The Malnutrition Awareness Scale for community-dwelling older adults: Development and psychometric properties.

BACKGROUND & AIMS: Qualitative studies suggest that malnutrition awareness is poor in older adults. The aim of this study was to develop a questionnaire to quantitatively assess malnutrition awareness in community-dwelling older adults aged 60+ years. METHODS: The Malnutrition Awareness Scale (MAS) was developed based on the awareness phase of the Integrated-Change model, and included four domains: knowledge, perceived cues, risk perceptions, and cognizance. Twenty-six scale items were developed using results from mainly qualitative research and the expertise of the authors. Items were piloted in 10 Dutch older adults using the Thinking Aloud method to optimize wording. In a feasibility study, annoyance, difficulty and time to complete the MAS and its comprehensibility were tested. After final revisions, the MAS was applied to a large sample to test its psychometric properties (i.e., inter-item correlations, Cronbach's alpha, score distribution) and relevance of the items was rated on a 5-point scale by 12 experts to determine content validity. RESULTS: The feasibility study (n = 42, 55 % women, 19 % 80+ y) showed that the MAS took 12 ± 6 min to complete. Most participants found it not (at all) annoying (81 %) and not (at all) difficult (79 %) to complete the MAS, and found it (very) comprehensible (83 %). Psychometric analyses (n = 216, 63 % women, 28 % 80+ y) showed no redundant items, but two items correlated negatively with other items, and one correlated very low. After removal, the final MAS consists of 23 items with a min-max scoring range from 0 to 22 (with higher scores indicating higher awareness) and an overall Cronbach's alpha of 0.67. The mean MAS score in our sample (n = 216) was 14.8 ± 3.2. The lowest obtained score was 6 (n = 3) and the highest 22 (n = 1), indicating no floor or ceiling effects. Based on the relevance rating, the overall median across all 22 items was 4.0 with IQR 4.0-5.0. CONCLUSION: The Malnutrition Awareness Scale is a novel, feasible and reliable tool with good content validity to quantitively assess malnutrition awareness in community-dwelling older adults. The scale is now ready to identify groups with poor malnutrition awareness, as a basis to start interventions to increase malnutrition knowledge and awareness.

Low micronutrient intake in nursing home residents, a cross-sectional study.

Low intake of micronutrients is associated with health-related problems in nursing home residents. As their food intake is generally low, it is expected that their micronutrient intake will be low as well. The nutrient intake of 189 residents (mean age 85.0 years (SD: 7.4)) in five different Dutch nursing homes was measured based on 3-day direct observations of intake. Micronutrient intake, without supplementation, was calculated using the Dutch food composition table, and SPADE software was used to model habitual intake. Intake was compared to the estimated average requirement (EAR) or adequate intake (AI) as described in the Dutch dietary reference values. A low intake was defined as >10% not meeting the EAR or when the P50 (median) intake was below the AI. Vitamin A, thiamin, riboflavin, niacin, B6, folate, B12, C, D, E, copper, iron, zinc, calcium, iodine, magnesium, phosphorus, potassium, and selenium were investigated. Our data showed that vitamin and mineral intake was low for most assessed nutrients. An AI was only seen for vitamin B12 (men only), iodine (men only), and phosphorus. A total of 50% of the population had an intake below the EAR for riboflavin, vit B6, folate, and vitamin D. For reference values expressed in AI, P50 intake of vitamin E, calcium, iodine, magnesium, potassium, and selenium was below the AI. To conclude: micronutrient intake in nursing home residents is far too low in most of the nursing home population. A "food-first" approach could increase dietary intake, but supplements could be considered if the "food-first" approach is not successful.

Behavioral and Cognitive Problems as Determinants of Malnutrition in Long-Term Care Facilities, a Cross-Sectional and Prospective Study.

OBJECTIVES: To investigate the cross-sectional and prospective associations between behavior and cognitive problems and malnutrition in long-term care facilities (LTCF). DESIGN: Cross-sectional and prospective routine care cohort study. SETTING: 6874 Residents in Dutch LTCFs (period 2005-2020). PARTICIPANTS: Data were obtained from the InterRAI-LTCF instrument. Cross-sectional analyses on prevalence of malnutrition at admission included 3722 residents. Prospective analyses studied incident malnutrition during stay (total follow-up time 7104 years) and included data of 1826 residents with first measurement on admission ('newly-admitted') and n=3152 with first measurement on average ~1 year after admission ('existing'). MEASUREMENTS: InterRAI scales for communication problems (CS), aggressive behavior (ABS), social engagement (RISE), depressive symptoms (DRS), cognitive performance (CPS) and the total number of behavior and cognitive problems were investigated as independent variables and malnutrition (ESPEN 2015 definition) as dependent variable in regression analyses. Results were stratified for gender and group 'newly-admitted' vs. 'existing'. RESULTS: On admission, 9.5% of residents was malnourished. In men, low social engagement was associated with prevalence of malnutrition. In women, all behavior and cognitive problems except depression were associated with malnutrition in the unadjusted analyses, but this attenuated in the full model taking all problems into account. The incidence of malnutrition during stay amounted to 8.9%. No significant associations of behavior and cognitive problems with malnutrition incidence were seen in 'newly-admitted' male residents while in 'existing' male residents all determinants were significantly associated. In 'newly-admitted' female residents CS, ABS and CPS, and in 'existing' female residents CS, RISE, ABS and CPS were significantly associated with incident malnutrition. All associations slightly attenuated after adjustment. Malnutrition incidence increased with increasing number of combined behavior and cognitive problems. CONCLUSION: Residents with behavior and cognitive problems are at an increased risk of being malnourished at admission, or becoming malnourished during stay in a LTCF, especially residents with multiple behavior and cognitive problems.

The association between polypharmacy and malnutrition(risk) in older people: A systematic review.

BACKGROUND & AIM: Malnutrition adversely influences a broad range of physical and psychological symptoms. Although polypharmacy is often mentioned to be associated with malnutrition, especially in older people it is unclear to what extent. The aim of this systematic review was to investigate the extent of the association between polypharmacy and malnutrition in older people. METHODS: The methodology followed the guidelines of the Cochrane Collaboration. Literature search was performed in PubMed, CINAHL and Embase. The population of interest for this systematic review were people of 65 years and older with polypharmacy. Because there is ambiguity with regard to the actual definition of malnutrition and polypharmacy, in this systematic review all articles describing malnutrition prevalence rates were included, regardless of the criteria used. Both observational and intervention studies were screened for eligibility. Selection and quality assessment of the included full text studies was assessed by two reviewers independently. A level of evidence and methodological quality score was adjudged to each article based on this assessment. RESULTS: A total of 3126 studies were retrieved by the literature search, of which seven studies were included in this systematic review. There was considerable variation in the definition of polypharmacy between studies. Two studies defined polypharmacy as the use of five or more drugs, two studies as the use of six or more drugs, two studies provided a mean and standard deviation that corresponded to the minimum of five drugs, and one study distinguished between polypharmacy (five or more drugs) and excessive polypharmacy (ten or more drugs). However, all studies showed a statistically significant association between (the risk) of becoming malnourished and polypharmacy regardless the instrument or criterion used to define risk of malnutrition. Studies presented the associations respectively as OR ≥ 1.177, p-value ≤ 0.028, ß ≥ -0.62 and r  ≥ -0.31. CONCLUSION: This review demonstrated a statistically significant association between polypharmacy and malnutrition. Further research is required to determine the magnitude of the effect by increased number of drugs in combination with the type of drugs, on the risk of malnutrition.

Malnutrition Prevalence Rates among Dutch Nursing Home Residents: What Has Changed over One Decade? A Comparison of the Years 2009, 2013 and 2018.

OBJECTIVES: To assess changes in prevalence of malnutrition and its associated factors among people living in Dutch nursing homes in 2009, 2013 and 2018. DESIGN: Secondary data analysis of the International Prevalence Measurement of Care Quality (LPZ) study. SETTING: Dutch nursing homes. PARTICIPANTS: Residents living at a psychogeriatric or somatic ward in Dutch nursing homes in 2009, 2013 or 2018. MEASUREMENTS: weight and height, unintentional weight loss over the last month and last six months, age, sex, length of stay up to the measurement day, care dependency, and the presence of various diseases (dementia, diabetes mellitus, stroke, diseases of the respiratory system, respiratory diseases and pressure ulcers). RESULTS: In total, 14,317 residents were included in this study with a mean age of 82.2, 70.9 female and 66.8% was living on a psychogeriatric ward. Results of this study show relative stability in background characteristics of the nursing home population over the last decade. In the total sample, 16.7% was malnourished and these percentages were 16.6% in 2009, 17.5% in 2013 and 16.3% in 2018. Multiple binary logistic regression analyses revealed having a pressure ulcer, female sex and living on a psychogeriatric department to be positively associated and having diabetes mellitus to be negatively associated with malnutrition throughout the years. These associations were strong and similar across years. CONCLUSION: Even though much attention has been paid to prevent malnutrition in Dutch nursing homes over the last decades, results show a relatively stable malnutrition prevalence rate of around 16%. This leads to the question if nursing staff is able to sufficiently recognize residents with (a risk of) malnutrition, and if they are aware of interventions they could perform to decrease this rate.

Global Leadership Initiative on Malnutrition (GLIM): Guidance on validation of the operational criteria for the diagnosis of protein-energy malnutrition in adults.

BACKGROUND: The Global Leadership Initiative on Malnutrition (GLIM) created a consensus-based framework consisting of phenotypic and etiologic criteria to record the occurrence of malnutrition in adults. This is a minimum set of practicable indicators for use in characterizing a patient/client as malnourished, considering the global variations in screening and nutrition assessment, and to be used across different health care settings. As with other consensus-based frameworks for diagnosing disease states, these operational criteria require validation and reliability testing as they are currently based solely on expert opinion. METHODS: Several forms of validation and reliability are reviewed in the context of GLIM, providing guidance on how to conduct retrospective and prospective studies for criterion and construct validity. FINDINGS: There are some aspects of GLIM criteria which require refinement; research using large data bases can be employed to reach this goal. Machine learning is also introduced as a potential method to support identification of the best cut-points and combinations of operational criteria for use with the different forms of malnutrition, which the GLIM criteria were created to denote. It is noted as well that the validation and reliability testing need to occur in a variety of sectors, populations and with diverse persons completing the criteria. CONCLUSION: The guidance presented supports the conduct and publication of quality validation and reliability studies for GLIM.

Joint action malnutrition in the elderly (MaNuEL) knowledge hub: summary of project findings.

PURPOSE: The Joint Action Malnutrition in the Elderly (MaNuEL) Knowledge Hub was established to extend scientific knowledge, strengthen evidence-based practice, build a sustainable, transnational network of experts and harmonize research and clinical practice in the field of protein-energy malnutrition in older persons. This paper aims to summarize the main scientific results achieved during the 2-year project and to outline the recommendations derived. METHODS: 22 research groups from seven countries (Austria, France, Germany, Ireland, Spain, The Netherlands and New Zealand) worked together on 6 relevant domains of malnutrition-i.e. prevalence, screening, determinants, treatment, policy measures and education for health care professionals-making use of existing datasets, evidence and expert knowledge. RESULTS: Four systematic reviews, six secondary data analyses of existing cohort and intervention studies, two web-based surveys and one Delphi study were performed. In addition, a scoring system to rate malnutrition screening tools and a theoretical framework on the aetiology of malnutrition in older persons were developed. Based on these activities and taking existing evidence into consideration, 13 clinical practice, 9 research and 4 policy recommendations were developed. The MaNuEL Toolbox was created and made available to effectively distribute and disseminate the MaNuEL results and recommendations. CONCLUSIONS: The MaNuEL Knowledge Hub successfully achieved its aims. Results and recommendations will support researchers, healthcare professionals, policy-makers as well as educational institutes to advance their efforts in tackling the increasing problem of protein-energy malnutrition in the older population.