A Review Of The Benefits Of Nutritional Intervention In Improving Body Weight, BMI, Activities Of Daily Living (ADL), Decrease Functional Limitation and Healthcare Cost Among Elderly.

Introduction

Malnutrition is a condition in which consumption of insufficient of nutrients that are required by the body to maintain optimal function of the organs and tissues. Secondary to chronic or progressive disease, older people are vulnerable to malnutrition (Klipstein-Grobusch, Reilly, Potter, Edwards, & Roberts, 1995; Watson, 1999). So it was believed that as the population of the elderly increases, cases of malnutrition among the elderly will also increase. 5-10% of non- institutionalized elderly are malnourished is shown in epidemiological studies (Posner et al., 1994). Furthermore, studies have shown that 51-61% of nursing home residents are at risk of malnutrition and 12-29% residents are malnourished (Guigoz, 2006; Suominen et al., 2005; Wojszel, 2006). Therefore, it can be concluded that malnutrition affect all the elderly no matter where they stay. The purpose of the review is to determine the effectiveness of nutritional intervention in improving nutritional status among the elderly and reduce healthcare cost at the same time in order to prevent further increasing of malnutrition among elderly. It is relevant to nursing with the use of nutritional intervention such as oral supplementation because nurses can help the patients to monitor nutritional status and give feedback to the dietician when the patients are not compliance or the supplementations are not suitable for them to consume.

Benefits of nutritional intervention

Continuous intervention

The first study used observational, prospective, longitudinal, cohort study which involved 378 elderly malnourished patients aged over 70 who lived in community, at home or in institutions which selected by general practitioners in France from two groups, group 1 with rare and group 2 with frequent prescription of oral nutritional supplements with contain high energy and protein. The aim of the study is to determine the impact of nutritional support on the cost and related comorbidities among elderly. Each patient was required to complete 12 months follow-up to measure the nutritional status, medical care consumption and identify malnutrition-related comorbidities. Nutritional status was adjusted using a generalized linear modeling approach and medical care costs were adjusted using a propensity score framework. Mini Nutritional Assessment (MNA) was significantly better in group 2 than 1from the first evaluation until the end of the study (P < 0.005). The total mean cost per patient over 12 months follow up is higher in group 1 than 2 due to cost of hospital care, nursing care, medication intake and decubitus ulcer care and average length of stay in hospital for group 2 lesser than group 1.

Another study was done in Amsterdam to determine the effectiveness of oral supplementation in decreasing functional limitation among malnourished elderly patients in hospital which involved 210 Dutch patients who aged 60 years and above using randomized control trial. Patients in intervention group received standardized nutritional support in hospital and continuing until three months after discharge. Telephone counseling by dietician is done to give advice and stimulate compliance to the proposed nutritional intake every other week after discharge. Patients in control group received the usual care and did not receive post-discharge nutritional support. Cost data were collected from societal perspective and measures using two cost diaries. The degree of difficulties patient experience with 6 activities such as climbing stairs, dress themselves, getting up and sitting down in a chair (score 0-6) measured by Functional Limitation Questionnaire (Kriegsman, Deej, van Eijk, Penninx & Boeke , 1997). After three months follow-up, patients in control group had longer mean length of hospital stay and often admitted to other inpatient institutions compared to patients in intervention group. Patients in intervention groups were able to do more physical activities and costs spent were lower than in control group. The probability of the cost-effective for the intervention lies around 0.5 compared with the usual care which was 0.6 at maximum. After oral nutritional support was given, significant improvements in functional limitations was confirmed by the study done by Woo, Ho, Mak, Law, Cheung (1994).

Need-based intervention

A group of 92 elderly who aged 65 years and above in nursing home at Taiwan participated in a randomized, double blind, controlled trial which included one year follow-up to observe mortality. This study done to examine the effectiveness of need-based strategy in improving the nutritional status among elderly in nursing home. Elderly in intervention group were given routine monitoring and a warm soup which contained nutrient supplement while elderly in control group were given routine care and normal warm soup. The content in the soup and detail about the study was not told to the resident involved. The participants’ nutritional status was evaluated using MNA and the height, weight, mid-arm circumference, calf circumference, BMI was measured and calculated. The elderly in intervention group who give supplement would be suspended once either one of the “at risk” condition was corrected. Over-nutrition can be prevented and saved cost by giving supplements when it is needed. There was significantly improved body weight, BMI, mid-arm circumference, calf circumference and others in intervention group (all p< 0.05) although need based-strategy was used. Previous studies done by Lauque et al. (2000), Milne, Potter, Vivanti and Avenell (2009) and Wouters-Wesseling, Wouters, Kleijer, Bindels, de Groot and van Staveren (2002) shown that nutritional intervention is effective for improving weight gain and BMI status in frail elderly.

Conclusion

From this review, it concluded that nutritional intervention such as oral supplementation is effective in preventing malnutrition among elderly. Oral supplementation can be taken with warm soup that is easily prepared, saved costs and with no associated digestive problems. Even though overall studies used different methods implementing oral supplementations, the results clearly showed that there was improvement in patients’ body weight, BMI, ADL and nutrition status after nutritional intervention used. It is also effective using oral supplementation with routine screening such as MNA which enables early identification of those who are at risk so that an appropriate intervention can be taken. We as nurses are able to assess the patients’ nutritional status frequently using MNA by reporting any changes to the dietician and able to administer the oral supplementation ordered for the patients. Limitations for all the studies were small sample sizes used and health condition of the patients participated may change during the study which will cause the ineffective of the oral supplementation. Future research should be done in various hospitals, community hospitals and nursing homes so that results obtained will be more accurate. The study should be done with a longer follow-up to give more opportunities for the patients to improve and a more accurate cost spent can be obtained. A longer follow-up can determine the effectiveness of nutritional intervention on quality of life and physical activities accurately.

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