Interdisciplinary communication and collaboration as key to improved nutritional care of malnourished older adults across health‐care settings – A qualitative study

Twenty years ago, ESPEN published its "Guidelines for nutritional screening 2002", with the note that these guidelines were based on the evidence available until 2002, and that they needed to be updated and adapted to current state of knowledge in the future. Twenty years have passed, and tremendous progress has been made in the field of malnutrition risk screening. Many screening tools have been developed and validated for different patient groups and different health care settings. Some countries even have introduced mandatory screening for malnutrition at admission to hospital. Yet, changes in society and healthcare require a reflection on current practice and policies regarding malnutrition risk screening. In this opinion paper, we share our perspectives on malnutrition risk screening in the twenty-twenties, addressing the changing and varying profile of the malnourished individual, the goals of screening and screening tools (i.e., preventive or reactive), the construct of malnutrition risk (i.e., screening for risk factors or screening for existing malnutrition), and screening alongside a patient's journey.

Improved nutritional care of malnourished older adults: A matter of interdisciplinary communication and collaboration

The aim of this study was to evaluate district nurses' perceived and factual knowledge about nutritional care after an updated and expanded educational intervention. Furthermore, we aimed to compare the outcomes of the revised and the original educational intervention. In-depth knowledge of nutritional care is a prerequisite to supporting older adults' well-being and health. District nurses' actual knowledge of the nutrition care process, older adults' need for food, and palliative care in diverse phases of disease is therefore of utmost importance. An updated and expanded educational intervention meeting these needs was evaluated. A study-specific questionnaire about nutritional care was used before and after the educational intervention. Participants (n = 118) were district nurses working in primary health care in Region Stockholm. Additionally, a pre- and post-test quasi-experimental design was used to assess differences in learning outcomes of the revised intervention compared with the original intervention. District nurses who completed the questionnaire had worked in health care for about 18 years and as district nurses for 5 years after their specialist examination. After the revised educational intervention, significant improvements were found in all statements concerning perceived challenges and actions related to nutritional care, while questions about factual knowledge showed significant improvements in three of the four questions.Comparison between the revised and the original intervention revealed no differences in most areas of perceived challenges and actions related to nutritional care. Additionally, in half of the areas assessed, factual knowledge improved more after the revision than after the original educational intervention, including the maximum length of overnight fast and the type of oral nutritional supplements (ONS) that should be prescribed. The intervention was successful in increasing knowledge about nutritional care, nutritional counselling, food adaptation, and prescribing ONS in an individually tailored way. In-depth knowledge supports usability in clinical practice. Nevertheless, we need to follow-up and understand how increased knowledge about undernutrition and ONS prescription are implemented in primary health care when caring for older adults' desires and needs.

This scoping review aimed to identify and map the available information on the nutrition care process in older adults with delirium to analyse and summarise key concepts, and gaps, including the barriers and enablers to providing nutrition care for this group. Scoping review. This review was conducted in accordance with the JBI methodology for scoping reviews. Published and grey sources in English were considered. Databases searched were CINAHL, Medline, Embase, JBI Evidence-based Practice, Scopus, ProQuest and Google. The initial search was conducted from October 2021 to March 2022 and repeated in October 2023. The database search identified 1561 articles, 186 underwent full-text review and 17 articles were included. The grey literature search identified eight articles. Malnutrition and delirium were identified as mutually reinforcing, and nutrition strategies were included as part of multicomponent interventions for delirium management. There was no mention of barriers or enablers to nutrition care and minimal descriptive or empirical data available to guide nutrition care processes in this group. This scoping review revealed a need for further research into nutrition care processes in older patients with delirium, in particular the barriers and enablers, to inform appropriate management strategies in this vulnerable group. Providing nutrition care for older patients with delirium is important and further practical guidance could help patients, healthcare staff and families. This scoping review yielded instructive data suggesting that delirium is an important risk factor for malnutrition and vice versa, which leads to poor patient and health service outcomes. This scoping review adhered to relevant EQUATOR guidelines and used the Preferred Reporting Items For Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR). No patient or public contribution.

Reprint of: Development and Evaluation of a Global Malnutrition Composite Score.

Development and Evaluation of a Global Malnutrition Composite Score

Objective: to characterize and analyze Nutritional Care (NC) for older adults in Primary Health Care (PHC), identifying how food and nutrition actions (F&N) were performed and the conceptions that guided them. Methods: a cross-sectional, quantitative and qualitative study was performed in PHC in Santos, São Paulo, Brazil, in two phases: i) a census study was carried out of health units, N=28 (100%), with managers who answered a structured interview to assess NC; followed by descriptive analysis. ii) a deeper investigation of this diagnosis was performed, using semi-structured interviews with key informants (interviewees) of care for older adults; being a nutritionist was not a criteria, as there were only three such professionals throughout the entire PHC, and one of the health regions studied was not served by a nutrition professional. The concept of theoretical saturation was used for the sampling plan; content analysis was carried out and the inferences were supported by references of integrality and aging. Results: NC for older adults was highlighted by individual care, predominant in all the services studied (28) (100%); nutritionists participated in this activity in just nine units (32.1%). Theoretical saturation was achieved with nine interviews. According to the discourse analysis, F&N actions were generic, focused on the treatment of diseases, influenced by negative aspects attributed to aging, there was no planning based on the needs of the territory, and health professionals identified themselves as information transmitters, leaving the responsibility of acting on such information to the older adults themselves. Conclusion: F&N actions were guided by the biomedical paradigm, fragmented, restricted to disease management, imputing the responsibility for health to the individual themselves. Thus, NC distanced itself from the promotion of healthy aging, weakening its strategic role in the quest for integrated care.

Guiding Principles for the Care of Older Adults with Multimorbidity: An Approach for Clinicians

Introduction: The Australian population is ageing. Older adults, who are more vulnerable to the deleterious effects of hospitalisation, are increasingly undergoing surgery. Better adherence to quality of care indicators, such as evidence-based practice guidelines, has been shown to improve outcomes in older patients. The Royal Brisbane and Women’s Hospital Internal Medicine Research Unit and Nutrition and Dietetics Department have a history of implementing collaborative, systems-based approaches aimed at improving care of older adults, spanning over a decade. These efforts have predominantly been focused on medical settings, with limited work undertaken targeting the care of older adults in the surgical setting prior to this thesis. Therefore, the overarching aim of this thesis is to improve perioperative nutrition care of older general surgical patients by increasing adherence to evidence-based practice guidelines; more specifically, the Enhanced Recovery After Surgery (ERAS) perioperative care guidelines.Methods: In this pragmatic, multiphase Action Research study, mixed methods were used to: investigate validity of hand grip strength as an objective method of malnutrition screening and adjusted weighed plate waste as an objective method of measuring impact of nutrition interventions (assessment method testing); observe current practice to identify gaps in practice in the nutrition-related care of patients ≥65 years admitted to general surgical wards at the Royal Brisbane and Women’s Hospital (Action Research Phase I: Observe); qualitatively explore clinician perspectives and identify barriers and enablers to practice change (Phase II: Reflect); develop a guideline tailored to the local setting (Phase III: Plan); and achieve practice change using a facilitative implementation approach (Phase IV: Act). Each phase of the study and facilitated implementation were prospectively informed by the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) implementation framework.Results: This study makes multiple contributions to the field and literature in terms of nutrition knowledge and practice, measurement methods and implementation of complex interventions. Some of the key findings are highlighted over the following paragraphs. In assessment method testing, hand grip strength was not found to be valid in screening for malnutrition, nor was calculating intake using an adjusted weighed plate waste method feasible for measuring impact of nutrition interventions outside of funded research in the clinical setting. Older patients were, however, found to eat poorly postoperatively, with few having an oral intake adequate to meet ≥50% theoretical requirements. No patient on a fluid diet met ≥50% of estimated protein requirements.Over half (59%) of admissions in older patients to general surgical wards were emergency admissions, a third (32%) of patients were at nutrition risk, with a quarter (25%) malnourished as per the Patient Generated Subjective Global Assessment (PG-SGA global rating B/C). Poor adherence to four nutrition care practices from ERAS guidelines (1. preoperative carbohydrate loading; 2. fasting from fluids limited to 2-4 hours; 3. fasting from solid food limited to 6-8 hours; and 4. diet upgraded to full ward diet either day of surgery or postoperative day one) identified gaps in practice, including prolonged preoperative fasting and delayed return to oral diet postoperatively.From qualitative interviews with multidisciplinary clinicians, three major themes presenting barriers to practice change were identified, including: a) complexity of the context (e.g. unpredictable theatre times, requirement for flexibility, and large, multidisciplinary workforce); b) strong decision making hierarchy, as well as lack of knowledge, confidence or authority of junior and non-surgical staff to implement change; and c) poor communication and teamwork (within and between disciplines). This highlighted the need for any intervention to be tailored to the local context to address these barriers to change.A facilitative implementation approach was successful in increasing the proportion of patients receiving early nutrition by 26% (from 53% pre-implementation to 79% post-implementation, P = 0.01) on the intervention ward, with associated odds (Adjusted OR [95% CI]) of receiving early nutrition post-implementation of 6.45 [1.86–22.40] (P = 0.01). Measuring implementation outcomes identified lower than expected fidelity (59%) and ongoing issues with feasibility, suggesting a need for further efforts to address these if practice change is to be sustained.Implications: Objective, easy to use methods for assessing nutrition risk and measuring impact of nutrition interventions remains a gap in the literature. Due to the pragmatic approach used in this thesis, the findings are directly applicable to the clinical setting. Additionally, the structured approach to achieving practice change in the clinical setting described by this thesis can be used by clinicians when undertaking complex interventions as part of research or quality improvement activities. An improvement in processes related to timeliness of postoperative diet upgrades on the intervention ward was observed; however, it was identified that further work to improve feasibility and fidelity is required, highlighting the importance of considering implementation outcomes when evaluating interventions.

Background/Objectives: Malnutrition among older adults remains a significant healthcare issue, yet existing questionnaires primarily measure knowledge and attitudes rather than actual behaviors. This study aimed to develop the Nursing Nutritional Care Behaviors Scale (B-NNC Scale) in its original Italian version, translate it into German, and evaluate its psychometric properties in registered nurses and nurse assistants in Austria. Methods: This study followed a two-phase, multi-method design. In Phase 1 (Development Phase), the scale was developed in Italian through a scoping review, expert focus group, and content validation involving 18 clinical nutrition experts using the Content Validity Ratio (CVR). In Phase 2 (Validation Phase), the scale was translated into German through a cross-cultural adaptation process, pilot-tested, and psychometrically validated in a sample of 1072 nurses and nurse assistants working in Austrian hospitals across various clinical settings. Exploratory and confirmatory factor analyses (EFA and CFA) were performed to assess construct validity, measurement invariance between professional roles was tested, and internal consistency was measured using McDonald's Omega. Results: Content validity was confirmed with a mean CVR of 0.634. EFA suggested a three-factor solution-(1) Nutritional Assessment and Calculation Skills, (2) Nutritional Evaluation and Care Planning, and (3) Nutritional Support and Care Implementation-leading to the retention of 19 items. CFA supported this structure, and McDonald's Omega indicated high internal consistency across subgroups. Partial measurement invariance revealed some differences in response patterns between registered nurses and nurse assistants. Conclusions: The B-NNC Scale demonstrated robust validity and reliability in measuring self-reported nursing behaviors related to nutritional care in older adults. It addresses a notable gap in existing instruments and may serve as a valuable tool for research and practice to improve malnutrition management.

To identify interventions to prevent and treat malnutrition in older adults, which can be integrated in nursing care, and to evaluate the effects of these interventions on outcomes related to malnutrition. Older adults are at great risk for malnutrition, which can lead to a number of serious health problems. Nurses have an essential role in nutritional care for older adults. Due to a lack of evidence for nursing interventions, adequate nursing nutritional care still lags behind. Systematic review. We searched for and included randomised controlled trials on interventions, which can be integrated in nursing care for older adults, to prevent and treat malnutrition. We assessed the risk of bias with the Cochrane tool and evidence for outcomes with the GRADE. The PRISMA statement was followed for reporting. We included 21 studies of which 14 studies had a high risk of bias. Identified interventions were oral nutritional supplements, food/fluid fortification or enrichment, dietary counselling and educational interventions. In evaluating the effects of these interventions on 11 outcomes related to malnutrition, significant and nonsignificant effects were found. We graded the certainty of evidence as very low to moderate. Although slight effects were found in protein intake and body mass index, there is no convincing evidence about the effectiveness of the four identified interventions. There seems no harm in using these interventions, although it should be kept in mind that the evidence is sparse. Therefore, there is a need for high-quality research in building evidence for interventions in nursing nutritional care. Nurses can safely provide oral nutritional supplements and food/fluid fortification or enrichment, and give dietary counselling and education to older adults, as they are well placed to lead the essential processes of nutritional care to older adults.

Addressing the Need for New Models of Care for Older Adults Receiving Long-term Dialysis

In light of the increasing life expectancy of Europe’s population and the rising significance of active and healthy ageing relating thereto, an integrated approach of nutritional care within primary health care is gaining importance. The aim of the review was to summarize evidence on the effectiveness of nutritional interventions in primary health care. The scoping review is based upon a comprehensive literature search of relevant literature published between January 2010 and August 2021 in PubMed, CINAHL, Cochrane Database of Systematic Reviews, Embase and Medline databases. Overall, 15 studies were included for evidence synthesis and interventions were basically clustered according to their type, into 1) eHealth and tele-medical interventions; 2) targeted single interventions; and 3) comprehensive, multi-faceted interventions. The review presents diverging evidence regarding the efficacy and effectiveness of interventions for nutritional care in primary health care, however, demonstrates encouraging outcomes. eHealth and tele-medical interventions partly show a careful positive tendency. Likewise, manifold single interventions on patient level present significant improvements in patient health outcomes. Multifaceted and comprehensive interventions found in the literature also partly demonstrate significant changes in intervention groups. Primary health care represents a critical setting for the care of older citizens and patients with complex health needs. This scoping review provides an overview of current nutrition care practices in primary health care and results reinforce the need to strengthen implementation of multi-faceted interventions carried out by the inter-disciplinary primary care team for advanced nutritional care.

BackgroundOlder adults often experience adverse health outcomes including malnutrition following discharge from emergency departments (ED). Discharge to community care is a transitionary time where nutritional vulnerability could be mitigated with the instigation of targeted nutrition care pathways in ED settings.Aims and objectivesThis scoping review aimed to establish and describe the level of nutrition care provided to older adults admitted and subsequently discharged from EDs.Research designSystematic searches of nine academic and grey literature databases (Medline (Ovid), Pubmed, CINAHL Complete (EBSCOhost), EMBASE, Cochrane Library and Scopus), grey literature sources (DART-Europe E-theses portal, Open Grey, and Trip Medical database) and four websites (Google, Google Scholar, NICE and LENUS) for relevant professional and organisational publications of research, policy, practice, and guidelines between January 2011 to 2023 were completed. Eligible studies included a population of older adults (≥ 65 years) with an ED attendance and subsequent community discharge, and where nutrition screening had identified malnutrition. Data were extracted on the level of nutrition and dietetic care initiated for older adults in the ED according to the Nutrition Care Process Model and summarised descriptively.ResultsOverall, 22 studies were included in the review. Nutrition status was screened on admission to the ED using validated tools: Mini Nutritional Assessment-Short Form (n = 13), Malnutrition Universal Screening Tool (n = 2), Short Nutritional Assessment Questionnaire (n = 2), NRS-2002 (n = 1) and the Mini Nutritional Assessment – Full Form (n = 1). A full nutrition assessment was reported by 5 studies. Only one study referred to documentation of malnutrition in healthcare records. Subsequent nutrition intervention after discharge from the ED for older adults was not described in any study.ConclusionWhile there is evidence to support malnutrition screening is taking place in EDs, there is a lack of information about subsequent nutrition care including assessment and therapy interventions. This points to the need for comprehensive exploration of nutrition care pathways, practice, policy, and research to inform models of integrated care for older persons.

Intensive glucose lowering in older adults with diabetes leads to increased risks with minimal benefits. Surveys indicate that clinician confidence for individualizing glycemic goals and regimens remains low. We created an interactive workshop and clinical tool kit to improve clinician knowledge of safe diabetes management in older adults. Finding the Sweet Spot was a 1-hour workshop taught by pharmacists to medical and pharmacy learners that introduced a five-step framework for diabetes management in older adults. The interactive presentation included cases and a clinical tool kit based on current recommendations from the American Diabetes Association and American Geriatrics Society. Pilot workshops were held for 6 months, allowing for real-time revisions based on feedback; final implementation occurred for 6 months thereafter. We evaluated learner self-efficacy (via a 5-point Likert scale) and knowledge (via multiple-choice questions) of diabetes management in older adults before and after the workshop. Thirty learners participated in Finding the Sweet Spot (70% medicine, 30% pharmacy). The percentage of confident learners increased from 55% to 97% (p < .05) after the workshop. All learners demonstrated improvements in knowledge, with the mean score on the knowledge assessment increasing from 61% to 80% (p < .05). Via open-ended feedback, learners expressed satisfaction and found the clinical tool kit especially helpful. Our Finding the Sweet Spot workshop demonstrated statistically significant changes in self-efficacy and knowledge among learners, indicating that this interactive workshop improves medical and pharmacy provider confidence and skills in caring for older adults with diabetes.