The feasibility of a 6-month dietary intervention aiming to increase protein intake among community-dwelling older adults with low habitual protein intake: A secondary analysis of the PROMISS randomised controlled trial.

BACKGROUND: The PROMISS randomised controlled trial showed that personalised dietary advice increased protein intake and improved 400-m walk time and leg strength among community-dwelling older adults with a low habitual protein intake. This secondary analysis describes and further evaluates the methods and feasibility of the model used to carry out dietary intervention in the PROMISS randomised controlled trial. METHODS: In total, 185 participants (≥65 years, 54% women) with a habitual low protein intake (<1.0 g/kg adjusted body weight/day) in Finland and the Netherlands received personalised dietary advice and complimentary protein-enriched food products for 6 months with two main objectives: (1) to increase protein intake to ≥1.2 g/kg adjusted body weight/day (energy-neutral) and (2) to include each day a 'high-protein meal' containing ≥ 30-35 g of protein. The feasibility of the model was evaluated by the adoption of the advice, feedback from the participants, and practical experiences by the nutritionists. RESULTS: In all, 174 participants (93.5%) completed the intervention. At the 6-month follow-up, 41.8% reached both main objectives of the advice. The participants' general rating for the dietary advice was 8.6 (SD 1.0) (on a scale of 1-10; 10 indicating very good). Sticking to the advice was (very) easy for 79.2% of the participants. The nutritionists perceived the model feasible for the participants except for those with low food intake. CONCLUSIONS: The methods used in this model are mainly feasible, well-received and effective in increasing protein intake among community-dwelling older adults with low habitual protein intake.

Relationship of occlusal status with health-related quality of life among older adults in long-term care facilities.

BACKGROUND: Loss of teeth is common among residents in long-term care facilities (LTCF). To maintain occlusal support, lost teeth may be replaced with removable dentures. OBJECTIVES: The relationship of occlusal status with health-related quality of life (HRQoL) was evaluated. METHODS: A cross-sectional FINORAL study (FINnish ORAL Health Studies in older adults), including comprehensive geriatric assessment, was performed in LTCF. Demographic and medical information was retrieved from medical records. HRQoL was assessed with the 15D instrument and nutritional status with Mini-Nutritional Assessment (MNA). A standardised questionnaire filled in by trained nurses collected information on need for assistance in personal care or mobility, eating, and food consistency and swallowing difficulties. Clinical oral examination focusing on occlusal status was conducted for 338 residents. Four study groups (Gr) were established: Gr1 ≥ 10 natural teeth occlusal contact units (CU) (N = 51), Gr2 < 10 natural teeth CU (N = 87), Gr3 having CU of removable denture/s with or without natural teeth (N = 89), and Gr4 no CU (N = 111). RESULTS: 15D index score (adjusted for age, sex, MNA, and Charlson comorbidity index) showed higher HRQoL in Gr1 and Gr3; Gr1 participants had significantly higher crude values in mobility and Gr3 participants in eating, speech, and mental function than the other groups. Differences were present between the study groups in nutritional status, swallowing difficulties, and need for assistance in eating and mobility. CONCLUSION: Occlusal status of partial or complete denture/s with or without natural teeth or natural teeth having 10 or more occlusal CU was associated with higher HRQoL than other statuses.

The cost effectiveness of personalized dietary advice to increase protein intake in older adults with lower habitual protein intake: a randomized controlled trial.

PURPOSE: To examine the cost effectiveness of dietary advice to increase protein intake on 6-month change in physical functioning among older adults. METHODS: In this multicenter randomized controlled trial, 276 community-dwelling older adults with a habitual protein intake < 1.0 g/kg adjusted body weight (aBW)/d were randomly assigned to either Intervention 1; advice to increase protein intake to ≥ 1.2 g/kg aBW/d (PROT, n = 96), Intervention 2; similar advice and in addition advice to consume protein (en)rich(ed) foods within half an hour after usual physical activity (PROT + TIMING, n = 89), or continue the habitual diet with no advice (CON, n = 91). Primary outcome was 6-month change in 400-m walk time. Secondary outcomes were 6-month change in physical performance, leg extension strength, grip strength, body composition, self-reported mobility limitations and quality of life. We evaluated cost effectiveness from a societal perspective. RESULTS: Compared to CON, a positive effect on walk time was observed for PROT; - 12.4 s (95%CI, - 21.8 to - 2.9), and for PROT + TIMING; - 4.9 s (95%CI, - 14.5 to 4.7). Leg extension strength significantly increased in PROT (+ 32.6 N (95%CI, 10.6-54.5)) and PROT + TIMING (+ 24.3 N (95%CI, 0.2-48.5)) compared to CON. No significant intervention effects were observed for the other secondary outcomes. From a societal perspective, PROT was cost effective compared to CON. CONCLUSION: Dietary advice to increase protein intake to ≥ 1.2 g/kg aBW/d improved 400-m walk time and leg strength among older adults with a lower habitual protein intake. From a societal perspective, PROT was considered cost-effective compared to CON. These findings support the need for re-evaluating the protein RDA of 0.8 g/kg BW/d for older adults. TRIAL REGISTRATION: The trial has been registered at ClinicalTrials.gov (NCT03712306). Date of registration: October 2018. Registry name: The (Cost) Effectiveness of Increasing Protein Intake on Physical Functioning in Older Adults. Trial Identifier: NCT03712306.

Dentition, nutritional status and adequacy of dietary intake among older residents in assisted living facilities.

OBJECTIVE: We examined the relationships between dentition, nutritional status and dietary intakes of energy, protein and micronutrients among older people in assisted living facilities in Helsinki. BACKGROUND: Poor dentition is associated with malnutrition. Less is known about how dentition is associated with detailed nutrient intakes in institutionalised older people. MATERIALS AND METHODS: This cross-sectional study assessed 343 participants (mean age 83 years). Dentition was assessed by trained ward nurses and divided into edentulous participants without dentures (group 1), edentulous participants with removable dentures (group 2) and those with any natural teeth (group 3). Nutritional status was assessed by Mini Nutritional Assessment (MNA). The energy, protein and nutrient intakes were calculated from detailed 1-day food diaries and compared with the recommendations of the Finnish National Nutrition Council as a measure of dietary adequacy. Assessment included also participants' cognitive and functional status. RESULTS: Of the participants, 8.2, 39.1 and 52.8% were in groups 1, 2 and 3, respectively. Altogether 22% were malnourished according to MNA. Group 1 had the poorest nutritional status. A large proportion of participants consumed less than the recommended amounts of energy, protein or micronutrients. Half of the participants consumed <60 g/day of protein. The intake of protein was significantly lower in group 1 than in other two groups. CONCLUSION: Malnutrition and inadequate protein intake were very common and associated with dentition among older people with multiple disabilities in assisted living facilities. Assessment of dental status should be part of good nutritional care in long-term care.

Nutritional Status and Health-Related Quality of Life among Home-Dwelling Older Adults Aged 75 Years: The PORI75 Study.

Malnutrition in older people has been considered as a health concern associated with a range of implications for health and functional ability. However, evidence of nutrition and health-related quality of life (HRQoL) among older people is limited. The aim of this study was to study the associations between nutritional status and HRQoL among home-dwelling older adults aged 75 years. In this cross-sectional study, we studied 75-year-old home-dwelling residents who participated in PORI75 preventive health screenings in 2020 and completed the full Mini Nutritional Assessment (MNA). The participants' HRQoL was measured using the 15D instrument. Altogether, 462 participants (60% women) were included. Of these, 11% had decreased nutritional status (MNA score < 24); 12.7% were women and 8.6% were men, with no difference between the sexes (p = 0.17). A relationship was found between HRQoL and the MNA: a decreased MNA score was associated with decreased HRQoL (p < 0.001, r = 0.45, 95% CI: 0.38 to 0.53). All 15 HRQoL dimensions (except hearing) were associated with the MNA score. Among the men, the association was stronger compared to the women, especially when the MNA score was <24, indicating decreased nutritional status. In conclusion, impaired nutritional status seems to be associated with impaired HRQoL among 75-year-old people living at home, especially among men.

Nutrition Education Improves Intakes of Protein, Polyunsaturated Fatty Acids, and Vitamins C and E in Community-Dwelling Older Adults.

This study investigated the effect of nutrition education program on protein and nutrient intake, physical performance, and health-related quality of life (HRQoL) in community-dwelling older adults (≥65 years). The participants were randomized in clusters to intervention (IG, n = 51) and control (CG, n = 45) groups. Those in IG took part in the Eating for Strong Aging education program consisting of nutrition education in peer groups, written materials, and personal advice. Nutrient intake was assessed with 3-day food diaries, physical performance with Short Physical Performance Battery (SPPB) and HRQoL with 15-D-QoL instrument. Total of 89 participants completed the study. The mean age was 76 years (IG) and 74 years (CG). At three months, the mean change in protein intake was 0.10 g/adjusted bodyweight (ABW) kg/d in the IG, and -0.07 g/ABW kg/d in the CG (p = 0.024). Intakes of polyunsaturated fatty acids and vitamins C and E increased in the IG compared to the CG (p < 0.05). Changes in SPPB or total HRQoL scores between the IG and the CG did not differ. HRQoL dimension mobility improved in the IG compared to the CG (p = 0.035). In conclusion, the Eating for Strong Aging educational program improved nutrition and may be beneficial for mobility-related QoL.

Relationship between oral frailty, health-related quality of life, and survival among long-term care residents.

PURPOSE: We evaluated oral frailty (OFr) and its association with health-related quality of life (HRQoL), energy and protein intake, and survival among older long-term care residents. METHODS: This cross-sectional study with a 3-year follow-up for survival assessed 349 residents in long-term care facilities (73% female, mean age 82 years). We defined OFr with six signs (dry mouth, food residue on oral surfaces, unclear speech, inability to keep mouth open or pain expression during the clinical oral examination, diet pureed/soft) and OFr severity was categorized as Group 1, (mild) = 0-1 signs, Group 2 (moderate) = 2-4 signs, and Group 3 (severe) = 5-6 signs. We measured HRQoL with 15D instrument, and energy and protein intake by a 1- to 2-day food record. Mortality was retrieved from central registers on March 2021. RESULTS: Of the residents, 15% had 0-1, 67% 2-4 and 18% 5-6 OFr signs. HRQoL decreased linearly from Group 1 to Group 3. OFr correlated with such dimensions of HRQoL as mobility, eating, speech, excretion, usual activities, mental function, and vitality. We found no association between OFr categories and energy and protein intake. Survival decreased linearly from Group 1 to Group 3. CONCLUSIONS: OFr was common among older long-term care residents and OFr severity predicts poorer outcomes. The six oral signs denoting OFr may be used at the bedside to screen residents at risk for OFr.

Effect of Milk Fat Globule Membrane- and Protein-Containing Snack Product on Physical Performance of Older Women-A Randomized Controlled Trial.

INTRODUCTION: Sarcopenia is common in people 70+ years of age, and its prevalence increases with further aging. Insufficient energy and protein intake accelerates muscle loss, whereas sufficient protein intake and milk fat globule membrane (MFGM) may suppress age-associated deterioration of muscle mass and strength. Our objective was to test whether a snack product high in MFGM and protein would improve physical performance in older women. METHODS: In this 12-week randomized controlled trial, women ≥ 70 years, with protein intake < 1.2 g/body weight (BW) kg/day (d), were randomized into intervention (n = 51) and control (n = 50) groups. The intervention group received a daily snack product containing ≥ 23 g of milk protein and 3.6-3.9 g of MFGM. Both groups were advised to perform a five-movement exercise routine. The primary outcome was the change in the five-time-sit-to-stand test between the groups. Secondary outcomes included changes in physical performance, cognition, hand grip strength, and health-related quality of life. RESULTS: The change in the five-time-sit-to-stand test did not differ between the intervention and the control groups. The change in the total Short Physical Performance Battery score differed significantly, favoring the intervention group (p = 0.020), and the balance test showed the largest difference. Protein intake increased significantly in the intervention group (+14 g) compared to the control group (+2 g). No other significant changes were observed. CONCLUSIONS: Our results indicate that the combination of MFGM and protein may improve the physical performance-related balance of older women.

Dietary fat intake and quality in long-term care residents in two cohorts assessed 10 years apart.

PURPOSE: To describe and compare detailed dietary fat intake, fat quality and associative factors between two measuring points 10 years apart of residents living in long-term care facilities, and to reflect how fat composition and fat quality corresponds to current nutrition recommendations. METHODS: In 2007 long-term care residents (n = 374) of 25 assisted-living facilities and nursing homes and in 2017-18 long-term care residents (n = 486) of 17 respective facilities in Helsinki metropolitan area were recruited for this study. Information on the residents' heights, demographic information and use of calcium and vitamin D supplementation were retrieved from medical records. Residents' clinical assessment included Clinical Dementia Rating (CDR), the Mini Nutritional Assessment (MNA) and questionnaire related to nutrition care. Participants' energy and fat intake were determined from 1--2-day food diaries kept by the ward nurses, and fat quality indicators calculated. RESULTS: Age, gender distribution, MNA score or body mass index did not differ between the two cohorts. Residents' cognitive status, subjective health and mobility were poorer in 2017 compared to 2007. Total fat and saturated fatty acid (SFA) intakes were higher and fat quality indicators lower in the 2017 cohort residents than in the 2007 cohort residents. Sugar intake, male gender, eating independently, eating larger amounts and not having dry mouth predicted higher SFA intake in the 2017 cohort. CONCLUSIONS: The fat quality in long-term care residents in our study worsened in spite of official recommendations between the two measurement points.

Effects of Home-Delivered Meals on Older People's Protein Intake, Physical Performance, and Health-Related Quality of Life: The Power Meals Randomized Controlled Trial.

This trial examined the effectiveness of an 8-week home meal service on protein and other nutrient intake, physical performance (PP) and health related quality of life (HRQoL) among older people living at home (≥65 years; home care clients, caregivers and care recipients). Participants were randomized into three groups; (1) protein-rich meal, snack, and bread (INT1), (2) regular meal (INT2) and (3) control group. Nutrient intake was assessed with 3-day food diaries, PP with Short Physical Performance Battery (SBBP) and HRQoL with 15 dimensional Health-related quality of life instrument. Total of 67 (59.7% women, mean age 78.2 years) participants (n = 22 INT1, n = 24 INT2, n = 21 CG) completed the trial. At baseline, mean protein intake was 0.92 (SD 0.32) g/kg adjusted body weight (aBW)/d. At 8 weeks, protein-rich home meal service in INT1 increased protein intake (+ 0.11 (95%CI -0.01 to 0.21) g/kg aBW/d, 9.4 (95%CI 1.0 to 17.8) g/d) compared to other groups. It also increased calcium intake (+169.9 (95%CI 26 to 314) mg/d) and improved results in Sit-to-Stand Test (-4.8 (95%CI -6.8 to -2.7) sec) in INT1 compared to CG. Both home meal services increased saturated fat intake (INT1; 4.6 (95%CI 1.0-8.2) g/d, INT2;7.8 (95%CI 1.9 to 13.7)g/d) and decreased salt intake (INT1;-2330.9 (95%CI -2998 to -1664) mg/d, INT2; -2371.9 (95%CI -3399 to -1345) mg/d) compared to CG. There was no effect on overall HRQoL.

Effect of Protein Supplementation on Physical Performance in Older People With Sarcopenia-A Randomized Controlled Trial.

OBJECTIVES: To test the long-term effects of whey-enriched protein supplementation on muscle and physical performance. DESIGN: A 12-month randomized controlled double blind trial with a 43-month of post-trial follow-up. SETTING: Porvoo, Finland. PARTICIPANTS: A total of 218 older (>74 years of age) community-dwelling people with sarcopenia. INTERVENTION: (1) Control with no supplementation; (2) isocaloric placebo; and (3) 20 g × 2 whey-enriched protein supplementation. All participants were given instructions on home-based exercise, dietary protein, and vitamin D supplementation of 20 µg/d. MEASUREMENTS: Physical performance was assessed by short physical performance battery and continuous summary physical performance scores. Hand grip strength and calf intracellular resistance based skeletal muscle index were measured by bioimpedance spectroscopy. The measurements were performed at 0, 6, and 12 months. The post-trial follow-up was performed by a postal questionnaire and national census record data. RESULTS: The participants were older (75-96 years of age) and mostly women (68%). The test supplements had no significant effects on physical performance; the 12-month changes for short physical performance battery were -0.55, -.05, and 0.03 points in control, isocaloric, and protein groups (P = .17), respectively. The changes in continuous summary physical performance scores were similar between the intervention groups (P = .76). The hand grip strength decreased significantly in all intervention groups, and the 12-month changes in calf intracellular resistance-based skeletal muscle index were minor and there were no differences between the intervention groups. One-half of the patients (56%) in both supplement groups reported mild gastrointestinal adverse effects. Differences were found neither in the all-cause mortality nor physical functioning in the post-trial follow-up. CONCLUSIONS: The whey-enriched protein supplementation in combination with low intensity home-based physical exercise did not attenuate the deterioration of muscle and physical performance in community-dwelling older people with sarcopenia.

Effectiveness and cost-effectiveness of personalised dietary advice aiming at increasing protein intake on physical functioning in community-dwelling older adults with lower habitual protein intake: rationale and design of the PROMISS randomised controlled trial.

INTRODUCTION: Short-term metabolic and observational studies suggest that protein intake above the recommended dietary allowance of 0.83 g/kg body weight (BW)/day may support preservation of lean body mass and physical function in old age, but evidence from randomised controlled trials is inconclusive. METHODS AND ANALYSIS: The PRevention Of Malnutrition In Senior Subjects in the EU (PROMISS) trial examines the effect of personalised dietary advice aiming at increasing protein intake with or without advice regarding timing of protein intake to close proximity of usual physical activity, on change in physical functioning after 6 months among community-dwelling older adults (≥65 years) with a habitual protein intake of <1.0 g/kg adjusted (a)BW/day. Participants (n=264) will be recruited in Finland and the Netherlands, and will be randomised into three groups; two intervention groups and one control group. Intervention group 1 (n=88) receives personalised dietary advice and protein-enriched food products in order to increase their protein intake to at least 1.2 g/kg aBW/day. Intervention group 2 (n=88) receives the same advice as described for intervention group 1, and in addition advice to consume 7.5-10 g protein through protein-(en)rich(ed) foods within half an hour after performing usual physical activity. The control group (n=88) receives no intervention. All participants will be invited to attend lectures not related to health. The primary outcome is a 6-month change in physical functioning measured by change in walk time using a 400 m walk test. Secondary outcomes are: 6-month change in the Short Physical Performance Battery score, muscle strength, body composition, self-reported mobility limitations, quality of life, incidence of frailty, incidence of sarcopenia risk and incidence of malnutrition. We also investigate cost-effectiveness by change in healthcare costs. DISCUSSION: The PROMISS trial will provide evidence whether increasing protein intake, and additionally optimising the timing of protein intake, has a positive effect on the course of physical functioning after 6 months among community-dwelling older adults with a habitual protein intake of <1.0 g/kg aBW/day. ETHICS AND DISSEMINATION: The study has been approved by the Ethics Committee of the Helsinki University Central Hospital, Finland (ID of the approval: HUS/1530/2018) and The Medical Ethical Committee of the Amsterdam UMC, location VUmc, Amsterdam, the Netherlands (ID of the approval: 2018.399). All participants provided written informed consent prior to being enrolled onto the study. Results will be submitted for publication in peer-reviewed journals and will be made available to stakeholders (ie, older adults, healthcare professionals and industry). TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Registry (NCT03712306).

Burden of Oral Symptoms and Its Associations With Nutrition, Well-Being, and Survival Among Nursing Home Residents.

OBJECTIVES: To explore how oral problems, chewing problems, dry mouth, and swallowing difficulties cluster and whether their burden is associated with nutritional status, eating habits, gastrointestinal symptoms, psychological well-being, and mortality among institutionalized residents. DESIGN: Cross-sectional study with 1-year mortality. SETTING AND PARTICIPANTS: 3123 residents living in assisted facilities and nursing homes in Helsinki, Finland. MEASURES: Trained nurses assessed residents in all nursing homes and assisted living facilities in Helsinki in 2011. A personal interview, the Mini Nutritional Assessment (MNA), oral symptoms, questions about eating habits, and psychological well-being were used to assess each resident. We divided the subjects first according to the number of oral symptoms into 4 groups: no oral symptoms (G0), 1 oral symptom (G1), 2 oral symptoms (G2), and all 3 symptoms (G3); and second according to the symptoms: dry mouth, chewing problems, and swallowing difficulties. The diagnoses and medications were retrieved from medical records, and mortality data were obtained from central registers. RESULTS: In all, 26% of the subjects had 1 oral problem (G1), 11% had 2 oral problems (G2), and 4% had all 3 oral problems (G3), whereas 60% (n = 1870) had no oral symptoms. Thus, the oral symptoms moderately overlapped. The burden of oral symptoms was linearly associated with malnutrition, higher numbers of comorbidities, dependency in physical functioning, gastrointestinal symptoms, and eating less and more often alone. The higher the burden of oral symptoms, the lower the self-rated health and psychological well-being. Mortality increased along with the higher oral symptoms burden. Among residents having 1 or more symptoms, 26% had chewing problems, 18% swallowing difficulties, and 15% dry mouth. CONCLUSIONS/IMPLICATIONS: The burden of oral health problems was associated in a stepwise fashion with poor health and psychological well-being, malnutrition, and mortality. Clinicians should routinely assess older institutionalized residents' oral health status to improve residents' well-being.

Changes in malnutrition and quality of nutritional care among aged residents in all nursing homes and assisted living facilities in Helsinki 2003-2011.

BACKGROUND: While nutritional problems have been recognized as common in institutional settings for several decades, less is known about how nutritional care and nutrition has changed in these settings over time. OBJECTIVES: To describe and compare the nutritional problems and nutritional care of residents in all nursing homes (NH) in 2003 and 2011 and residents in all assisted living facilities (ALF) in 2007 and 2011, in Helsinki, Finland. METHODS: We combined four cross-sectional datasets of (1) residents from all NHs in 2003 (N=1987), (2) residents from all ALFs in 2007 (N=1377), (3) residents from all NHs in 2011 (N=1576) and (4) residents from all ALFs in 2011 (N=1585). All participants at each time point were assessed using identical methods, including the Mini Nutritional Assessment (MNA). RESULTS: The mean age of both samples from 2011 was higher and a larger proportion suffered from dementia, compared to earlier collected samples. A larger proportion of the residents in 2011 were assessed either malnourished or at-risk for malnutrition, according to the MNA, than in 2003 (NH: 93.5% vs. 88.9%, p<0.001) and in 2007 (ALF: 82.1% vs. 78.1%, p=0.007). The use of nutritional, vitamin D and calcium supplements, and snacks between meals was significantly more common in the 2011 residents, compared to the respective earlier samples. CONCLUSIONS: In 2011, institutionalized residents were more disabled and more prone to malnourishment than in 2003 or 2007. Institutions do seem to be more aware of good nutritional care for vulnerable older people, although there is still room for improvement.

High Intake of Nonmilk Extrinsic Sugars Is Associated With Protein and Micronutrient Dilution in Home-Dwelling and Institutionalized Older People.

BACKGROUND: High dietary sugar intake may compromise protein and micronutrient intakes in people with low energy intakes. The results of micronutrient dilution studies in older people have been few and conflicting. We examined the nutritional status and nutrient intakes associated with nonmilk extrinsic sugars (NMES) intakes in older people representing a broad spectrum of both healthy and vulnerable older populations. DESIGN AND PARTICIPANTS: This cross-sectional study combined five Finnish data sets covering home-dwelling (n = 526) and institutionalized (n = 374) older people. Their nutritional status was assessed using Mini Nutritional Assessment (MNA) and nutrient intakes retrieved from 1- to 3-day food records. The participants were divided into quartiles corresponding to the proportions of energy received from NMES. Energy, nutrient, and fiber intakes were classified according to the NMES quartiles, and the participants were divided according to their places of residence (home, institution). RESULTS: High NMES intakes were associated with older age, female sex, poor cognition, low MNA scores, immobility, and institutionalization. In all, 90% of the participants in the highest NMES quartile (Q4) were institutionalized. In the institutionalized individuals, low protein and micronutrient intakes were observed in both those with low energy intake (Q1) and in those with very high NMES intakes (Q4). In home-dwelling individuals, the nutrient intakes tended to decline linearly with increasing NMES intakes in protein and most micronutrients. CONCLUSIONS: Institutionalized older people consumed diets high in NMES, compared with those living at home, and their low energy and high NMES intakes were associated with low protein and micronutrient intakes.

Herbal medications and other dietary supplements. A clinical review for physicians caring for older people.

Evidence for the safety and effectiveness of dietary supplements is mixed. The extent to which older people use dietary supplements concomitantly with conventional medications is often under-appreciated by physicians. We conducted a literature review on clinical considerations associated with dietary supplement use, focusing on benefits and harms, motivations for use and contribution to polypharmacy among older people. Vitamin D ≥ 800 IU has demonstrated benefits in fracture prevention. Vitamins A, E, and ß-carotene have been associated with an increase in total mortality in several meta-analyses. A range of non-vitamin dietary supplements have been studied in randomized controlled trials but their efficacy remains largely unclear. Supplement use has been associated with a range of adverse events and drug interactions yet physicians rarely initiate discussions about their use with older patients. Older people may take dietary supplements to exercise control over their health. Given the contribution of supplements to polypharmacy, supplements may be targeted for "deprescribing" if the risk of harm is judged to outweigh benefits. This is best done as part of a comprehensive, patient-centered approach. A respectful and non-judgmental discussion may result in a shared decision to reduce polypharmacy through cessation of dietary supplements. KEY MESSAGES Herbal medications and other dietary supplements are highly prevalent among older people. Physicians are often unaware that their patients use herbal medications and other dietary supplements concomitantly with conventional medications. Herbal medications and other dietary supplements contribute to high rates of polypharmacy, particularly among older people with multimorbidity. Herbal medications and other dietary supplements can interact with conventional medications and be associated with a range of adverse events. Physicians need to be patient-centered and non-judgmental when initiating discussions about herbal medications and other dietary supplements. This is important to maintain and develop patient empowerment and self-management skills.

ESPEN guidelines on nutrition in dementia.

BACKGROUND: Older people suffering from dementia are at increased risk of malnutrition due to various nutritional problems, and the question arises which interventions are effective in maintaining adequate nutritional intake and nutritional status in the course of the disease. It is of further interest whether supplementation of energy and/or specific nutrients is able to prevent further cognitive decline or even correct cognitive impairment, and in which situations artificial nutritional support is justified. OBJECTIVE: It is the purpose of these guidelines to cover these issues with evidence-based recommendations. METHODS: The guidelines were developed by an international multidisciplinary working group in accordance with officially accepted standards. The GRADE system was used for assigning strength of evidence. Recommendations were discussed, submitted to Delphi rounds and accepted in an online survey among ESPEN members. RESULTS: 26 recommendations for nutritional care of older persons with dementia are given. In every person with dementia, screening for malnutrition and close monitoring of body weight are recommended. In all stages of the disease, oral nutrition may be supported by provision of adequate, attractive food in a pleasant environment, by adequate nursing support and elimination of potential causes of malnutrition. Supplementation of single nutrients is not recommended unless there is a sign of deficiency. Oral nutritional supplements are recommended to improve nutritional status but not to correct cognitive impairment or prevent cognitive decline. Artificial nutrition is suggested in patients with mild or moderate dementia for a limited period of time to overcome a crisis situation with markedly insufficient oral intake, if low nutritional intake is predominantly caused by a potentially reversible condition, but not in patients with severe dementia or in the terminal phase of life. CONCLUSION: Nutritional care and support should be an integral part of dementia management. In all stages of the disease, the decision for or against nutritional interventions should be made on an individual basis after carefully balancing expected benefit and potential burden, taking the (assumed) patient will and general prognosis into account.

Vision impairment and nutritional status among older assisted living residents.

Vision impairment is common among older persons. It is a risk factor for disability, and it may be associated with nutritional status via decline in functional status. However, only few studies have examined the relationship between vision impairment and nutritional status, which was investigated in this cross-sectional study. The study included all residents living in the assisted living facilities in Helsinki and Espoo in 2007. Residents in temporary respite care were excluded (5%). Of permanent residents (N=2214), 70% (N=1475) consented. Trained nurses performed a personal interview and assessment of each resident including the Mini Nutritional Assessment (MNA), functional and health status. Patient records were used to confirm demographic data and medical history. Mortality in 2010 was retrieved from central registers. Of the residents, 17.5% (N=245) had vision impairment and they were not able to read regular print. Those with vision impairment were older, more often females, and malnourished according to MNA. They had lower BMI, and suffered more often from dementia and chewing problems than those without vision impairment. In logistic regression analysis controlling for age, gender, chewing problems and dementia, vision impairment was independently associated with resident's malnutrition (OR 2.51, 95% CI 1.80-3.51). According to our results older residents in assisted living with vision impairment are at high risk for malnutrition. Therefore it is important to assess nutritional status of persons with vision impairment. It would be beneficial to repeat this kind of a study also in elderly community population.