A multimodal nutritional intervention after discharge improves quality of life and physical function in older patients - a randomized controlled trial.

BACKGROUND: Many older hospitalized patients are at nutritional risk or malnourished and the nutritional condition is often further impaired during hospitalization. When discharged to own home, a "Nutrition Gap" often occurs, causing inadequate dietary intake, and potentially impeded recovery. Previously, cross-sectorial studies of single component nutritional intervention have shown a limited effect on clinically relevant outcomes. We hypothesized that a multimodal nutritional intervention is necessary to elicit a beneficial effect on clinically relevant outcomes. METHODS: A randomized controlled trial was performed for a period of 16 weeks. At discharge, the intervention group (IG) received dietetic counselling including a recommendation of daily training, an individual nutrition plan and a package containing foods and drinks covering dietary requirements for the next 24 h. Further, a goodie-bag containing samples of protein-rich milk-based drinks were provided. Information regarding recommendations of nutritional therapy after discharge was systematically and electronically communicated to the municipality. The dietician performed telephone follow-ups on day 4 and 30 and a home visit at 16 weeks. The control group (CG) received standard treatment. The primary outcome was readmissions within 6 month, secondary outcomes were Length of Stay (LOS), Health Related Quality of Life (EQ-5D-3L), nutritional status, physical function (30s-CST) and mortality. This trial was registered under ClinicalTrials.gov Identifier no. NCT03488329. RESULTS: We included 191 patients (IG: n = 93). No significant difference was seen in readmissions within 6 month (IG: 45% vs. CG: 45%, Risk Ratio (RR): 0.96 0.71-1.31, p = 0.885). At the 16-weeks follow-up more patients in the IG reached at least 75% of energy and protein requirements (82% vs. CG: 61%, p = 0,007). The energy (kcal) and protein intake (g) per kg was significantly higher in the IG (26.4 kcal/kg (±7.4) vs. 22.6 (±7.4), p = 0.0248) (1.1 g/kg (±0.3) vs. 0.9 g/kg (±0.3). Furthermore, significant lower weight loss was seen in IG (0.7 (±4.3) vs. -1.4 (±3.6), p = 0.002). A significant and clinically relevant difference was found in the EQ-5D-3L VAS-score (IG: mean 61.6 ± 16.2 vs. CG: 53.3 ± 19.3, p = 0.011) (Δ14.3 (±15.5) vs. Δ5.6 (±17.2), p = 0.002). A significant difference in mean 30s-CST in IG was also found (7.2 (±4.3) vs. 5.3 (±4.1), p = 0.010). The improvements in physical function were of clinical relevance in both groups, but significantly higher in the IG (Δ4.2 (±4.4) vs. Δ2.2 (±2.5), p = 0.008). In fact, 86% in IG experienced improvements in the 30s-CST compared with 68% in the CG (p = 0.022). LOS was found to be lower at all time points, however not significant (30 days: -3 (-8.5 to 2.5), p = 0.276, 16 weeks: -4 (-10.2 to 2.2, p = 0.204), 6 months: -3 (-9.3 to 3.3, p = 0346)). All-cause mortality was not different between groups, however RR showed a non-significantly 47% reduction at day 30 (0.53 (0.14-2.05, p = 0.499)) and a 17% reduction at 16 weeks (0.83 (0.40-1.73, p = 1.000)) in IG. Per protocol (PP) analysis revealed a non-significant decrease of 32% in readmission at 6 months (RR: 0.68 (0.42-1.08), p = 0.105). CONCLUSION: The present study, using a multimodal nutritional approach, revealed no significant effect on readmissions however a significant positive effect on nutritional status, quality of life and physical function was found. The improvements in quality of life and physical function were of clinical relevance. No significant effect was found on LOS and mortality.

Poor performance in nutrition risk screening may have serious consequences for hospitalized patients.

BACKGROUND AND AIM: Finding patients at nutrition risk and securing sufficient nutritional intake, is vital to decrease risk of adverse outcomes and all-cause mortality. The aims of this study were therefore to investigate the prevalence of patients being screened for nutrition risk, to determine nutritional coverage in at-risk patients and assess the prevalence of readmissions and mortality within 30 days. METHODS: A one-day cross-sectional study was performed at Herlev Hospital, Denmark in June 2019. Patients >18 y and hospitalized for ≥4 days were enrolled. Exclusion criteria were admission to the intensive, palliative, acute medical or maternal ward. If a patient was not screened by the ward a clinical dietitian screened the patient. Patients found to be at nutrition-risk underwent a 24-h dietary recall to assess energy and protein intake. Data on length of stay, readmissions, and mortality within 30 days were collected from the hospital patient register. RESULTS: In total 197 (F:52%) patients were included. Median (IQR) age 74y (65-81). At the audit day n = 76 (39%) had a primary screening, and n = 42 (21%) were screened within 24 h. A NRS-2002-score ≥ 3 was found in 111 patients (63%). At-risk patients were more likely to be readmitted within 30 days (45% vs. 27%, p = 0.024) and had a higher mortality within 30 days after discharge (23% vs. 10%., p = 0.0285). In patients at nutrition risk 23% covered ≥75% of their energy- and protein requirement the last 24 h. More patients covered their energy- and protein-need if they were supplemented with enteral and/or parenteral nutrition fully or partly (63% vs. 15%, p < 0.001 or had been in contact with a clinical dietitian during the admission (33% vs. 15%, p = 0.0337. There were no differences in prevalence of readmissions and mortality between those patients at nutrition risk, who covered their energy and protein need and those who did not. CONCLUSIONS: The results demonstrate that the current nutritional care process is inadequate and may have serious consequences for hospitalized patients. Further effort is needed on the awareness of screening patients and how to fulfil their requirements during hospitalization. An abstract with part of the results has been accepted as a poster to ESPEN 2020.

Effect of nutritional interventions on discharged older patients: study protocol for a randomized controlled trial.

BACKGROUND: During hospitalization, many older patients are at nutritional risk or malnourished, and their nutritional condition is often further impaired during hospitalization. After discharge, a "nutrition gap" often occurs in which the patient does not receive enough nutrition to ensure an optimal recovery. METHODS: The study is a randomized controlled study ongoing over 112 days. At discharge, the intervention group receives guidance from a clinical dietitian, and an individualized nutrition plan is made. The dietitian will perform telephone follow-up after 4 and 30 days. It will also be possible for the participant, the participant's relatives, or the participant's municipality to contact the dietitian if nutritional questions arise. At the time of discharge, the intervention group will receive a package containing foods and drinks that will cover their nutritional needs on the first day after discharge. They will also receive a goodie bag containing samples of protein-rich, milk-based drinks. Data are collected on quality of life, appetite, physical function, dietary intake, weight, height, energy and protein needs, and experience of discharge and cooperation with the municipality. Information about nutrition status will be sent to the municipality so that the municipality can take over nutritional treatment. The control group receives a standard treatment. DISCUSSION: This study is the first to combine previously successful single nutritional interventions into a multimodal intervention whose aim is to obtain an effect on patient-related outcomes. We hope that the results will prove beneficial and help to ensure the cross-sector quality of nutritional support to older patients. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03488329. April 5, 2018.