Adrienne Young

Helping understand nutritional gaps in the elderly (HUNGER): A prospective study of patient factors associated with inadequate nutritional intake in older medical inpatients

BACKGROUND & AIMS Malnutrition and poor intake during hospitalisation are common in older medical patients. Better understanding of patient-specific factors associated with poor intake may inform nutritional interventions. The aim of this study was to measure the proportion of older medical patients with inadequate nutritional intake, and identify patient-related factors associated with this outcome. METHODS Prospective cohort study enrolling consecutive consenting medical inpatients aged 65 years or older. Primary outcome was energy intake less than resting energy expenditure estimated using weight-based equations. Energy intake was calculated for a single day using direct observation of plate waste. Explanatory variables included age, gender, number of co-morbidities, number of medications, diagnosis, usual residence, nutritional status, functional and cognitive impairment, depressive symptoms, poor appetite, poor dentition, and dysphagia. RESULTS Of 134 participants (mean age 80 years, 51% female), only 41% met estimated resting energy requirements. Mean energy intake was 1220 kcal/day (SD 440), or 18.1 kcal/kg/day. Factors associated with inadequate energy intake in multivariate analysis were poor appetite, higher BMI, diagnosis of infection or cancer, delirium and need for assistance with feeding. CONCLUSIONS Inadequate nutritional intake is common, and patient factors contributing to poor intake should be considered in designing nutritional interventions.

Encouraging, assisting and time to EAT: Improved nutritional intake for older medical patients receiving Protected Mealtimes and/or additional nursing feeding assistance

BACKGROUND & AIMS Inadequate feeding assistance and mealtime interruptions during hospitalisation may contribute to malnutrition and poor nutritional intake in older people. This study aimed to implement and compare three interventions designed to specifically address mealtime barriers and improve energy intakes of medical inpatients aged ≥ 65 years. METHODS Pre-post study compared three mealtime assistance interventions: PM: Protected Mealtimes with multidisciplinary education; AIN: additional assistant-in-nursing (AIN) with dedicated meal role; PM + AIN: combined intervention. Dietary intake of 254 patients (pre: n = 115, post: n = 141; mean age 80 ± 8) was visually estimated on a single day in the first week of hospitalisation and compared with estimated energy requirements. Assistance activities were observed and recorded. RESULTS Mealtime assistance levels significantly increased in all interventions (p < 0.01). Post-intervention participants were more likely to achieve adequate energy intake (OR = 3.4, p = 0.01), with no difference noted between interventions (p = 0.29). Patients with cognitive impairment or feeding dependency appeared to gain substantial benefit from mealtime assistance interventions. CONCLUSIONS Protected Mealtimes and additional AIN assistance (implemented alone or in combination) may produce modest improvements in nutritional intake. Targeted feeding assistance for certain patient groups holds promise; however, alternative strategies are required to address the complex problem of malnutrition in this population. AUSTRALIAN NEW ZEALAND CLINICAL TRIALS REGISTRY NUMBER: ACTRN12609000525280.

Malnutrition in geriatric rehabilitation: Prevalence, patient outcomes, and criterion validity of the scored patient-generated subjective global assessment and the mini nutritional assessment

BACKGROUND Accurate identification and management of malnutrition is essential so that patient outcomes can be improved and resources used efficaciously. OBJECTIVES In malnourished older adults admitted to rehabilitation: 1) report the prevalence, health and aged care use, and mortality of malnourished older adults; 2) determine and compare the criterion (concurrent and predictive) validity of the Scored Patient-Generated Subjective Global Assessment (PG-SGA) and the Mini Nutritional Assessment (MNA) in diagnosing malnutrition; and 3) identify the Scored PG-SGA score cut-off value associated with malnutrition. DESIGN Observational, prospective cohort. PARTICIPANTS/SETTING Participants were 57 older adults (65 years and older; mean±standard deviation age=79.1±7.3 years) from two rural rehabilitation units in New South Wales, Australia. MEASUREMENTS/STATISTICAL ANALYSIS Scored PG-SGA; MNA; and the International Statistical Classification of Diseases and Health Related Problems, 10th revision, Australian Modification (ICD-10-AM) classification of malnutrition were compared to establish concurrent validity and report malnutrition prevalence. Length of stay, discharge location, rehospitalization, admission to a residential aged care facility, and mortality were measured to report health-related outcomes and to establish predictive validity. RESULTS Malnutrition prevalence varied according to assessment tool (ICD-10-AM: 46%; Scored PG-SGA: 53%; MNA: 28%). Using the ICD-10-AM as the reference standard, the Scored PG-SGA ratings (sensitivity 100%, specificity 87%) and score (sensitivity 92%, specificity 84%, ROC AUC [receiver operating characteristics area under the curve]=0.910±0.038) showed strong concurrent validity, and the MNA had moderate concurrent validity (sensitivity 58%, specificity 97%, receiver operating characteristics area under the curve=0.854±0.052). The Scored PG-SGA rating, Scored PG-SGA score, and MNA showed good predictive validity. Malnutrition can increase the risk of longer rehospitalization length of stay, admission to a residential aged care facility, and discharge to hospital or residential aged care facility instead of home. CONCLUSIONS Malnutrition prevalence in the geriatric rural rehabilitation population is high, and is associated with increased health and aged care use. The Scored PG-SGA ratings and score are suitable for nutrition assessment in geriatric rehabilitation. The MNA may be suitable for nutrition assessment in geriatric rehabilitation, but care should be taken to ensure all malnourished patients are identified. Additional examination of the criterion validity of the Scored PG-SGA and MNA will lend confidence to these findings.

Role of domiciliary and family carers in individualised nutrition support for older adults living in the community

Protein-energy malnutrition is common amongst people aged 65 years and older, has a multifactorial aetiology, and numerous negative outcomes. Domiciliary carers (non-clinical paid carers) and family carers (including family, friends and neighbours) are required to support the increasing demand for in-home assistance with activities of daily living due to the ageing population. This review provides insight into the role of both domiciliary and family carers in providing individualised nutrition support for older, community-dwelling adults with malnutrition. Four electronic databases were searched for intervention studies from database inception to December 2016. Both domiciliary and family carers are well placed to monitor the dietary intake and nutritional status of older adults; to assist with many food-related tasks such as the sourcing and preparation of meals, and assisting with feeding when necessary; and to act as a conduit between the care recipient and formal nutrition professionals such as dietitians. There is moderate evidence to support the role of domiciliary carers in implementing nutrition screening and referral pathways, and emerging evidence suggests they may have a role in malnutrition interventions when supported by health professionals. Moderate evidence also supports the engagement of family carers as part of the nutrition care team for older adults with malnutrition. Interventions such as group education, skill-development workshops and telehealth demonstrate promise and have significantly improved outcomes in older adults with dementia. Further interventional and translational research is required to demonstrate the efficacy of engaging with domiciliary and family carers of older adults in the general community.

From hospital to home: Limited nutritional and functional recovery for older adults

BACKGROUND The post-hospital period may be a vulnerable time for elders recovering from acute illness. Few studies have examined nutrition outcomes of older people at nutrition risk after acute hospitalisation. OBJECTIVES This study aims to describe a) standard nutrition care received by recently discharged older medical patients, b) change in nutritional and functional status at six weeks post-discharge and c) clinical outcomes at twelve weeks post discharge. DESIGN Prospective cohort study. SETTING Two metropolitan teaching hospitals in Brisbane, Australia. PARTICIPANTS Medical patients aged ≥65 years at risk of malnutrition (Malnutrition Screening Score ≥2) and discharged to independent living in the community. MEASUREMENT Nutritional status (Mini Nutritional Assessment (MNA), weight, lean body mass), functional status (grip strength, walk speed, activities of daily living) and health-related quality of life assessed on discharge and six weeks post-discharge. Inpatient and post-discharge nutrition intervention was recorded. Death and unplanned admissions were measured at 12 weeks. RESULTS Of the 42 consented participants, only 14% (n=6) received post-discharge dietitian review and 19% (n=8) received practical nutrition supports at home (meal delivery, shopping assistance) as part of standard care. While there was a small improvement in MNA (18.4±4.0 to 20.1±4.2, p=0.004) and walk speed (0.7±0.3 m/s to 0.9±0.3, p=0.004) at six weeks, there was no difference in mean weight, lean body mass, grip strength or activities of daily living. Five (15%) participants lost ≥5% body weight. By twelve weeks, 17 participants (46%) had at least one unplanned hospital admission and four (10%) had died. CONCLUSIONS Few patients at nutrition risk received nutrition-focussed care in the post-hospital period, and most did not improve nutritional or functional status at 6 weeks.

Enhanced Recovery After Surgery as an auditing framework for identifying improvements to perioperative nutrition care of older surgical patients

Older patients are at increased risk of malnutrition and reduced physical function. Using Enhanced Recovery After Surgery (ERAS) guidelines as an auditing framework, this study aimed to determine adherence of nutrition care to perioperative best practice in older patients. A single researcher retrieved data via chart review. Seventy-five consenting patients ≥65 years (median 72 (range 65–95) years, 61% male) admitted postoperatively to general surgical wards were recruited. Sixty per cent had a primary diagnosis of cancer and 51% underwent colorectal resection. Seventeen per cent and 4% of patients met fasting targets of 2–4 h for fluid and 6–8 h for food, respectively. Fifty-five per cent were upgraded to full diet by first postoperative day. Nil received preoperative carbohydrate loading. Minimally invasive surgery (p = 0.01) and no anastomosis formation (p = 0.05) were associated with receiving ERAS-concordant nutrition care. This study highlights areas for improvement in perioperative nutrition care of older patients at our facility.

Rationale and developmental methodology for the SIMPLE approach: A Systematised, Interdisciplinary Malnutrition Pathway for impLementation and Evaluation in hospitals: The SIMPLE approach to managing malnutrition

AIM Changing population demographics, service demands, and healthcare provider expectations suggest that a shift is required regarding how malnutrition care is managed in hospitals. The present study aims to build the reason for required change, and to describe the process used to develop a model for managing malnutrition for implementation across six Queensland hospitals. METHODS A cross-sectional survey of approaches to managing malnutrition in Queensland public hospitals, and development of a new model of care (guided by Knowledge-to-Action Framework and qualitative interviews) for testing within a broader implementation program. RESULTS Twenty-three surveys were distributed with 21 completed by metropolitan (n = 11), regional (n = 8), and rural/remote (n = 2) settings. Substantial within and across site variance was observed, with care processes focused towards highly individualised, dietitian delivered care. Some early adopter sites demonstrated systematic, interdisciplinary or delegated malnutrition care processes; however, the latter was rarely or never undertaken in eight sites. A model for the Systematised, Interdisciplinary Malnutrition Pathway for impLementation and Evaluation (SIMPLE) in hospitals was drafted based on identified contemporary models and supporting literature. A mixed-methods approach combined survey data with structured interviews conducted in six sites, purposively sampled for maximal variation to iteratively refine the model. Consensus for implementation of the final model was achieved across site clinicians, leaders, and governance structures. CONCLUSIONS Systematised, delegated, and interdisciplinary nutrition care activities are realistic in at least some settings. A model is now available to provide interdisciplinary care. Next steps including testing implementation will determine if this interdisciplinary model improves malnutrition care delivered in hospitals.

Accuracy and confidence of allied health assistants administering the subjective global assessment on inpatients in a rural setting: a preliminary feasibility study

AIM Malnutrition has a significant impact on patient outcomes and duration of inpatient stay. However, conducting timely nutrition assessments can be challenging for rural dietitians. A solution could be for allied health assistants (AHAs) to assist with these assessments. The present study aimed to assess the accuracy and confidence of AHAs trained to conduct the subjective global assessment (SGA) compared with dietitians. METHODS A non-inferiority study design was adopted. Forty-five adult inpatients admitted to a rural and remote health service were assessed independently by both a trained AHA and dietitian within 24 hours. The order of assessment was randomised, with the second assessor blind to the outcome of the initial SGA. Levels of agreement were examined using kappa and percent exact agreement (PEA; set a priori at ≥80%). Rater confidence after each assessment was assessed using a 10-point scale. RESULTS Agreement for overall SGA ratings was high (kappa = 0.84; PEA 84.4%). PEA for individual sub-components of the SGA ranged from 66.4 to 86.7%. Where discrepancies were identified in global SGA ratings, AHAs provided a more severe rating of malnutrition than dietitians. AHAs reported significantly lower confidence than dietitians (t = 4.49, P < 0.001), although mean confidence for both groups was quite high (AHA=7.5, dietitians = 9.0). CONCLUSIONS Trained AHAs completed the SGA with similar accuracy to dietitians. Using AHAs may help facilitate timely nutrition assessment in rural health services when a dietitian is not physically present. Further investigation is required to determine the benefits of incorporating this extended role into rural and remote health-care services.

Use of hand grip strength in nutrition risk screening of older patients admitted to general surgical wards: HGS in nutrition risk screening

AIM Hand grip strength (HGS) has been proposed as an indicator of nutritional status that is objective, requires minimal assessor training and is quick to administer, making it attractive for use in the acute setting. This study aimed to determine the discriminatory ability of impaired HGS to screen for malnutrition in an older hospital population and assess the added value of combining this with existing screening tools. METHODS Measures were undertaken during acute admission in patients ≥65 years admitted to general surgical wards. Impaired HGS was defined as a mean value below the lower limit of the 95% CI of population norms and observed HGS standardised as a percentage of this value. Nutritional risk was assessed using the Malnutrition Screening Tool (MST) and malnutrition defined as Patient-Generated Subjective Global Assessment (PG-SGA) rating B or C. Discriminatory ability of impaired HGS to identify malnourished patients was tested using the area under the receiver operating characteristic curve (AUC). RESULTS Seventy-five patients (mean age: 74.0 (SD 6.7) years, 60% male) were recruited. Impaired HGS did not accurately identify malnutrition (AUC (95% CI): 0.41 (0.25-0.58), P < 0.001), nor did it improve discriminatory ability of the MST (AUC (95% CI), MST: 0.83 (0.71-0.95), P = 0.32; MST/HGS combined: 0.68 (0.51-0.86), P = 0.035). CONCLUSIONS HGS was not found to be suitable in screening older inpatients for malnutrition during admission to surgical wards. As such, screening for nutrition risk using an existing validated tool to identify patients for further in-depth nutritional assessment by an appropriately trained clinician remains the preferred method.

Prospective application of an implementation framework to improve postoperative nutrition care processes: Evaluation of a mixed methods implementation study: Evaluation of a mixed methods implementation study

AIM To describe prospective application of an implementation framework to guide and evaluate a quality improvement (QI) project to improve adherence to evidence-based postoperative diet guidelines (consistent with Enhanced Recovery After Surgery, ERAS) in older surgical patients. METHODS A hybrid mixed methods study guided by the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework was used. A pre-implementation audit identified gaps in nutrition-related care practices against ERAS guidelines for older surgical patients. Qualitative interviews explored barriers to practice change, informing development of the facilitated implementation strategy. Iterative facilitation interventions were identified by field notes and classified using i-PARIHS facilitators tool-kit. Post-implementation audit measured implementation outcomes, and clinical processes and outcomes using controlled before-after comparative study. RESULTS Implementation involved 17 discrete facilitation activities. Early postoperative diet upgrade was acceptable, well adopted (79%) and appropriate for 89% of patients. Fidelity (i.e. protocol delivered as intended) was 59%, with loss of fidelity primarily because of incorrect diet codes. Clinical processes and outcome evaluation (n = 155) compared data pre-implementation (intervention: n = 45, control: n = 27; mean age 73 (SD 6) years, 60% male) and post-implementation (intervention: n = 47, control: n = 36; mean age 74 (SD 6) years, 57% male). Patients on the intervention ward had higher odds of receiving early nutrition post-implementation (adjusted odds ratio [95% CI]: 6.5 [1.9-22.4], P = 0.01). CONCLUSIONS Prospective application of an implementation framework supported planning and successful implementation in this QI project. Multi-level evaluation of facilitation strategies, implementation outcomes, and clinical processes and outcomes helps to understand areas of success and continuing challenges.