Elsevier

Clinical Nutrition

Volume 32, Issue 4, August 2013, Pages 543-549
Clinical Nutrition

Original article
Encouraging, assisting and time to EAT: Improved nutritional intake for older medical patients receiving Protected Mealtimes and/or additional nursing feeding assistance

https://doi.org/10.1016/j.clnu.2012.11.009Get rights and content

Summary

Background & aims

Inadequate feeding assistance and mealtime interruptions during hospitalisation may contribute to malnutrition and poor nutritional intake in older people. This study aimed to implement and compare three interventions designed to specifically address mealtime barriers and improve energy intakes of medical inpatients aged ≥65 years.

Methods

Pre–post study compared three mealtime assistance interventions: PM: Protected Mealtimes with multidisciplinary education; AIN: additional assistant-in-nursing (AIN) with dedicated meal role; PM + AIN: combined intervention. Dietary intake of 254 patients (pre: n = 115, post: n = 141; mean age 80 ± 8) was visually estimated on a single day in the first week of hospitalisation and compared with estimated energy requirements. Assistance activities were observed and recorded.

Results

Mealtime assistance levels significantly increased in all interventions (p < 0.01). Post-intervention participants were more likely to achieve adequate energy intake (OR = 3.4, p = 0.01), with no difference noted between interventions (p = 0.29). Patients with cognitive impairment or feeding dependency appeared to gain substantial benefit from mealtime assistance interventions.

Conclusions

Protected Mealtimes and additional AIN assistance (implemented alone or in combination) may produce modest improvements in nutritional intake. Targeted feeding assistance for certain patient groups holds promise; however, alternative strategies are required to address the complex problem of malnutrition in this population.

Australian New Zealand Clinical Trials Registry Number

ACTRN12609000525280.

Introduction

The prevalence of protein-energy malnutrition in elderly hospital patients is reported to be as high as 60%,1, 2 and is associated with poor clinical outcomes.3 Nutritional intake of older people during hospitalisation is often inadequate,4, 5, 6 which may lead to further decline in nutritional status during the hospital admission.7, 8, 9 The reasons for poor nutritional intake in hospital are multi-factorial. They include patient factors such as poor appetite, feeding dependency and cognitive impairment,5 staff factors such as competing tasks, lack of role clarity and unclear responsibility for mealtimes10, 11, 12 and environmental factors such as interruptions and a poor mealtime environment.13 These challenges may explain the marginal benefits seen in studies of oral nutritional interventions in this patient group.14

Interventions to improve nutritional intake in the acute hospital setting through explicitly addressing these barriers have not been adequately researched.14 Studies using feeding assistance provided by volunteers or healthcare assistants have shown mixed results,14, 15, 16, 17 which may be explained by differences in the assistant's scope of practice, unintentional improvements in care of the control group and/or differences in the ward culture or environment where research was conducted. There has also been limited evaluation of the impact of mealtime environment strategies, such as Protected Mealtimes where mealtimes are protected from “unnecessary and avoidable interruptions, providing an environment conducive to eating”.18 Das et al.19 demonstrated a small increase in energy intake and weight during their pilot of Protected Mealtimes; however other authors report no significant difference in nutritional intake after implementation of Protected Mealtimes.20, 21, 22, 23 An unexpected reduction in feeding assistance was noted in one study,22 highlighting the potential for perverse outcomes in this complex environment and the need for a multi-faceted approach to enhance patient mealtimes. No studies have investigated the impact of mealtime interventions on patients at particular risk of poor intake.

This study aimed to implement and compare three interventions designed to specifically address mealtime barriers in older medical patients, with the primary objective of improving energy and protein intakes of elderly medical inpatients in the first week of their acute hospital admission. This study also aimed to explore the benefit of these interventions in patient sub-groups known to be nutritionally vulnerable during hospitalisation (patients with anorexia, cognitive impairment and functional dependency).

Section snippets

Study setting and participants

This prospective study was conducted on three Internal Medicine wards in a large metropolitan public teaching hospital in Brisbane, Australia. Participants were consecutive patients aged 65 years or older who had a hospital stay of more than 2 days, and were admitted from the emergency department to the study wards. Patients who were critically or terminally ill, or were not receiving an oral diet at the time of admission were excluded. Informed consent was obtained from all participants; where

Participants

Two-hundred and fifty-four participants were enrolled in the study, of whom 115 were recruited in the pre-intervention observational study and 139 participants during the post-intervention study (AIN: n = 58; PM: n = 39; PM + AIN: n = 42). This represents a consent rate of 40%, with participants and eligible non-participants being similar in age (mean 80 years vs. 81 years), gender distribution (47% male vs. 42% male) and primary diagnosis. Characteristics of participants differed across

Discussion

In this study, we implemented and compared three interventions to improve the mealtime experience for older patients in acute medical wards. All three strategies resulted in greater assistance and fewer non-clinical tasks during mealtimes, although mealtime interruptions were not significantly reduced. While the mean energy or protein intake did not significantly increase in the post-intervention groups, patients who received any of the three interventions were more likely to achieve adequate

Author contribution

AY conceived and designed the study, implemented interventions, undertook data collection, analysis and interpretation and drafted the manuscript.

AM contributed to conception and design of study, supported implementation of interventions, provided statistical advice and contributed to data interpretation and critical review of the manuscript.

MB and LR contributed to conception and design of study, supported implementation of interventions, contributed to data interpretation and critical review

Conflict of interest

None.

Acknowledgements

This study was supported by Queensland Health (QH) Strengthening Aged Care Funding, QH Health Practitioners Funding Scheme and RBWH Research Foundation. AY received scholarship funding from RBWH and Queensland University of Technology. The sponsors had no role in study design, analysis or manuscript preparation.

We would like to thank Lee Jones (biostatistician, Queensland Institute of Medical Research) for statistical advice; Karen Kasper, Maria Cenita and Dianne Jones for their invaluable role

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  • Cited by (0)

    Conference presentations: these findings were presented at the 33rd ESPEN Congress in Gothenberg, Sweden (oral presentation OP037).

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