Barriers and facilitators to screening and treating malnutrition in older adults living in the community: a mixed-methods synthesis.

BACKGROUND: Malnutrition (specifically undernutrition) in older, community-dwelling adults reduces well-being and predisposes to disease. Implementation of screen-and-treat policies could help to systematically detect and treat at-risk and malnourished patients. We aimed to identify barriers and facilitators to implementing malnutrition screen and treat policies in primary/community care, which barriers have been addressed and which facilitators have been successfully incorporated in existing interventions. METHOD: A data-base search was conducted using MEDLINE, Embase, PsycINFO, DARE, CINAHL, Cochrane Central and Cochrane Database of Systematic Reviews from 2012 to June 2016 to identify relevant qualitative and quantitative literature from primary/community care. Studies were included if participants were older, community-dwelling adults (65+) or healthcare professionals who would screen and treat such patients. Barriers and facilitators were extracted and mapped onto intervention features to determine whether these had addressed barriers. RESULTS: Of a total of 2182 studies identified, 21 were included (6 qualitative, 12 quantitative and 3 mixed; 14 studies targeting patients and 7 targeting healthcare professionals). Facilitators addressing a wide range of barriers were identified, yet few interventions addressed psychosocial barriers to screen-and-treat policies for patients, such as loneliness and reluctance to be screened, or healthcare professionals' reservations about prescribing oral nutritional supplements. CONCLUSION: The studies reviewed identified several barriers and facilitators and addressed some of these in intervention design, although a prominent gap appeared to be psychosocial barriers. No single included study addressed all barriers or made use of all facilitators, although this appears to be possible. Interventions aiming to implement screen-and-treat approaches to malnutrition in primary care should consider barriers that both patients and healthcare professionals may face. REVIEW REGISTRATIONS: PROSPERO: CRD42017071398 . The review protocol was registered retrospectively.

Environmental interventions to promote healthier eating and physical activity behaviours in institutions: a systematic review.

OBJECTIVE: The present review evaluated the effectiveness of environmental-based interventions aimed at improving the dietary and physical activity behaviours and body composition indices of adults in institutions. DESIGN: A systematic review was conducted. Electronic databases (MEDLINE, Embase, PsycINFO, CINAHL, The Cochrane Library, Web of Science, ProQuest Dissertation and Theses, Scopus and Athena) were searched for relevant articles published between database inception and October 2017. Searching, selecting and reporting were undertaken according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. SETTING: Military establishments and maritime workplaces.ParticipantsAdults in institutions, aged 18-45 years. RESULTS: A total of 27842 articles were screened for eligibility, nine studies (reported in eleven articles) were included in the review. Five studies used multilevel strategies and four used environmental strategies only. Duration of follow-up ranged from 3 weeks to 10 years. Eight of the studies reported significant positive effects on dietary behaviours, but effect sizes varied. The study that targeted physical activity had no effect on activity levels but did have a significant positive effect on physical fitness. No evidence was identified that the studies resulted in improvements in body composition indices. CONCLUSIONS: The evidence base appears to be in favour of implementing environmental interventions in institutions to improve the dietary behaviours of adults. However, due to the small number of studies included in the review, and the variable methodological quality of the studies and intervention reporting, further well-designed evaluation studies are required.

Cost-effectiveness of oral nutritional supplements in older malnourished care home residents.

BACKGROUND & AIMS: Malnutrition is common in care home residents, but information on the cost-effectiveness of nutritional interventions is lacking. This study, involving a randomised trial in care home residents, aimed to examine whether oral nutritional supplements (ONS) are cost-effective relative to dietary advice. METHODS: An incremental cost-effectiveness analysis was undertaken prospectively in 104 older care home residents (88 ± 8 years) without overt dementia, who were randomised to receive either ONS or dietary advice for 12 weeks. Costs were estimated from resource use and quality adjusted life years (QALYs) from health-related quality of life, assessed using EuroQoL (EQ-5D-3L, time-trade-off) and mortality. The incremental cost-effectiveness ratio (ICER) was calculated using 'intention to treat' and 'complete case' analyses. RESULTS: The ONS group gained significantly more QALYs than the dietary advice group at significantly greater costs. The ICER (extra cost per QALY gained), adjusted for nutritional status, type of care, baseline costs and quality of life, was found to be £10,961 using the 'intention to treat' analysis (£190.60 (cost)/0.0174 (QALYs); n = 104) and £11,875 using 'complete case' analysis (£217.30/0.0183; n = 76) (2016 prices). Sensitivity analysis based on 'intention to treat' data indicated an 83% probability that the ICER was ≤£20,000 and 92% that it was ≤£30,000. With the 'complete case data' the probabilities were 80% and 90% respectively. CONCLUSION: This pragmatic randomised trial involving one of the oldest populations subjected to a cost-utility analysis, suggests that use of oral nutritional supplements in care homes are cost-effective relative to dietary advice.

Oral nutritional supplements in a randomised trial are more effective than dietary advice at improving quality of life in malnourished care home residents.

BACKGROUND & AIMS: Few trials have explored the effect of nutrition support on quality of life (QoL). This study examined the effects of oral nutritional supplements (ONS) vs dietary advice on QoL in malnourished care home residents. METHODS: 104 malnourished, care home residents (medium + high risk), identified using the Malnutrition Universal Screening Tool ('MUST'), (mean age 88.5 ± 7.9y) were randomised to receive either oral nutritional supplements (ONS) (n = 53) or dietary advice (n = 51) for 12 weeks. Dietary intake was measured using 24 h dietary recall, and QoL assessed using EuroQol (EQ-5D), including time trade off (TTO) (range -0.59 to 1) and visual analogue scale (VAS) (score 0 to 100) for self-perceived health. RESULTS: QoL (adjusted for baseline QOL, malnutrition risk, type of care received (nursing or residential)) was significantly higher in the ONS than the dietary advice group (intention to treat analysis at week 12; n = 104 ). EQ-5D TTO scores (mean ± SE) were 0.50 ± 0.04 vs 0.36 ± 0.05 (P = 0.005), VAS rescaled scores were 0.54 + 0.03 vs 0.046 + 0.03 (P = 0.006) and VAS scores were 61.3 ± 4.5 vs 54.6 ± 6.3 (P = 0.533) for ONS vs dietary advice respectively. Total energy, protein and the majority of micronutrient intakes were significantly greater in the ONS group, with energy intake being 423 kcal greater in the ONS than the dietary advice group at week 12. CONCLUSIONS: This study in malnourished care home residents indicates that ONS can improve QoL and nutritional intake more effectively than dietary advice alone. CLINICAL TRIAL REGISTRY: This trial was registered with clinicaltrials.gov on 10th August 2007. Clinical trials identifier is NCT00515125http://www.clinicaltrials.gov/ct2/show/NCT00515125?term=nutrition+support&rank=60.

Designing a national clinical audit of nutritional care in health and social care settings: consideration and future directions.

The aim of this review paper is to consider how the principles of clinical audit could be applied to the development of an audit of nutritional care in hospitals and care homes, based on criteria derived from the Essence of Care: Food and Drink. A literature review identified fifteen key papers that included guidance or standards for nutritional care in hospitals or care homes. These were used to supplement the ten factors suggested by the Essence of Care to develop a set of potential audit criteria covering all aspects of the nutritional care pathway including the identification of risk of malnutrition, implementation of nutritional care plans, referral to healthcare professionals for further nutritional assessment and nutritional support strategies. A series of audit tools have been developed, including an organisational level audit tool, a staff questionnaire, a patients' and residents' records audit tool and a patients' and residents' experiences questionnaire. Further issues to consider in designing a national nutritional audit include the potential role of direct observation of care, the use of trained auditors and the scope for including the results of pre-existing local audits. In conclusion, a national audit would need to encompass a very large number of health and care organisations of widely varying sizes and types and a diverse range of people.