two independent reviews. The health policy triangle (HPT) framework (ie, actors, content, contexts and processes considerations for policy) guided data extraction and thematic analysis.
Results
A total of 67 articles were included out of the 37 196 identified. Some articles (n=14) explored established policies at the local level related to food and mealtime, nutrition care practices, oral nutritional supplement prescribing or reimbursement. Other articles gave direction or rationale for DRM policy. As part of the HPT, actors included researchers, advocacy groups and DRM champions while content pertained to standard processes for nutrition care such as screening, assessment, intervention and monitoring. Contexts included acute care and care home settings with a focus on paediatrics, adults, older adults. Processes identified were varied and influenced by the type of policy (eg, local, national, international) and its goal (eg, advocating, developing, implementing).
Discussion
There is a paucity of global DRM policy. Nutrition screening, assessment, intervention and monitoring are consistently identified as important to DRM policy. Decision makers are important actors and should consider context, content and processes to develop and mobilise DRM policy to improve nutrition care. Future efforts need to prioritise the development and implementation of policies addressing DRM.
Large language models (LLMs) are fundamentally transforming human-facing applications in the health and well-being domains: boosting patient engagement, accelerating clinical decision-making, and facilitating medical education. Although state-of-the-art LLMs have shown superior performance in several conversational applications, evaluations within nutrition and diet applications are still insufficient. In this paper, we propose to employ the Registered Dietitian (RD) exam to conduct a standard and comprehensive evaluation of state-of-the-art LLMs, GPT-4o, Claude 3.5 Sonnet, and Gemini 1.5 Pro, assessing both accuracy and consistency in nutrition queries. Our evaluation includes 1050 RD exam questions encompassing several nutrition topics and proficiency levels. In addition, for the first time, we examine the impact of Zero-Shot (ZS), Chain of Thought (CoT), Chain of Thought with Self Consistency (CoT-SC), and Retrieval Augmented Prompting (RAP) on both accuracy and consistency of the responses. Our findings revealed that while these LLMs obtained acceptable overall performance, their results varied considerably with different prompts and question domains. GPT-4o with CoT-SC prompting outperformed the other approaches, whereas Gemini 1.5 Pro with ZS recorded the highest consistency. For GPT-4o and Claude 3.5, CoT improved the accuracy, and CoT-SC improved both accuracy and consistency. RAP was particularly effective for GPT-4o to answer Expert level questions. Consequently, choosing the appropriate LLM and prompting technique, tailored to the proficiency level and specific domain, can mitigate errors and potential risks in diet and nutrition chatbots.
Aim: The present study aimed to determine whether decreased masticatory performance and tongue-lip motor function are associated with an increased incidence of adverse health events in patients with metabolic disease.
Methods: One thousand patients with metabolic diseases including diabetes, dyslipidemia, hypertension, and hyperuricemia were recruited. Masticatory performance was assessed using a gummy jelly test, wherein glucose elution from chewed gummy jelly was measured. The tongue-lip motor function was measured using repeatedly pronounced syllables per second. Their association with the incidence of adverse health events (a composite of all-cause death, cardiovascular disease, bone fracture, malignant neoplasm, pneumonia, and dementia) was investigated using the generalized propensity score (GPS) method.
Results: During a median follow-up period of 36.6 (interquartile range, 35.0–37.7) months, adverse health events were observed in 191 patients. The GPS adjusted dose-response function demonstrated that masticatory performance was inversely associated with the incidence of adverse health events. The 3-year incidence rate was 22.8% (95% confidence interval, 19.0–26.4%) for the lower quartile versus 13.6% (10.5–16.7%) for the upper quartile (P＜0.001). Similarly, the tongue-lip motor function was inversely associated with the incidence of adverse health events, with a 3-year incidence rate of 23.6% (20.0–27.0%) for the lower quartile versus 13.2% (10.4–15.9%) for the upper quartile (P＜0.001).
Conclusions: Decreased masticatory performance and tongue-lip motor function were associated with an increased incidence of adverse health events in patients with metabolic disease.
Objective
Previous research on food, nutrition and dining practices in Australian residential aged care (RAC) homes has been based on a limited sample of single‐home or multiple‐home providers, but a nationwide study has not been conducted. The aim of this study was to provide a preliminary overview of current food, nutrition and dining practices across Australian RAC facilities using a nationwide survey.
Methods
A survey was distributed to Australian RAC homes in August–September 2020, as part of the National Congress on Food, Nutrition and the Dining Experience in Aged Care (February 2021). The survey, administered via an online portal, consisted of 38 semistructured questions including yes/no or multiple‐choice responses, free text, frequency scales and number entry. Six key topics were explored, including ‘food service system and environment’, ‘catering style’, ‘menu planning and evaluation’, ‘nutrition planning and requirements’, ‘nutrition‐related screening and assessment’ and ‘training and additional information’, which were informed by the Australian Government Department of Health and reflected the interests of the Congress.
Results
The final sample included 292 respondents (204 individual homes and 88 multiple‐home proprietors) representing 1152 homes and 125,393 residents, encompassing approximately 43% of RAC homes (of a possible 2671) and 57% of residents (of a possible 219,965) in Australia. Survey respondents representing RAC homes included service managers, catering managers, Chief Executive Officers, cooks, chefs, dietitians or staff from other roles within homes. A number of potential areas of need were identified, included increasing the autonomy of residents to select the foods they desire, increasing the variety and choice (including timing) of meals, enhancing the dining environments in homes to stimulate food intake and increasing staff training and the number of trained chefs in homes, so that meals are prepared which address diverse nutritional needs of residents.
Conclusions
This study provides insight into the food service and mealtime practices of over a third of Australian RAC homes. The findings of this survey may help to identify key targets for intervention to improve the food, nutrition and quality of life of aged care residents.
Purpose:
Person-centred care (PCC) is an essential component of high-quality healthcare across professions and care settings. While research is emerging in subacute nutrition services more broadly, there is limited literature exploring the person-centredness of nutrition care in rehabilitation. This study aimed to explore person-centred nutrition care (PCNC) in rehabilitation units, as described and actioned by patients, support persons and staff. Key factors influencing PCNC were also explored.
Materials and methods:
An ethnographic study was undertaken across three rehabilitation units. Fifty-eight hours of field work were completed with 165 unique participants to explore PCNC. Field work consisted of observations and interviews with patients, support persons and staff. Data were analysed through the approach of reflexive thematic analysis, informed by PCC theory.
Results:
Themes generated were: (1) tensions between patient and staff goals; (2) disconnected moments of PCNC; (3) the necessity of interprofessional communication for PCNC; and (4) the opportunity for PCNC to enable the achievement of rehabilitation goals.
Conclusions:
PCNC was deemed important to different stakeholders but was at times hindered by a focus on profession-specific objectives. Opportunities exist to enhance interprofessional practice to support PCNC in rehabilitation. Future research should consider the system-level factors influencing PCNC in rehabilitation settings.
Disorders of smell, taste, and oral somatosensation (irritation, touch, temperature, pain) challenge the ability to consume safe and healthy diets as well as enjoy eating and food-related behaviors. From nationally representative US health monitoring, these disorders are as prevalent as hearing or vision disorders. Olfactory dysfunction is most common among older adults, although aging itself may not be the cause. Primary causes of olfactory dysfunction are sensorineural (e.g., chronic nasal/sinus disease, head trauma, respiratory tract infections) and neurodegenerative (e.g., Alzheimer’s disease). Less vulnerable to loss is taste, especially at levels experienced while eating. Individuals can suffer distorted or phantom sensations (i.e., dysgeusia) related to medications or conditions that disrupt normal interactions between cranial nerves that mediate taste sensation. Oral sensation (integrated taste, retronasal olfaction, and oral somatosensation) can be altered in systemic diseases (e.g., chronic kidney disease), especially if control is poor; by medications that treat and manage systemic diseases (e.g., cancer); and with poor oral health. Normal variation in taste associates with differences in food preferences and nutritional status, including obesity, while chemosensory disorders, if severe enough, can alter dietary patterns leading to weight gain or weight loss. Excessive alcohol consumption and chronic smoking increase the risk of chemosensory disorders directly or indirectly through exposures/conditions that, in turn, cause these disorders. Individuals with chemosensory disorders should have full medical evaluation, including assessment of the impact on eating behaviors, diet quality, and nutritional status. Access to healthcare and medical advances hold continued promise toward prevention and treatment of chemosensory disorders.
Continuing care (CC) facilities have been impacted by a growing demand for services, insufficient resources for the provision of quality food and nutrition care, and, most recently, the COVID-19 pandemic. This study explored the roles and responsibilities of dietitians working in CC facilities in Nova Scotia (NS) before and after the COVID-19 first wave. Using ethics-approved questionnaires, the estimated 75 dietitians working in CC facilities in NS were surveyed in Fall 2019 and Fall 2020 about their roles and responsibilities. Twenty responded to the first questionnaire and 15 to the second. Analysis of data included simple statistical and qualitative description methods. The findings highlighted the complexities and challenges faced by these dietitians in the provision of resident nutrition care, overseeing foodservices, training staff and dietetic interns, and contributing to facility specific care committees before and after the COVID-19 first wave. There is a need to advocate for minimum standards for dietetic and foodservice funding in CC facilities based on higher acuity and complex care needs of residents and considering the multifaceted roles of dietitians in CC. Efforts to improve awareness about the roles of dietitians working in CC among resident families, other dietitians, and dietetic interns are also needed.
There is a need for more Registered Dietitian Nutritionists (RDNs) trained to provide nutritional care to older adults with dementia who experience mealtime difficulties. The purpose of this single-arm, pre/post pilot study was to adapt a generalized dementia care curriculum to the learning needs of RDNs who work with individuals with dementia and to determine the feasibility and acceptability of the adapted program. Using an existing evidence-based dementia care curriculum, the research team identified learning objectives and content pertinent to the scope of RDNs. The adapted program was piloted with RDNs who work with older adults with dementia. Twenty-five RDNs registered for the training while 80% (20) attended the training and completed the post-training survey. All participants agreed that the module met the learning needs of RDNs who work with older adults with dementia, the two-hour workshop was a good use of their time, and the experience and skills gained would be useful in their work as an RDN. Implementation costs totaled $1,310. Based on the post-training feedback, the adapted program was deemed feasible and acceptable by RDN participants, who also expressed interest in using the module to train other caregivers on providing mealtime assistance to older adults with dementia.
This study aimed to examine how allied healthcare professionals as informal leaders can lead reforms to improve patient care on an interprofessional team. With 284 interprofessional team members working in 59 geriatric facilities, our findings demonstrated that informal leaders exhibiting more championship behaviors gained higher innovation success scores. In addition, the champion’s professional tenure and institutional size were both negatively associated with innovation success. We discuss important implications for this understudied issue in interprofessional team research: how a low-status informal leader can direct reform aimed at improving patient care within a healthcare organization.
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.
Long-term care services provided by paid, regulated providers are an important component of personal health care spending in the United States. This report presents the most current national descriptive results from the National Study of Long-Term Care Providers (NSLTCP), which is conducted by the Centers for Disease Control and Prevention's National Center for Health Statistics (NCHS). Data presented are drawn from multiple sources, primarily NCHS surveys of adult day services centers and residential care communities (covers 2014 data year); and administrative records obtained from the Centers for Medicare and Medicare Services (CMS) on home health agencies, hospices, and nursing homes (covers 2013 and 2014 data years). This report provides information on the supply, organizational characteristics, staffing, and services offered by paid, regulated providers of long-term care services; and the demographic, health, and functional composition of users of these services. Services users include residents of nursing homes and residential care communities, patients of home health agencies and hospices, and participants of adult day services centers. This report updates "Long-Term Care Services in the United States: 2013 Overview" (available from: http://www.cdc.gov/nchs/data/nsltcp/long_term_care_services_2013.pdf), which covered data years 2011 and 2012. In contrast, the title of this report and future reports will reflect the years of the data used rather than the publication year, in this case 2013 through 2014. A forthcoming companion product to this report, "Long-Term Care Providers and Services Users in the United States—State Estimates Supplement: National Study of Long-Term Care Providers, 2013–2014," contains tables and maps showing comparable state estimates for the national findings in this report, and will be available from: http://www.cdc.gov/nchs/ nsltcp/nsltcp_products.htm.
Older people frequently fail to ingest adequate amount of food to meet their essential energy and nutrient requirements. Anorexia of aging, defined by decrease in appetite and/or food intake in old age, is a major contributing factor to under-nutrition and adverse health outcomes in the geriatric population. This disorder is indeed highly prevalent and is recognized as an independent predictor of morbidity and mortality in different clinical settings. Even though anorexia is not an unavoidable consequence of aging, advancing age often promotes its development through various mechanisms. Age-related changes in life-style, disease conditions, as well as social and environmental factors have the potential to directly affect dietary behaviors and nutritional status. In spite of their importance, problems related to food intake and, more generally, nutritional status are seldom attended to in clinical practice. While this may be the result of an “ageist” approach, it should be acknowledged that simple interventions, such as oral nutritional supplementation or modified diets, could meaningfully improve the health status and quality of life of older persons.
Diabetes is more common in older adults, has a high prevalence in long-term care (LTC) facilities, and is associated with significant disease burden and higher cost. The heterogeneity of this population with regard to comorbidities and overall health status is critical to establishing personalized goals and treatments for diabetes. The risk of hypoglycemia is the most important factor in determining glycemic goals due to the catastrophic consequences in this population. Simplified treatment regimens are preferred, and the sole use of sliding scale insulin (SSI) should be avoided. This position statement provides a classification system for older adults in LTC settings, describes how diabetes goals and management should be tailored based on comorbidities, delineates key issues to consider when using glucose-lowering agents in this population, and provides recommendations on how to replace SSI in LTC facilities. As these patients transition from one setting to another, or from one provider to another, their risk for adverse events increases. Strategies are presented to reduce these risks and ensure safe transitions. This article addresses diabetes management at end of life and in those receiving palliative and hospice care. The integration of diabetes management into LTC facilities is important and requires an interprofessional team approach. To facilitate this approach, acceptance by administrative personnel is needed, as are protocols and possibly system changes. It is important for clinicians to understand the characteristics, challenges, and barriers related to the older population living in LTC facilities as well as the proper functioning of the facilities themselves. Once these challenges are identified, individualized approaches can be designed to improve diabetes management while lowering the risk of hypoglycemia and ultimately improving quality of life.
A nutritionally vulnerable older adult has a reduced physical reserve that limits the ability to mount a vigorous recovery in the face of an acute health threat or stressor. Often, this vulnerability contributes to more medical complications, longer hospital stays, and increased likelihood of nursing home admission. We have characterized in this review the etiology of nutritional vulnerability across the continuum of the community, hospital, and long-term care settings. Frail older adults may become less vulnerable with strong, consistent, and individualized nutritional care. Interventions for the vulnerable older adult must take their nutritional needs into account to optimize resiliency in the face of the acute and/or chronic health challenges they will surely face in their life course.
Based on current scientific literature, gastrostomy tube (G-tube) placement or other long-term enteral access devices should be withheld in patients with advanced dementia or other near end-of-life conditions. In many instances healthcare providers are not optimally equipped to implement this recommendation at the bedside. Autonomy of the patient or surrogate decision maker should be respected, as should the patient's cultural, religious, social, and emotional value system. Clinical practice needs to address risks, burdens, benefits, and expected short-term and long-term outcomes in order to clarify practice changes. This paper recommends a change in clinical practice and care strategy based on the results of a thorough literature review and provides tools for healthcare clinicians, particularly in the hospital setting, including an algorithm for decision making and a checklist to use prior to the placement of G-tubes or other long-term enteral access devices. Integrating concepts of patient-centered care, shared decision making, health literacy, and the teach-back method of education enhances the desired outcome of ethical dilemma prevention. The goal is advance care planning and a timely consensus among health team members, family members, and significant others regarding end-of-life care for patients who do not have an advance directive and lack the capacity to advocate for themselves. Achieving this goal requires interdisciplinary collaboration and proactive planning within a supportive healthcare institution environment.
Acute care providers have had little financial incentive to ensure effective transitions to post-acute care or support post-acute care providers when discharged patients have complications. Medicare's bundled-payment and shared-savings programs should help change that.
Hypertension is the most common condition seen in primary care and leads to myocardial infarction, stroke, renal failure, and death if not detected early and treated appropriately. Patients want to be assured that blood pressure (BP) treatment will reduce their disease burden, while clinicians want guidance on hypertension management using the best scientific evidence. This report takes a rigorous, evidence-based approach to recommend treatment thresholds, goals, and medications in the management of hypertension in adults. Evidence was drawn from randomized controlled trials, which represent the gold standard for determining efficacy and effectiveness. Evidence quality and recommendations were graded based on their effect on important outcomes. There is strong evidence to support treating hypertensive persons aged 60 years or older to a BP goal of less than 150/90 mm Hg and hypertensive persons 30 through 59 years of age to a diastolic goal of less than 90 mm Hg; however, there is insufficient evidence in hypertensive persons younger than 60 years for a systolic goal, or in those younger than 30 years for a diastolic goal, so the panel recommends a BP of less than 140/90 mm Hg for those groups based on expert opinion. The same thresholds and goals are recommended for hypertensive adults with diabetes or nondiabetic chronic kidney disease (CKD) as for the general hypertensive population younger than 60 years. There is moderate evidence to support initiating drug treatment with an angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, calcium channel blocker, or thiazide-type diuretic in the nonblack hypertensive population, including those with diabetes. In the black hypertensive population, including those with diabetes, a calcium channel blocker or thiazide-type diuretic is recommended as initial therapy. There is moderate evidence to support initial or add-on antihypertensive therapy with an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in persons with CKD to improve kidney outcomes. Although this guideline provides evidence-based recommendations for the management of high BP and should meet the clinical needs of most patients, these recommendations are not a substitute for clinical judgment, and decisions about care must carefully consider and incorporate the clinical characteristics and circumstances of each individual patient.
The current era of health care delivery, with its focus on providing high-quality, affordable care, presents many challenges to hospital-based health professionals. The prevention and treatment of hospital malnutrition offers a tremendous opportunity to optimize the overall quality of patient care, improve clinical outcomes, and reduce costs. Unfortunately, malnutrition continues to go unrecognized and untreated in many hospitalized patients. This article represents a call to action from the interdisciplinary Alliance to Advance Patient Nutrition to highlight the critical role of nutrition intervention in clinical care and suggest practical ways for prompt diagosis and treatment of malnourished patients and those at risk for malnutrition. We underscore the importance of an interdisciplinary approach to addressing malnutrition both in the hospital and in the acute post-hospital phase. It is well recognized that malnutrition is associated with adverse clinical outcomes. Although data vary across studies, available evidence shows early nutrition intervention can reduce complication rates, length of hospital stay, re-admission rates, mortality, and cost of care. The key is to identify patients systematically who are malnourished or at risk and to promptly intervene. We present a novel care model to drive improvement, emphasizing the following six principles: (1) create an institutional culture where all stakeholders value nutrition; (2) redefine clinicians' roles to include nutrition care; (3) recognize and diagnose all malnourished patients and those at risk; (4) rapidly implement comprehensive nutrition interventions and continued monitoring; (5) communicate nutrition care plans; and (6) develop a comprehensive discharge nutrition care and education plan.
Preventing and ameliorating chronic conditions has long been a priority in the United States; however, the increasing recognition that people often have multiple chronic conditions (MCC) has added a layer of complexity with which to contend. The objective of this study was to present the prevalence of MCC and the most common MCC dyads/triads by selected demographic characteristics. We used respondent-reported data from the 2010 National Health Interview Survey (NHIS) to study the US adult civilian noninstitutionalized population aged 18 years or older (n = 27,157). We categorized adults as having 0 to 1, 2 to 3, or 4 or more of the following chronic conditions: hypertension, coronary heart disease, stroke, diabetes, cancer, arthritis, hepatitis, weak or failing kidneys, chronic obstructive pulmonary disease, or current asthma. We then generated descriptive estimates and tested for significant differences. Twenty-six percent of adults have MCC; the prevalence of MCC has increased from 21.8% in 2001 to 26.0% in 2010. The prevalence of MCC significantly increased with age, was significantly higher among women than men and among non-Hispanic white and non-Hispanic black adults than Hispanic adults. The most common dyad identified was arthritis and hypertension, and the combination of arthritis, hypertension, and diabetes was the most common triad. The findings of this study contribute information to the field of MCC research. The NHIS can be used to identify population subgroups most likely to have MCC and potentially lead to clinical guidelines for people with more common MCC combinations.
KEY FINDINGS: Data from the National Health and Nutrition Examination Survey, 2007-2010 More than one-third of older adults aged 65 and over were obese in 2007-2010. Obesity prevalence was higher among those aged 65‒74 compared with those aged 75 and over in both men and women. The prevalence of obesity in women aged 65-74 was higher than in women aged 75 and over in all racial and ethnic groups except non-Hispanic black women, where approximately one in two were obese among both age groups. Between 1999‒2002 and 2007‒2010, the prevalence of obesity among older men increased.
Obesity exacerbates the age-related decline in physical function and causes frailty in older adults; however, the appropriate treatment for obese older adults is controversial.
In this 1-year, randomized, controlled trial, we evaluated the independent and combined effects of weight loss and exercise in 107 adults who were 65 years of age or older and obese. Participants were randomly assigned to a control group, a weight-management (diet) group, an exercise group, or a weight-management-plus-exercise (diet-exercise) group. The primary outcome was the change in score on the modified Physical Performance Test. Secondary outcomes included other measures of frailty, body composition, bone mineral density, specific physical functions, and quality of life.
A total of 93 participants (87%) completed the study. In the intention-to-treat analysis, the score on the Physical Performance Test, in which higher scores indicate better physical status, increased more in the diet-exercise group than in the diet group or the exercise group (increases from baseline of 21% vs. 12% and 15%, respectively); the scores in all three of those groups increased more than the scores in the control group (in which the score increased by 1%) (P<0.001 for the between-group differences). Moreover, the peak oxygen consumption improved more in the diet-exercise group than in the diet group or the exercise group (increases of 17% vs. 10% and 8%, respectively; P<0.001); the score on the Functional Status Questionnaire, in which higher scores indicate better physical function, increased more in the diet-exercise group than in the diet group (increase of 10% vs. 4%, P<0.001). Body weight decreased by 10% in the diet group and by 9% in the diet-exercise group, but did not decrease in the exercise group or the control group (P<0.001). Lean body mass and bone mineral density at the hip decreased less in the diet-exercise group than in the diet group (reductions of 3% and 1%, respectively, in the diet-exercise group vs. reductions of 5% and 3%, respectively, in the diet group; P<0.05 for both comparisons). Strength, balance, and gait improved consistently in the diet-exercise group (P<0.05 for all comparisons). Adverse events included a small number of exercise-associated musculoskeletal injuries.
These findings suggest that a combination of weight loss and exercise provides greater improvement in physical function than either intervention alone. (Funded by the National Institutes of Health; ClinicalTrials.gov number, NCT00146107.).
Multiple definitions for malnutrition syndromes are found in the literature resulting in confusion. Recent evidence suggests that varying degrees of acute or chronic inflammation are key contributing factors in the pathophysiology of malnutrition that is associated with disease or injury.
An International Guideline Committee was constituted to develop a consensus approach to defining malnutrition syndromes for adults in the clinical setting. Consensus was achieved through a series of meetings held at the A.S.P.E.N. and ESPEN Congresses.
It was agreed that an etiology-based approach that incorporates a current understanding of inflammatory response would be most appropriate. The Committee proposes the following nomenclature for nutrition diagnosis in adults in the clinical practice setting. "Starvation-related malnutrition", when there is chronic starvation without inflammation, "chronic disease-related malnutrition", when inflammation is chronic and of mild to moderate degree, and "acute disease or injury-related malnutrition", when inflammation is acute and of severe degree.
This commentary is intended to present a simple etiology-based construct for the diagnosis of adult malnutrition in the clinical setting. Development of associated laboratory, functional, food intake, and body weight criteria and their application to routine clinical practice will require validation.
The Academy of Nutrition and Dietetics (Academy) is the world's largest organization of food and nutrition professionals and the association that represents credentialed nutrition and dietetics practitioners-nutrition and dietetics technicians, registered (NDTRs) and registered dietitian nutritionists (RDNs). An NDTR's scope of practice in nutrition and dietetics has flexible boundaries to capture the depth and breadth of the individual's practice. The NDTR's practice expands with advances in many areas, including nutrition, food production, food safety, food systems management, health care, public health, community health, and information and communication technology. The Revised 2017 Scope of Practice for the NDTR reflects the position of the Academy on the essential role of the NDTR in the management and delivery of food and nutrition services. The scope of practice for the NDTR is composed of education and credentialing, practice resources, Academy Standards of Practice and Standards of Professional Performance, codes of ethics, accreditation standards, state and federal regulations, national guidelines, and organizational policy and procedures. The Revised 2017 Scope of Practice for the NDTR is used in conjunction with the Revised 2017 Standards of Practice in Nutrition Care and the Standards of Professional Performance for NDTRs. The Standards of Practice address activities related to direct patient and client care. The Standards of Professional Performance address behaviors related to the technical role of NDTRs. These standards reflect the minimum competent level of nutrition and dietetics practice and professional performance for NDTRs. A companion document addresses the scope of practice for the RDN.
The Academy of Nutrition and Dietetics (Academy) is the world's largest organization of food and nutrition professionals and the association that represents credentialed nutrition and dietetics practitioners-registered dietitian nutritionists (RDNs) and nutrition and dietetics technicians, registered (NDTRs). RDNs integrate research, professional development, and practice to stimulate innovation and discovery; collaborate to solve the greatest food and nutrition challenges now and in the future; focus on systemswide impact across the food, wellness, and health sectors; have a global impact in eliminating all forms of malnutrition; and amplify the contribution of nutrition and dietetics practitioners and expand workforce capacity and capability. The Revised 2017 Scope of Practice for the RDN reflects the position of the Academy on the essential role of the RDN in the direction and delivery of food and nutrition services. The scope of practice for the RDN is composed of education and credentialing, practice resources, Academy Standards of Practice and Professional Performance, codes of ethics, accreditation standards, state and federal regulations, national guidelines, and organizational policy and procedures. The Revised 2017 Scope of Practice for the RDN is used in conjunction with the Revised 2017 Standards of Practice (SOP) in Nutrition Care and the Standards of Professional Performance (SOPP) for RDNs. The SOP address activities related to direct patient and client care. The SOPP address behaviors related to the professional role of RDNs. These standards reflect the minimum competent level of nutrition and dietetics practice and professional performance for RDNs. A companion document addresses the scope of practice for the NDTR.
Registered dietitian nutritionists (RDNs) face complex situations every day. Competently addressing the unique needs of each situation and applying standards appropriately are essential to providing safe, timely, patient-/client-/customer-centered, quality nutrition and dietetics care and services. The Academy of Nutrition and Dietetics (Academy) leads the profession by developing standards that can be used by RDNs (who are credentialed by the Commission on Dietetic Registration) for self-evaluation to assess quality of practice and performance. The Standards of Practice reflect the Nutrition Care Process and workflow elements as a method to manage nutrition care activities with patients/clients/populations that include nutrition screening, nutrition assessment, nutrition diagnosis, nutrition intervention/plan of care, nutrition monitoring and evaluation, and discharge planning and transitions of care. The Standards of Professional Performance consist of six domains of professional performance: Quality in Practice, Competence and Accountability, Provision of Services, Application of Research, Communication and Application of Knowledge, and Utilization and Management of Resources. Within each standard, specific indicators provide measurable action statements that illustrate how the standard can be applied to practice. The Academy's Revised 2017 Standards of Practice and Standards of Professional Performance for RDNs, along with the Academy's Code of Ethics and the Revised 2017 Scope of Practice for the RDN, provide minimum standards and tools for demonstrating competence and safe practice and are used collectively to gauge and guide an RDN's performance in nutrition and dietetics practice.
Aging is associated with a loss in muscle mass, muscle strength and an increase in fat mass. The mean age of the population is reaching non-preceding numbers so as the obesity prevalence. As a consequence, researchers and clinicians are trying to understand the impact of changes in body composition and how to help the situation. The terminology used to describe age-related loss of muscle mass and muscle strength has evolved since 1989. To study the change in body composition associated with age, four distinctive categories of older people have been studied: sarcopenic, dynapenic, sarcopenic-obese, and dynapenic-obese. This chapter discusses the prevalence, consequences, and possible prevention/treatment strategies of sarcopenia, dynapenia, sarcopenic obesity, and dynapenic obesity. The current literature shows that well-designed longitudinal studies show little or no association between sarcopenia and the risk of impaired physical function, falls, and mortality. Conversely, dynapenia is consistently associated with these outcomes. Studies are showing that the best treatment for these conditions is unknown as weight loss is associated with both muscle mass and muscle strength loss. Physical activity, particularly resistance exercise, is one of the most promising approaches for preventing and treating both sarcopenia and dynapenia in obese and non-obese older adults.
By the year 2050, the number of persons with dementia aged 65 and older in the United States is expected to increase from 5.4 to 16 million persons [1]. While most persons with dementia (PWD) prefer to be cared for in their home environment, as the disease causes progressive functional and behavioral decline many will require institutional care. For these PWD, this means placement in assisted-living facilities or skilled nursing homes (NH). The number of PWD in the NH setting is expected to double to three million by the year 2050 [1]. While NHs attempt to address the multiple needs of their residents, the very basic need for adequate nutrition to promote health may be compromised by frailty, chronic illness, and cognitive decline.
To review the 2014 Pressure Ulcer Prevention and Treatment Clinical Practice Guideline nutrition strategies.
This continuing education activity is intended for physicians and nurses with an interest in skin and wound care.
After participating in this educational activity, the participant should be better able to:1. Describe the risk factors for and the pathophysiology of pressure ulcers (PrUs).2. Identify evidence-based nutrition strategies for PrU management.
Nutrition and hydration play an important role in preserving skin and tissue viability and in supporting tissue repair for pressure ulcer (PrU) healing. The majority of research investigating the relationship between nutrition and wounds focuses on PrUs. This white paper reviews the 2014 National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance Nutrition Guidelines and discusses nutrition strategies for PrU management.
Obesity rates are high among all age groups, including older adults. Obesity negatively affects health and functional ability, increasing the risk for nursing home (NH) admission. The current study examines trends over 11 years in moderate to severe obesity rates among NH residents. A generalized least squares regression model for panel data was used to test the effect of time (years) on the rates. A significant increase in rates and significant variation in rates were observed. Little research has focused on the issue of obesity in NHs. High and increasing rates and variation in rates raise questions on demand and access to NH care for obese older adults. Additional research is needed to consider factors other than time that may affect NHs' ability to admit moderate to severely obese individuals. Understanding these trends will help NHs prepare for future demand, ensure equal access, quality care, and financing of services. [Res Gerontol Nurs. 20xx; x(x):xx-xx.].
Copyright 2015, SLACK Incorporated.
Objective
To discuss possible explanations for the obesity paradox and explore whether the paradox can be attributed to a form of selection bias known as collider stratification bias.
Method
The paper is divided into three parts. First, possible explanations for the obesity paradox are reviewed. Second, a simulated example is provided to describe collider stratification bias and how it could generate the obesity paradox. Finally, an example is provided using data from 17,636 participants in the US National and Nutrition Examination Survey (NHANES III). Generalized linear models were fit to assess the effect of obesity on mortality both in the general population and among individuals with diagnosed cardiovascular disease (CVD). Additionally, results from a bias analysis are presented.
Results
In the general population, the adjusted risk ratio relating obesity and all-cause mortality was 1.24 (95% CI 1.11, 1.39). Adjusted risk ratios comparing obese and non-obese among individuals with and without CVD were 0.79 (95% CI 0.68, 0.91) and 1.30 (95% CI = 1.12, 1.50), indicating that obesity has a protective association among individuals with CVD.
Conclusion
Results demonstrate that collider stratification bias is one plausible explanation for the obesity paradox. After conditioning on CVD status in the design or analysis, obesity can appear protective among individuals with CVD.
Whether the association between body mass index (BMI) and all-cause mortality for older adults is the same as for younger adults is unclear.
The objective was to determine the association between BMI and all-cause mortality risk in adults ≥65 y of age.
A 2-stage random-effects meta-analysis was performed of studies published from 1990 to 2013 that reported the RRs of all-cause mortality for community-based adults aged ≥65 y.
Thirty-two studies met the inclusion criteria; these studies included 197,940 individuals with an average follow-up of 12 y. With the use of a BMI (in kg/m(2)) of 23.0-23.9 as the reference, there was a 12% greater risk of mortality for a BMI range of 21.0-21.9 and a 19% greater risk for a range of 20.0-20.9 [BMI of 21.0-21.9; HR (95% CI): 1.12 (1.10, 1.13); BMI of 20.0-20.9; HR (95% CI): 1.19 (1.17, 1.22)]. Mortality risk began to increase for BMI >33.0 [BMI of 33.0-33.9; HR (95% CI): 1.08 (1.00, 1.15)]. Self-reported anthropometric measurements, adjustment for intermediary factors, and exclusion of early deaths or preexisting disease did not markedly alter the associations, although there was a slight attenuation of the association in never-smokers.
For older populations, being overweight was not found to be associated with an increased risk of mortality; however, there was an increased risk for those at the lower end of the recommended BMI range for adults. Because the risk of mortality increased in older people with a BMI <23.0, it would seem appropriate to monitor weight status in this group to address any modifiable causes of weight loss promptly with due consideration of individual comorbidities.
To address the debate on "obesity paradox" in patients with type 2 diabetes (T2DM) by evaluating the cardiovascular and mortality risks associated with normal and overweight patients compared to obese at diagnosis of diabetes, separately for patients with and without cardiovascular disease (CVD) before diagnosis.
retrospective study with two study cohorts with/without prior CVD (n=10237/37272) with complete measures of body mass index (BMI) at diagnosis of T2DM from UK General Practice Research Database. Primary outcomes were long-term risks of cardiovascular events (CVE) and all-cause mortality in patients with normal weight, overweight and obesity at diagnosis. The mortality rates per 1000 person-years in normal weight, overweight and obese patients among patients without prior CVD were 13.1, 8.6 and 6.0 respectively during 5 years of median follow-up. For patients with prior CVD, these estimates were 30.1, 21.1 and 15.5 respectively. Among patients without and with prior CVD, normal weight patients had 47% (HR CI: 1.29, 1.69) and 30% (HR CI: 1.11, 1.53) increased mortality risk respectively compared to obese patients. In the cohort without prior CVD, compared to obese patients, those with normal body weight did not have increased CVE risk. Interactions between age, HbA1c and BMI at diagnosis were observed in both cohorts.
Adults with normal weight at the diagnosis of T2DM have significantly higher mortality risk compared to those who are obese, with significant interactions between age, BMI and HbA1c. Elevated cardiovascular risk was not observed in normal weight patients without prior CVD.
It is the position of the Academy of Nutrition and Dietetics that individuals have the right to request or refuse nutrition and hydration as medical treatment. Registered dietitians (RDs) should work collaboratively as part of the interprofessional team to make recommendations on providing, withdrawing, or withholding nutrition and hydration in individual cases and serve as active members of institutional ethics committees. RDs have an active role in determining the nutrition and hydration requirements for individuals throughout the life span. When individuals choose to forgo any type of nutrition and hydration (natural or artificial), or when individuals lack decision-making capacity and others must decide whether or not to provide artificial nutrition and hydration, RDs have a professional role in the ethical deliberation around those decisions. Across the life span, there are multiple instances when nutrition and hydration issues create ethical dilemmas. There is strong clinical, ethical, and legal support both for and against the administration of food and water when issues arise regarding what is or is not wanted by the individual and what is or is not warranted by empirical clinical evidence. When a conflict arises, the decision requires ethical deliberation. RDs' understanding of nutrition and hydration within the context of nutritional requirements and cultural, social, psychological, and spiritual needs provide an essential basis for ethical deliberation. RDs, as health care team members, have the responsibility to promote use of advanced directives. RDs promote the rights of the individual and help the health care team implement appropriate therapy. This paper supports the "Practice Paper of the Academy of Nutrition and Dietetics: Ethical and Legal Issues of Feeding and Hydration" published on the Academy website at: www.eatright.org/positions.
Background & aimsOlder malnourished patients experience increased length of hospital stay and greater morbidity compared to their well nourished counterparts. This study aimed to assess whether nutritional status at hospital admission predicted clinical outcomes at 12 months follow-up.Methods
Secondary data analysis of 2602 consecutive patient admissions to an acute tertiary hospital in New South Wales, Australia on or before 1st June 2009. Twelve-month data was analysed in a sub-sample of 774 patients. Nutritional status was determined within 72 h of admission using the Mini Nutritional Assessment (MNA). Outcomes, obtained from electronic patient records included hospital readmission rate, total length of stay (LOS), change in level of care at discharge, and in-hospital mortality.ResultsA third (34%) of patients were malnourished and 55% at risk of malnutrition. Using a Cox proportional hazards regression model, controlling for underlying illness and age, patients at risk of malnutrition were 2.46 (95% CI: 1.36, 4.45; p = 0.003) times more likely to have a poor clinical outcome (mortality/discharge to higher level of care), while malnourished patients had a 3.57 (95% CI: 1.94, 6.59; p = 0.000) times higher risk.ConclusionsA poor nutritional status carries a substantially greater risk of death and/or loss of dependency in older adults. Interventions to improve the nutritional status of patients during their hospital stay, and following discharge back to the community, are needed to lower the risk of adverse outcomes.
: To examine the prevalence of obesity and its relationship with pressure ulcers among nursing home (NH) populations, and whether such relationship varies with certified nursing assistant (CNA) level in NHs. DATA AND STUDY POPULATION:: The 1999-2009 nationwide Minimum Data Sets were linked with Online Survey of Certification and Reporting records. We identified newly admitted NH residents who became long-stayers and followed them up to 1 year.
: The outcome variable was presence of pressure ulcers during the 1-year follow-up period. Residents were categorized as normal [18.5≤ body mass index (BMI)<30 kg/m], mild obesity (30≤BMI<35 kg/m), and moderate or severe obesity (BMI≥35 kg/m). Pooled and stratified analyses were performed to examine the relationship between obesity and pressure ulcers, and how it varied by facility CNA level.
: The prevalence of obesity increased from 16.9% to 25.8% among newly admitted NH residents over the last decade. Obesity was associated with higher risks of pressure ulcers among long-stay residents. The relationship between obesity and pressure ulcers persisted after accounting for individual health conditions at the baseline and facility-level variations. Further, the within-facility relationship between obesity and pressure ulcers varied by facility CNA levels. The odds of pressure ulcers were 18.9% higher for residents with moderate or severe obesity than for nonobese residents within NHs with low CNA levels. The percents for medium and high CNA level facilities were 14.0% and 12.8%, respectively.
: To prepare for the growing obesity epidemic in NHs, policies should focus on strategies to improve care provided for obese residents.