Oral nutritional support in malnourished elderly decreases functional limitations with no extra costs

doi:10.1016/j.clnu.2011.10.009

Clinical Nutrition

Volume 31, Issue 2, April 2012, Pages 183-190

https://doi.org/10.1016/j.clnu.2011.10.009 Get rights and content

Summary

Background & aims

Older people are vulnerable to malnutrition which leads to increased health care costs. The aim of this study was to evaluate the cost-effectiveness of nutritional supplementation from a societal perspective.

Design

This randomized controlled trial included hospital admitted malnourished elderly (≥60 y) patients. Patients in the intervention group received nutritional supplementation (energy and protein enriched diet, oral nutritional support, calcium-vitamin D supplement, telephone counselling by a dietician) until three months after discharge from hospital. Patients in the control group received usual care (control). Primary outcomes were Quality Adjusted Life Years (QALYs), physical activities and functional limitations. Measurements were performed at hospital admission and three months after discharge. Data were analyzed according to the intention-to-treat principle and multiple imputation was used to impute missing data. Incremental cost-effectiveness ratios were calculated and bootstrapping was applied to evaluate cost-effectiveness. Cost-effectiveness was expressed by cost-effectiveness planes and cost-effectiveness acceptability curves.

Results

210 patients were included, 105 in each group. After three months, no statistically significant differences in quality of life and physical activities were observed between groups. Functional limitations decreased significantly more in the intervention group (mean difference -0.72, 95% CI-1.15; -0.28). There were no differences in costs between groups. Cost-effectiveness for QALYs and physical activities could not be demonstrated. For functional limitations we found a 0.95 probability that the intervention is cost-effective in comparison with usual care for ceiling ratios >€6500.

Conclusions

A multi-component nutritional intervention to malnourished elderly patients for three months after hospital discharge leads to significant improvement in functional limitations and is neutral in costs. A follow-up of three months is probably too short to detect changes in QALYs or physical activities.

Introduction

Older people are vulnerable to malnutrition secondary to chronic or progressive disease.1, 2 The number of people in Europe aged 65–79 years is expected to increase with approximately 35% between 2010 and 2030.³ In the Netherlands, people aged 65 years and older are the most rapidly growing age group. In 2009, there were 2,5 million adults in this age group. In 2040 the number of adults of 65 years and older will have grown to 4,5 million.4, 5 Thus, also malnutrition is expected to become a larger problem in the near future.

Next to the expected increase in malnutrition prevalence rates in elderly, its treatment will quickly shift from the hospital setting to the community. In our university hospital, for example, the mean hospital admission time for patients ≥60 years of age, has decreased from 15 to 9 days between 1999 and 2009.

Disease-related malnutrition is associated with adverse clinical outcomes, as has been shown in a large number of studies. These adverse effects vary from impaired wound healing and postoperative complications to increased mortality.⁶

Poor nutritional status has not only been associated with in hospital adverse effects, but also with adverse effects both pre-admission and post-discharge. These effects include an increased need for (re-)hospitalization, a higher mortality, a higher frequency of general practitioner consultations, a higher frequency of medication prescriptions, longer rehabilitation, an increased need for nursing home admission, an increased likelihood of requiring home health care after discharge, and earlier institutionalization.7, 8

Thus, malnutrition leads to increased health care costs. Calculations extrapolated from the United Kingdom to the EU situation indicate that as many as 20 million Europeans are at risk for malnutrition and that the cost for society of malnutrition is around 120 billion euros annually, mostly due to the extended stay of malnourished patients in hospital and in long-term care facilities.9, 10

Randomized controlled trials have shown that additional Oral Nutritional Support (ONS) can be effective in malnourished elderly people, both in hospitalized patients and in the community.¹¹ In hospitalized patients, ONS has been shown to reduce unintentional weight loss, to shorten hospital stay and to improve functional status in malnourished hospitalized patients.¹² In the community, ONS has been shown to increase activities of daily living, to reduce the number of falls and to reduce health care utilization.13, 14, 15, 16, 17

Evidence on the cost-effectiveness of ONS in the community is needed considering the large economic consequences of malnutrition. However, cost-effectiveness studies of ONS in the community are lacking. Therefore, the aim of this study was to investigate the cost-effectiveness of post-discharge nutritional support in malnourished elderly patients, from hospital admission until three months after discharge. We hypothesized that the costs of a nutritional intervention will be offset by costs of hospitalizations and other health care utilization.

Section snippets

Design

The study was designed as a randomized controlled trial comparing nutritional support from hospital admission until three months after discharge (intervention) with usual nutritional care (control) in malnourished elderly patients.

The study design is in accordance with the Declaration of Helsinki and has been approved by the Medical Ethics Committee (METC) of VU University Medical Center, Amsterdam. The design has been more extensively described elsewhere.¹⁸

Randomization

A computerized random number

Results

Patient inclusion, patient characteristics and clinical outcomes are extensively described elsewhere³⁰ and summarized in this manuscript.

We screened 3291 elderly patients on nutritional status, 2716 of which did not meet the malnutrition criteria; 575 patients were malnourished, of which 365 patients were excluded (due to: dementia/confusion (n = 114), refused to participate (n = 103), department transfer (n = 73), too ill (n = 29), not speaking the Dutch language (n = 12), no data on

Discussion

The main finding in this randomized controlled trial is that a multi-component nutritional intervention, consisting of oral nutritional support and calcium/vitamin D supplementation, supported by dietetic counselling, for malnourished elderly from hospital admission until three months after discharge, is effective and cost-effective for functional limitations. For quality of life and physical activities this was not the case. All these results were confirmed by sensitivity analyses.

Conclusion

This study shows that post-discharge multi-component nutritional support (supplementation of energy, protein, calcium and vitamin D, supported by dietetic counselling)improves functional limitations, but not quality of life or physical activities, in comparison to usual care. Cost-effectiveness analyses show that the intervention is cost-effective for functional limitations as well, after a follow-up period of only three months.

Future research should replicate the findings of our study. We

Statement of authorship

FN, JB, AT, JS and MB have made substantial contributions and final approval of the conceptions, drafting, and final version. Geraldine Droog, Suzanne ten Dam, Ingrid Nan, Lisa van Swieten, Evelien van Meel, Monique Bosman and Merel Gerding contributed to the acquisition of patients and data collection.

Contribution

FN, JB, AT, JS and MB were responsible for the study design, data collection, analysis and manuscript preparations.

Conflict of interest

No conflict of interest for all authors.

Poster and oral presentations at meetings

-
ESPEN (Clinical Nutrition and Metabolism International Congress), Nice, France.
Oral: 7 September 2010.
Poster: 6 and 7 September 2010.
-
ASPEN Clinical Nutrition week, Vancouver, Canada.
Oral: 30 January 2011.
Poster: 30 January 2011
-
Dutch Geriatrician’s meeting, Den Bosch, The Netherlands.
Oral: 4 February 2011

Funding

The Netherlands Organisation for Health Research and Development (ZonMw) funded the trial, project number 94506203. ZonMw had no further role in the study design, in the data collection, analysis and interpretation of the data, writing the report and in the decision to submit the paper for publication.

Trial registration

This trial was registered on http://www.trialregister.nl (candidate number 1660, NTR number NTR476, ISRCTN ISRCTN29617677, date ISRCTN created 27-jan-2006).

Acknowledgement

Sponsor’s role The Netherlands Organisation for Health Research and Development (ZonMw) funded the trial, project number 94506203. ZonMw had no further role in the study design, in the data collection, analysis and interpretation of the data, writing the report and in the decision to submit the paper for publication.

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ESPEN practical guideline: Nutritional support for polymorbid medical inpatients
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Disease-related malnutrition in polymorbid medical inpatients is a highly prevalent syndrome associated with significantly increased morbidity, disability, short- and long-term mortality, impaired recovery from illness, and healthcare costs.
As there are uncertainties in applying disease-specific guidelines to patients with multiple conditions, our aim was to provide evidence-based recommendations on nutritional support for the polymorbid patient population hospitalized in medical wards.
The 2023 update adheres to the standard operating procedures for ESPEN guidelines. We undertook a systematic literature search for 15 clinical questions in three different databases (Medline, Embase and the Cochrane Library), as well as in secondary sources (e.g., published guidelines), until July 12th, 2022. Retrieved abstracts were screened to identify relevant studies that were used to develop recommendations (including SIGN grading), which was followed by submission to Delphi voting. Here, the practical version of the guideline is presented which has been shortened and equipped with flow charts for patients care.
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Recent high-quality trials have provided increasing evidence that nutritional support can reduce morbidity and other complications associated with malnutrition in polymorbid patients. The timely screening of patients for risk of malnutrition at hospital admission followed by individualized nutritional support interventions for at-risk patients should be part of routine clinical care and multimodal treatment in hospitals worldwide. Use of this updated practical guideline offers an evidence-based nutritional approach to polymorbid medical inpatients and may improve their outcomes.
ESPEN guideline on nutritional support for polymorbid medical inpatients
2023, Clinical Nutrition
Disease-related malnutrition in polymorbid medical inpatients is a highly prevalent syndrome associated with significantly increased morbidity, disability, short- and long-term mortality, impaired recovery from illness, and cost of care.
As there are uncertainties in applying disease-specific guidelines to patients with multiple conditions, our aim was to provide evidence-based recommendations on nutritional support for the polymorbid patient population hospitalized in medical wards.
This update adheres to the standard operating procedures for ESPEN guidelines. We did a systematic literature search for 15 clinical questions in three different databases (Medline, Embase and the Cochrane Library), as well as in secondary sources (e.g. published guidelines), until July 12th. Retrieved abstracts were screened to identify relevant studies that were used to develop recommendations (incl. SIGN grading), which was followed by submission to Delphi voting.
From a total of 3527 retrieved abstracts, 60 new relevant studies were analyzed and used to generate a guideline draft that proposed 32 recommendations (7x A, 11x B, 10x O and 4x GPP), which encompass different aspects of nutritional support including indication, route of feeding, energy and protein requirements, micronutrient requirements, disease-specific nutrients, timing, monitoring and procedure of intervention. The results of the first online voting showed a strong consensus (agreement of >90%) on 100% of the recommendations. Therefore, no final consensus conference was needed.
Recent high-quality trials have provided increasing evidence that nutritional support can reduce morbidity and other complications associated with malnutrition in polymorbid patients. The timely screening of patients for risk of malnutrition at hospital admission followed by individualized nutritional support interventions for at-risk patients should be part of routine clinical care and multimodal treatment in hospitals worldwide. Use of this updated guideline offers an evidence-based nutritional approach to the polymorbid medical inpatients and may improve their outcomes.
Letter to the Editor: Is nutritional support effective in malnourished polymorbid medical inpatients?
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Nutrition-Focused Care for Community-Living Adults: Healthcare Utilization and Economic Benefits
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We assessed the impact of a recently reported nutritional quality improvement program (QIP) on healthcare resource utilization and costs for older, community-living adults in Bogotá, Colombia.
The study included 618 community-dwelling, older adults (> 60 years) who were at risk or malnourished and receiving outpatient clinical care. The intervention was a QIP that emphasized nutritional screening, dietary education, lifestyle counseling, 60-day consumption of oral nutritional supplements, and 90-day follow-up. For economic modeling, we performed 90-day budget impact and cost-effectiveness analyses from a Colombian third-party payer perspective. The base-case analysis quantified mean healthcare resource use in the QIP study population. Analysis was based on mean input values (deterministic) and distributions of input parameters (probabilistic). As the deterministic analysis provided a simple point estimate, the cost-effectiveness analysis focused on the probabilistic results informed by 1000 iterations of a Monte-Carlo simulation.
Results showed that the total use of healthcare resources over 90 days was significantly reduced by > 40% (hospitalizations were reduced by approximately 80%, emergency department visits by > 60%, and outpatient clinical visits by nearly 40%; P < .001). Based on economic modeling, total cost savings of $129 740 or per-patient cost savings of $210 over 90 days could be attributed to the use of nutritional QIP strategies. Total cost savings equated to nearly twice the initial investment for QIP intervention; that is, the per-dollar return on investment was $1.82.
For older adults living in the community in Colombia, the use of our nutritional QIP improved health outcomes while lowering costs of healthcare and was thus cost-effective.
Nutritional status and quality-of-life of older adults in aged care: A systematic review and meta-analysis
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The effect of malnutrition beyond morbidity and mortality has become a critical area of investigation in older people with an increased focus on quality-of-life (QoL), but as yet the relationship between malnutrition and QoL remains to be reviewed in older people from aged care settings. The current study conducted a systematic review and meta-analyses of studies published between the years 1995 and 2020 examining the relationship between nutritional status and QoL or the effects of a nutrition-based intervention on QoL in older people in residential aged care. Based on searches of the databases MEDLINE, PsycINFO, Emcare, and Embase, 21 studies were identified. Meta-analyses of the cross-sectional and quasi-experimental studies revealed a significant positive relationship between nutritional status and QoL and that nutritional intervention significantly improved QoL. By contrast, meta-analysis of randomised controlled trials revealed a non-significant but improved trend post-intervention in QoL. Although the effect sizes were small, the present findings indicate that nutrition-based interventions improve QoL in older people in residential aged care and align with previous reviews based on findings from other aged settings. Future research is needed to determine causality and to better identify and control for confounding factors which may influence both nutritional status and QoL.
ESPEN practical guideline: Clinical nutrition and hydration in geriatrics
2022, Clinical Nutrition
Malnutrition and dehydration are widespread in older people, and obesity is an increasing problem. In clinical practice, it is often unclear which strategies are suitable and effective in counteracting these key health threats.
To provide evidence-based recommendations for clinical nutrition and hydration in older persons in order to prevent and/or treat malnutrition and dehydration. Further, to address whether weight-reducing interventions are appropriate for overweight or obese older persons.
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We provide eighty-two evidence-based recommendations for nutritional care in older persons, covering four main topics: Basic questions and general principles, recommendations for older persons with malnutrition or at risk of malnutrition, recommendations for older patients with specific diseases, and recommendations to prevent, identify and treat dehydration. Overall, we recommend that all older persons shall routinely be screened for malnutrition in order to identify an existing risk early. Oral nutrition can be supported by nursing interventions, education, nutritional counselling, food modification and oral nutritional supplements. Enteral nutrition should be initiated if oral, and parenteral if enteral nutrition is insufficient or impossible and the general prognosis is altogether favorable. Dietary restrictions should generally be avoided, and weight-reducing diets shall only be considered in obese older persons with weight-related health problems and combined with physical exercise. All older persons should be considered to be at risk of low-intake dehydration and encouraged to consume adequate amounts of drinks. Generally, interventions shall be individualized, comprehensive and part of a multimodal and multidisciplinary team approach.
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Original articleOral nutritional support in malnourished elderly decreases functional limitations with no extra costs

Summary

Background & aims

Design

Results

Conclusions

Introduction

Section snippets

Design

Randomization

Results

Discussion

Conclusion

Statement of authorship

Contribution

Conflict of interest

Poster and oral presentations at meetings

Funding

Trial registration

Acknowledgement

Clin Nutr

Clin Nutr

J Am Diet Assoc

Clin Nutr

Clin Nutr

Clin Nutr

J Clin Epidemiol

J Clin Epidemiol

J Am Med Dir Assoc

Clin Nutr

Clin Nutr

Energy intake and expenditure in elderly patients admitted to hospital with acute illness

Br J Nutr

The prevalence of malnutrition in patients admitted to care of the elderly wards

Proc Nutr Soc

Confronting demographic change: a new solidarity between the generations

Research for man en environment health and disease

Statistics Netherlands population aging

The cost of disease-related malnutrition in the UK and economic considerations for the use of ONS in adults; Health economic report on malnutrition in the UK

Disease related malnutrition: an evidence-based approach to treatment

Consequences of disease related malnutrition

Meta-analysis: protein and energy supplementation in older people

Ann Intern Med

Dietary advice for illness-related malnutrition in adults

Cochrane Database Syst Rev

Original article
Oral nutritional support in malnourished elderly decreases functional limitations with no extra costs