Summary Background Older adults are at increased risk of malnutrition compared to their younger counterparts. Malnutrition screening should be conducted using a valid malnutrition screening tool. An ...aim of the Healthy Diet for a Healthy Life (HDHL) Joint Programming Initiative (JPI) 'Malnutrition in the Elderly Knowledge Hub' (MaNuEL) was to review the reported validity of existing malnutrition screening tools used in older adults. Methods A literature search was conducted to identify validation studies of malnutrition screening tools in older populations in community, rehabilitation, residential care and hospital settings. A database of screening tools was created containing information on how each tool was validated. Results Seventy-four articles containing 119 validation studies of 34 malnutrition screening tools used in older adults were identified across the settings. Twenty-three of these tools were designed for older adults. Sensitivity and specificity ranged from 6 to 100% and 12–100% respectively. Seventeen different reference standards were used in criterion validation studies. Acceptable reference standards were used in 68 studies; 38 compared the tool against the Mini Nutritional Assessment-Full Form (MNA-FF), 16 used clinical assessment by a nutrition-trained professional and 14 used the Subjective Global Assessment (SGA). Twenty-five studies used inappropriate reference standards. Predictive validity was measured in 14 studies and was weak across all settings. Conclusions Validation results differed significantly between tools, and also between studies using the same tool in different settings. Many studies have not been appropriately conducted, leaving the true validity of some tools unclear. Certain tools appear to be more valid for use in specific settings.
Malnutrition is widespread among older people and related to poor outcome. Reported prevalences vary widely, also because of different diagnostic criteria used. This study aimed to describe ...prevalences in several populations of older persons in different settings using harmonized definitions.
Available studies within the Joint Programming Initiative (JPI) Knowledge Hub ‘Malnutrition in the Elderly’ (MaNuEL) were used to calculate and compare prevalences of malnutrition indicators: low BMI (<20 kg/m2; age-specific BMI <20 if age 65–<70 and <22 kg/m2 if age ≥70 years), previous weight loss (WL), moderate and severe decrease in food intake, and combined BMI <20 kg/m2 and/or WL in participants aged ≥65 years.
Fifteen samples with in total 5956 participants (59.3% women) were included: 7 consisting of community-dwelling persons, 2 studies in geriatric day hospitals, 3 studies in hospitalized patients and 3 in nursing homes. Mean age of participants ranged between 67 and 87 years. Up to 4.2% of community-dwelling persons had a BMI <20 kg/m2, 1.6 and 9% of geriatric day hospital patients, 4.5–9.4% of hospital patients and 3.8–18.2% of nursing home residents. Using age-specific cut-offs doubled these prevalences. WL was reported in 2.3–10.5% of community-dwelling persons, 6% and 12.6% of geriatric day hospital patients, 5–14% of hospitalized patients and 4.5–7.7% of nursing home residents. Severe decrease in food intake was recorded in up to 9.6% of community-dwelling persons, 1.5% and 12% of geriatric day hospital patients, 3.4–34.2% of hospitalized patients and 1.5–8.2% of nursing home residents. The criteria age-specific BMI and WL showed opposing prevalences across all settings. Compared to women, low BMI and moderate decrease in food intake showed low prevalences in men but similar prevalences were observed for weight loss and severe decrease in food intake. In half of the study samples, participants in a younger age group had a higher prevalence of WL compared to those of an older age group. Prevalence of BMI <20 kg/m2 and WL at the same time did not exceed 2.6% in all samples. The highest prevalences were observed based on combined definitions when only one of the three criteria had to be present.
Prevalences for different criteria vary between and within the settings which might be explained by varying functional status. The criteria used strongly affect prevalence and it may be preferable to look at each criterion separately as each may indicate a nutritional problem.
In older persons, the origin of malnutrition is often multifactorial with a multitude of factors involved. Presently, a common understanding about potential causes and their mode of action is ...lacking, and a consensus on the theoretical framework on the etiology of malnutrition does not exist. Within the European Knowledge Hub “Malnutrition in the Elderly (MaNuEL),” a model of “Determinants of Malnutrition in Aged Persons” (DoMAP) was developed in a multistage consensus process with live meetings and written feedback (modified Delphi process) by a multiprofessional group of 33 experts in geriatric nutrition. DoMAP consists of three triangle-shaped levels with malnutrition in the center, surrounded by the three principal conditions through which malnutrition develops in the innermost level: low intake, high requirements, and impaired nutrient bioavailability. The middle level consists of factors directly causing one of these conditions, and the outermost level contains factors indirectly causing one of the three conditions through the direct factors. The DoMAP model may contribute to a common understanding about the multitude of factors involved in the etiology of malnutrition, and about potential causative mechanisms. It may serve as basis for future research and may also be helpful in clinical routine to identify persons at increased risk of malnutrition.
Context: Vitamin D deficiency is common among older people and can cause mineralization defects, bone loss, and muscle weakness.
Objective: The aim of this study was to investigate the association of ...serum 25-hydroxyvitamin D (25-OHD) concentration with current physical performance and its decline over 3 yr among elderly.
Design: The study consisted of a cross-sectional and longitudinal design (3-yr follow-up) within the Longitudinal Aging Study Amsterdam.
Setting: An age- and sex-stratified random sample of the Dutch older population was used.
Other Participants: Subjects included 1234 men and women (aged 65 yr and older) for cross-sectional analysis and 979 (79%) persons for longitudinal analysis.
Main Outcome Measure(s): Physical performance (sum score of the walking test, chair stands, and tandem stand) and decline in physical performance were measured.
Results: Serum 25-OHD was associated with physical performance after adjustment for age, gender, chronic diseases, degree of urbanization, body mass index, and alcohol consumption. Compared with individuals with serum 25-OHD levels above 30 ng/ml, physical performance was poorer in participants with serum 25-OHD less than 10 ng/ml regression coefficient (B) = −1.69; 95% confidence interval (CI) = −2.28; −1.10, and with serum 25-OHD of 10–20 ng/ml (B = −0.46; 95% CI = −0.90; −0.03). After adjustment for confounding variables, participants with 25-OHD less than 10 ng/ml and 25-OHD between 10 and 20 ng/ml had significantly higher odds ratios (OR) for 3-yr decline in physical performance (OR = 2.21; 95% CI = 1.00–4.87; and OR = 2.01; 95% CI = 1.06–3.81), compared with participants with 25-OHD of at least 30 ng/ml. The results were consistent for each individual performance test.
Conclusions: Serum 25-OHD concentrations below 20 ng/ml are associated with poorer physical performance and a greater decline in physical performance in older men and women. Because almost 50% of the population had serum 25-OHD below 20 ng/ml, public health strategies should be aimed at this group.
This study aimed to identify dietary patterns using reduced rank regression (RRR) and to explore their associations with depressive symptoms over 9 years in the Invecchiare in Chianti study. At ...baseline, 1362 participants (55·4 % women) aged 18–102 years (mean age 68 (sd 15·5) years) were included in the study. Baseline data collection started in 1998 and was repeated after 3, 6 and 9 years. Dietary intake information was obtained using a country-specific, validated FFQ with 188 food items. For baseline diet, dietary pattern scores in quartiles (Q) were derived using RRR with the nutrients EPA+DHA, folate, Mg and Zn as response variables. Continuous depression scores from the Centre for Epidemiologic Studies Depression (CES-D) scale were used for assessing depressive symptoms. The derived dietary pattern was rich in vegetables, olive oil, grains, fruit, fish and moderate in wine and red and processed meat, and was labelled as ‘typical Tuscan dietary pattern’. After full adjustment, an inverse association was observed between this dietary pattern and depressive symptoms at baseline (Q1 v. Q4, B −2·77; 95 % CI −4·55, −0·98). When examining the relationship between the above-mentioned dietary pattern at baseline and depressive symptoms over 9 years, a similar association was found after full adjustment for confounding factors (Q1 v. Q4, B −1·78; 95 % CI −3·17, −0·38). A diet rich in vegetables, olive oil, grains, fruits, fish and moderate in wine and red and processed meat was consistently associated with lower CES-D scores over a 9-year period in the Tuscan population.
A poor appetite or ability to eat and its association with physical function have not been explored considerably amongst community-dwelling older adults. The current study examined whether having an ...illness or physical condition affecting one’s appetite or ability to eat is associated with body composition, muscle strength, or physical function amongst community-dwelling older adults. This is a secondary analysis of cross-sectional data from the age, gene/environment susceptibility-Reykjavik study (
n
= 5764). Illnesses or physical conditions affecting one’s appetite or ability to eat, activities of daily living, current level of physical activity, and smoking habits were assessed with a questionnaire. Fat mass, fat-free mass, body mass index, knee extension strength, and grip strength were measured, and the 6-m walk test and timed up-and-go test were administered. Individuals who reported illnesses or physical conditions affecting their appetite or ability to eat were considered to have a poor appetite. The associations of appetite or the ability to eat with body composition and physical function were analysed with stepwise linear regression models. A total of 804 (14%) individuals reported having conditions affecting their appetite or ability to eat and had a significantly lower fat-free mass and body mass index, less grip strength, and poorer physical function than did those without any conditions affecting their appetite or ability to eat. Although the factors reported to affect one’s appetite or ability to eat are seldom considered severe, their strong associations with physical function suggest that any condition affecting one’s appetite or ability to eat requires attention.
Background
Lower protein intake in older adults is associated with loss of muscle mass and strength. The present study aimed to provide a pooled estimate of the overall prevalence of protein intake ...below recommended (according to different cut‐off values) among community‐dwelling older adults, both within the general older population and within specific subgroups.
Methods
As part of the PRevention Of Malnutrition In Senior Subjects in the EU (PROMISS) project, a meta‐analysis was performed using data from four cohorts (from the Netherlands, UK, Canada, and USA) and four national surveys from the Netherlands, Finland (two), and Italy. Within those studies, data on protein and energy intake of community‐dwelling men and women aged ≥55 years were obtained by either a food frequency questionnaire, 24 h recalls administered on 2 or 3 days, or food diaries administered on 3 days. Protein intake below recommended was based on the recommended dietary allowance of 0.8 g/kg body weight (BW)/d, by using adjusted BW (aBW) instead of actual BW. Cut‐off values of 1.0 and 1.2 were applied in additional analyses. Prevalences were also examined for subgroups according to sex, age, body mass index (BMI), education level, appetite, living status, and recent weight loss.
Results
The study sample comprised 8107 older persons. Mean ± standard deviation protein intake ranged from 64.3 ± 22.3 (UK) to 80.6 ± 23.7 g/d the Netherlands (cohort) or from 0.94 ± 0.38 (USA) to 1.17z ± 0.30 g/kg aBW/d (Italy) when related to BW. The overall pooled prevalence of protein intake below recommended was 21.5% (95% confidence interval: 14.0–30.1), 46.7% (38.3–55.3), and 70.8% (65.1–76.3) using the 0.8, 1.0, and 1.2 cut‐off value, respectively. A higher prevalence was observed among women, individuals with higher BMI, and individuals with poor appetite. The prevalence differed only marginally by age, education level, living status, and recent weight loss.
Conclusions
In community‐dwelling older adults, the prevalence of protein intake below the current recommendation of 0.8 g/kg aBW/d is substantial (14–30%) and increases to 65–76% according to a cut‐off value of 1.2 g/kg aBW/d. To what extent the protein intakes are below the requirements of these older people warrants further investigation.
Background
In 2016, an expert working group was convened under the auspices of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) and formulated ...consensus recommendations for the conduct of clinical trials for drugs to prevent or treat sarcopenia.
Aims
The objective of the current paper is to provide a 2020 update of the previous recommendations in accordance with the evidence that has become available since our original recommendations.
Methods
This paper is based on literature reviews performed by members of the ESCEO working group and followed up with face to face meetings organized for the whole group to make amendments and discuss further recommendations.
Results
The randomized placebo-controlled double-blind parallel-arm drug clinical trials should be the design of choice for both phase II and III trials. Treatment and follow-up should run at least 6 months for phase II and 12 months for phase III trials. Overall physical activity, nutrition, co-prescriptions and comorbidity should be recorded. Participants in these trials should be at least 70-years-old and present with a combination of low muscle strength and low physical performance. Severely malnourished individuals, as well as bedridden patients, patients with extremely limited mobility or individuals with physical limitations clearly attributable to the direct effect of a specific disease, should be excluded. Multiple outcomes are proposed for phase II trials, including, as example, physical performance, muscle strength and mass, muscle metabolism and muscle-bone interaction. For phase III trials, we recommend a co-primary endpoint of a measure of functional performance and a Patient Reported Outcome Measure.
Conclusion
The working group has formulated consensus recommendations on specific aspects of trial design, and in doing so hopes to contribute to an improvement of the methodological robustness and comparability of clinical trials. Standardization of designs and outcomes would advance the field by allowing better comparison across studies, including performing individual patient-data meta-analyses, and different pro-myogenic therapies.
In old age, sufficient protein intake is important to preserve muscle mass and function. Around 50% of older adults (65+ y) consumes ≤1.0 g/kg adjusted body weight (BW)/day (d). There is no rapid ...method available to screen for low protein intake in old age. Therefore, we aimed to develop and validate a short food questionnaire to screen for low protein intake in community-dwelling older adults. We used data of 1348 older men and women (56-101 y) of the LASA study (the Netherlands) to develop the questionnaire and data of 563 older men and women (55-71 y) of the HELIUS study (the Netherlands) for external validation. In both samples, protein intake was measured by the 238-item semi-quantitative HELIUS food frequency questionnaire (FFQ). Multivariable logistic regression analysis was used to predict protein intake ≤1.0 g/kg adjusted BW/d (based on the HELIUS FFQ). Candidate predictor variables were FFQ questions on frequency and amount of intake of specific foods. In both samples, 30% had a protein intake ≤1.0 g/kg adjusted BW/d. Our final model included adjusted body weight and 10 questions on the consumption (amount on average day or frequency in 4 weeks) of: slices of bread (number); glasses of milk (number); meat with warm meal (portion size); cheese (amount and frequency); dairy products (like yoghurt) (frequency); egg(s) (frequency); pasta/noodles (frequency); fish (frequency); and nuts/peanuts (frequency). The area under the receiver operating characteristic curve (AUC) was 0.889 (95% CI 0.870-0.907). The calibration slope was 1.03 (optimal slope 1.00). At a cut-off of ≤0.8 g/kg adjusted BW/d, the AUC was 0.916 (96% CI 0.897-0.936). Applying the regression equation to the HELIUS sample, the AUC was 0.856 (95% CI 0.824-0.888) and the calibration slope 0.92. Regression coefficients were therefore subsequently shrunken by a linear factor 0.92. To conclude, the short food questionnaire (Pro55+) can be used to validly screen for protein intake ≤1.0 g/kg adjusted BW/d in community-dwelling older adults. An online version can be found at www.proteinscreener.nl. External validation in other countries is recommended.
Objective: The aim of this article is to study the associations between healthy lifestyle in old age and decline in physical, psychological, cognitive, and social functioning. Method: A ...population-based sample of 3,107 Dutch men and women aged 55 and 85 years (1992/1993; Longitudinal Aging Study Amsterdam) was used with five 3-yeary follow-up examinations. Lifestyle score, based on smoking status, alcohol consumption, physical activity, and body mass index (BMI), ranged from 0 (unhealthy) to 4 (healthy). Outcomes included gait speed, depressive symptoms, cognitive status, and social contacts. Results: Persons with a healthy lifestyle had a 10.6% slower decline in gait speed (0.04 m/s, 95% confidence interval CI = 0.03, 0.05), 10.8% slower increase in depressive symptoms (–1.07 –1.70, –0.44), a 1.8% slower decline in cognitive functioning (0.47 0.23, 0.70), and a 4.9% slower decline in social contacts (0.58 0.01, 1.15) compared with persons with no or one healthy lifestyle factor. Discussion: A healthy lifestyle benefits physical, psychological, cognitive, and social functioning up to very old age.