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Journal of Clinical Gerontology & Geriatrics
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Original article
Effects of individual dietary counseling as part of a comprehensive geriatric assessment (CGA) on frailty status: A population-based intervention study
Irma Nykänen, PhDa,b*, Tiina H. Rissanen, PhDc, Raimo Sulkava, MD, PhD Sirpa Hartikainen, MD, PhD
a Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland
b Clinical Pharmacology and Geriatric Pharmacotherapy Unit, School of Pharmacy, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland c Institute of Public Health and Clinical Nutrition, Unit of Public Health, University of Eastern Finland, Kuopio, Finland d Institute of Public Health and Clinical Nutrition, Unit of Geriatrics, University of Eastern Finland, Kuopio, Finland e Department of Neurology, Kuopio University Hospital, Kuopio, Finland
ARTICLE INFO
ABSTRACT
Article history: Received 20 January 2012 Received in revised form 15 May 2012 Accepted 16 May 2012
Keywords: Aged
Community dwelling
Frailty
Risk of malnutrition
Background/Purpose: In this study, our aim was to evaluate the effects of individual dietary counseling as part of a comprehensive geriatric assessment (CGA) on frailty status among community-dwelling people aged 75 years or older.
Methods: Data were obtained from a subpopulation of participants in the population-based Geriatric Multidisciplinary Strategy for the Good Care of the Elderly (GeMS) intervention study in 2004 to 2007. In the present study, the population consisted of 159 persons at risk of malnutrition in the year 2005 in an intervention and a control group. Nutritional status was assessed with the Mini Nutritional Assessment (MNA). Frailty was defined according to the five frailty criteria used in the Cardiovascular Health Study (CHS). Assessment of nutritional status and frailty status was performed at the beginning of the study and at 1-year follow-up.
Results: At baseline the mean age of the 159 community-dwelling participants with risk of malnutrition was 83 years and 126 (79%) of them were female. The proportions of frail and pre-frail persons were 25% (n = 19) and 61% (n = 47) in the intervention group, and 26% (n = 21) and 61% (n = 50) in the control group. After the 1-year nutritional intervention, compared to the control group, the intervention group tended to have a better outcome of frailty and MNA (OR = 1.89,95% CI: 1.08-3.54, OR = 2.61,95% CI: 1.67 —5.56, respectively) and was less likely to deteriorate as assessed with MNA (OR = 0.23, 95% CI: 0.14 -0.87). In multivariate analysis, change in MNA (OR = 1.12, 95% CI: 1.03—1.31) was associated independently with improved frailty status.
Conclusion: It appears that multidisciplinary geriatric assessment including individual dietary counseling has a positive effect on frailty status. More emphasis on good nutrition in the older population might have a preventive effect on the incidence of frailty.
Copyright © 2012, Asia Pacific League of Clinical Gerontology & Geriatrics. Published by Elsevier Taiwan
LLC. All rights reserved.
1. Introduction
Frailty as a clinical entity belongs to the family of geriatric syndromes and should be distinguished from the aging process.1,2 There have been a number of attempts to define frailty. Fried et al3 describe the criteria of the frailty syndrome. These criteria
* Corresponding author. Kuopio Research Centre of Geriatric Care, Faculty of Health Sciences, University of Eastern Finland, Kuopio Campus, P.O. Box 1627, FI-70211 Kuopio, Finland.
E-mail address: Irma.Nykanen@uef.fi (I. Nykanen).
offer an empirically derived and validated definition for frailty based on the presence of at least three or more defined characteristics: unexplained weight loss, muscle weakness, self-reported exhaustion, poor endurance and low activity level.3
Poor nutritional status is conceptualized to be a component of frailty.4,5 One of the main characteristics of frailty is shrinking defined by muscle and total body mass wasting. Frail older people suffer from a combination of unintentional weight loss and/or low body mass index, as well as a low functional capacity.3 Earlier intervention studies have shown that physical exercise interventions have positive outcomes for disability for community-dwelling frail older persons,6,7 but there is no evidence that nutritional
2210-8335/$ — see front matter Copyright © 2012, Asia Pacific League of Clinical Gerontology & Geriatrics. Published by Elsevier Taiwan LLC. All rights reserved. http://dx.doi.Org/10.1016/j.jcgg.2012.05.001
interventions for frail older people alone result in positive effects on disability level.8,9 To our knowledge, this is the first study to evaluate the effects of dietary counseling without supplements on frailty status among community-dwelling older people. The aim of this study was to evaluate the effects of individual dietary counseling as part of a comprehensive geriatric assessment (CGA) on frailty status among community-dwelling people aged 75 years or older.
2. Methods
2.1. Study sample
This study is based on a subpopulation of participants in the population-based Geriatric Multidisciplinary Strategy for the Good Care of the Elderly (GeMS) intervention aimed at preventing disability and maintaining autonomy in older people. The intervention group underwent CGA at the baseline and in 2005. The intervention of the parent GeMS study focused on optimizing medical treatment and medication and improving and preventing decline in nutrition and function. A team of two physicians, two study nurses, one nutritionist and two physiotherapists performed the CGA. The control group was interviewed and tested annually and they received usual medical care. The population of this study consists of those persons (n = 159) who were at risk of malnutrition (MNA scores 23.5—17.0). After one year, the dropout rate was 8.8% (14/159) of the participants at the baseline. A total of 11 participants died and 3 refused during the one-year follow-up. Mortality was higher in the control group (n = 9,11.0%) than in the intervention group (n = 2, 2.6%). All participants or their proxies gave written informed consent to participate in the study. The Research Ethics Committee of the Northern Savo Hospital District, Kuopio, Finland, approved the study protocol.
2.2. Data collection
Trained nurses interviewed all participants. Sociodemographic factors (age, sex, length of education, living conditions), health status, cognitive functioning and functioning in the activities of daily living were assessed. Each individual completed yearly an initial nutritional screening. The groups were examined and interviewed yearly by nurses and a nutritionist. Data collection, including nutritional assessment, was supplemented by a caregiver interview if the participant had cognitive impairment.
2.3. Assessment of nutritional status
The nutritional screening was performed using the Mini Nutritional Assessment (MNA) test.10 The MNA test is a validated and standardized screening tool developed to detect nutritional problems in older people.11 In this study, the researcher (an authorized nutritionist) trained nurses to use the MNA form, and the nurses completed the forms. Body weight was measured with an electronic balance scale, with the participants wearing light clothes, and height was measured in standing position and rounded to the nearest centimeter. The maximum sum score of the MNA is 30; scores 30.0—24.0 indicate normal nutritional status, scores 23.5—17.0 risk of malnutrition, and 16.5—0.0 malnutrition.
2.4. Clinical assessments
Self-rated health was determined using a 5-step scale (very poor, poor, moderate, good and very good). In the analyses, the variable was dichotomized into poor and good self-rated health, with the first two steps representing poor and the latter three good self-rated health. Oral health assessment included questions about
dry mouth and chewing problems. In the analyses, these were dichotomized into two groups: (1) persons with dry mouth or problems with chewing; and (2) persons not having dry mouth, no problems with chewing. Use of medication was self-reported by participants during the interviews, and verified from prescription forms, drug packages and medical records. Data on medication name, frequency, and pattern of use (regular, when required) were recorded. Plasma albumin levels were also measured.
Performance in the instrumental activities of daily living (IADL) was assessed by the 8-item Lowton and Brody scale.12 The scoring for the IADL index is from 0—8, with higher scores indicating better functioning. Cognitive assessment was performed with the MiniMental State Examination (MMSE) with a scale from 0—30, higher scores indicating better function.
Ability to walk outside and ability to walk at least 400 m were assessed by asking the participants: "Are you able to walk outside? Can you walk at least 400 m?" Both questions contained four response categories from dependent (0) to totally independent (3). Categories 0—1 (unable to walk independently) and 2—3 (able to walk independently) were combined for the analyses. Maximum walking speed was measured with a stopwatch (0.1 seconds accuracy) during a 10-m walk. The participants started walking a few meters before the start line to achieve maximum speed and were timed from the moment their lead foot crossed the start line until the front foot crossed the 10-m line. The results were expressed as meters per second (m/s). Grip strength of the dominant hand was measured using a Saehan dynamometer (Saehan Corporation, South Korea) in a sitting position and with the elbow in 90-degree flexion close to the body. Participants were allowed two maximal efforts, and the highest value was accepted as the result.
Comorbidities for each participant were scored using a modified version of the Functional Comorbidity Index (FCI).13 In the GeMS study the FCI sum score (1 point per disease) consisted of 13 diagnoses including arthritis (rheumatoid arthritis and other connective tissue diseases), osteoporosis, chronic asthma or chronic obstructive pulmonary disease, coronary artery disease, congestive heart failure, myocardial infarction, neurological disease such as multiple sclerosis or Parkinson's disease, stroke, diabetes mellitus (type I and II), depression, visual impairment, hearing impairment and obesity (body mass index > 30). Self-reported diagnoses were verified from medical records and complemented from the Finnish National Prescription and Special Reimbursement Register maintained by the Social Insurance Institution of Finland.
2.5. Definition of frailty — application to GeMS
Frailty was defined according to the five frailty criteria used in the Cardiovascular Health Study (CHS): shrinking/sarcopenia, weakness, poor endurance and energy, slowness and low physical activity level.3 The same criteria as in the CHS were applied for shrinking/sarcopenia, weakness and slowness. Adapted criteria were used for poor endurance/energy and low physical activity as outlined below.
(1) Shrinking/sarcopenia was defined as a weight loss of >5% of body weight in the prior year.3 Weight was measured at each study examination by the study nurse using the same digital scale with an error of 100 g.
(2) Weakness was defined as the lowest quintile for grip strength3 adjusted for gender. Grip strength was measured on the left and right using a Saehan dynamometer. The highest value of the two measurements was used. Participants who were unable to perform the grip strength test received the value of zero.
(3) Poor endurance and energy was defined based on the answer to the following item of the self-report Geriatric Depression Scale (GDS)14: "Do you feel full of energy? Yes/No". Participants who answered 'No' were positively identified for this criterion.
(4) Slowness was defined as the slowest quintile3 of the participants based on the time to walk 10 m, adjusted for gender, and as the participants that were unable to perform this test. A digital stopwatch was used. Two-meter run-in distance was applied.
(5) Low physical activity level was defined using a modified version of the six-grade Grimby scale for classification of physical activity.15 Participants who reported to be in the lowest grade ("I do not move any more than necessary to cope with activities of daily life") or who were bedridden were defined as having a low physical activity level.
Participants considered evaluable for frailty had three or more of the five frailty criteria. Pre-frail participants had one or two frailty criteria, while robust (non frail) participants had none of the five criteria. Frailty status was defined for 40/159 (25.2%) participants in 2005, 46/145 (31.7%) in 2006.
2.6. Nutritional intervention
Nutritional intervention included an individually tailored comprehensive geriatric intervention in which the other components were medical, oral health and physical intervention. In the medical intervention, the main focus was on the optimization of care and medication, and on the management of major medical problems commonly encountered in old age.16 In the physical activity component, the participants were offered an opportunity to participate the individually tailored physical activity counseling by a physiotherapist and in strength and balance training once a week where one of the main objectives was to prevent mobility disability, the emphasis of strength training was the lower extremities.17 The participants of the control group did not receive any interventions but took part in the annual interviews and measurements and used normal health care services. The tailored nutritional treatment consisted of individual dietary counseling based on baseline MNA-test. The individual dietary counseling was based on the recommendations of the National Nutrition Council.18 The individualized treatment strategy for each participant was designed by the nutritionist according to the participant's medical and nutritional characteristics. The main aim of the intervention was to help participants improve the wholesomeness of their diet in line with Finnish recommendations by increasing the frequency of meals and/or adding energy (if necessary) and proteins to the meals without nutritional supplements.
Each participant had two nutritional treatment meetings with the nutritionist, the first in 2005, and the second in 2006. During the first visit, the authorized nutritionist collected important information, such as the client's history of health problems, current dietary intake and specific nutritional problems, food preferences and appetite status. Based on this evaluation, the nutritionist helped the participants draw up their own meal plan with enough energy and proteins. Special leaflets covering, for example, snack-ing, were handed out. Telephone calls between the visits, as deemed necessary by the nutritionist, provided opportunities to reinforce the dietary advice and give additional support. All participants received telephone counseling every 2 months during the intervention. Participants' family members were encouraged to attend dietary counseling sessions. Participants with cognitive impairments had a caregiver present during the sessions; participants and caregivers provided written informed consent. During the second visit, the nutritionist evaluated the dietary intake of the
participants and made changes according to the treatment protocol, if necessary. At the same time, participants as well as family members and caregivers received instructions on how to follow the recommended diet.
2.7. Study outcomes
The study outcomes were changes in frailty categories and MNA scores. Those who were frail or pre-frail initially and moved to better categories in frailty "improved". Those who moved down to worse categories were considered "declined".
2.8. Statistical analysis
The participants were categorized into two groups: intervention and control groups. Statistical comparisons between the groups were made using chi-square test or t test, with <0.05 considered significant. The results were expressed as means or frequencies with standard deviations (SD) or percentile. Multinomial logistic regression analysis, adjusted age, sex and baseline measures by FCI, IADL and MMSE, was used to calculate odd ratios (OR) of improved and deteriorated frailty status and MNA in relation to intervention and associations between the changes of frailty status and MNA scores. Frail and pre-frail participants were compared to robust participants (referent category). Results are expressed as odds ratios and their 95% confidence intervals. Analyses were performed using SPSS version 19.0. (SPSS, Inc., Chicago, IL, USA).
3. Results
The mean age of 159 community-dwelling participants with risk of malnutrition was 83.1 years (SD 5.1) and 79.2% (n = 126) were female. Mean body mass index (BMI) of participants was 26.2 kg/ m2 (SD 5.1). Participant characteristics are summarized in Table 1. The participants in the invention group had higher mean MMSE scores (p = 0.03) than the participants in the control group. Nineteen (24.7%) participants in the intervention group and 21 (25.6%) in the control group were classified as frail, while 47 (61.0%) in the intervention group and 50 (61.0%) in the control group were classified as pre-frail. A total of 145 (91.2%) participants participated in 1-year follow-up assessment.
Frailty status was improved for 16.4% (n = 12) of the participants in the intervention group and 8.2% (n = 6) in the control group. After the 1-year nutritional intervention, mean MNA scores increased by 2.5 in the intervention group and decreased by 0.7 in the control group (Table 2). The difference in MNA change (3.2, 95% CI: 0.3—6.0) was significant between the intervention and control groups among persons with improved frailty status.
After the 1-year nutritional intervention, compared to the control group, the intervention group tended to have a better outcome of frailty and MNA (OR = 1.89, 95% CI: 1.08—3.54, OR = 2.61, 95% CI 1.67—5.56, respectively) and they were less likely to have deteriorated MNA (OR = 0.23, 95% CI 0.14—0.87) (Table 3). In multivariate analysis, change in MNA of the intervention group (OR = 1.12, 95% CI 1.03—1.31) was associated independently with improved frailty status after adjustment for age, gender, MMSE and FCI.
4. Discussion
In this study, the nutrition intervention improved frailty status at the 1-year follow-up. Frailty status improved in a higher proportion of participants in the intervention group than in the control group.
Table 1
Baseline characteristics of participants.
Control Intervention P
group group
(n = 82) (n = 77)
Demographic characteristics
Mean age, y (SD) 82.9 (5.0) 83.2 (5.2) 0.65a
Female, n (%) 65 (79.3) 61 (79.2) 0.99
Living alone, n (%) 52 (63.4) 41 (58.4) 0.52
Education > 7 y, n (%) 41 (50.0) 28 (37.8) 0.12
Clinical characteristics
Mean MNA score (SD) 21.6(1.7) 21.4(1.6) 0.52a
Mean BM1, kg/m2 (SD) 26.3 (5.1) 26.7 (5.1) 0.64a
Good self-rated health, n (%) 60 (73.2) 61 (79.2) 0.37
Dry mouth/chewing problems, n (%) 49 (59.7) 52 (67.3) 0.28
Mean drugs in regular use (SD) 6.0 (3.2) 6.8 (3.5) 0.66a
Mean P-Albumin, g/L (SD) 35.5 (4.1) 35.6 (3.9) 0.82a
Functioning
Walking 400 m independently, n (%) 61 (79.2) 57 (69.5) 0.16
Mean walking speed, m/s (SD) 1.0 (0.5) 1.1 (0.5) 0.46a
Mean grip strength, kg (SD)
Women 16.3 (5.2) 16.1 (5.2) 0.80a
Men 26.2 (11.6) 33.5 (9.8) 0.06a
1ADL scores <6, n (%) 4.5 (2.7) 4.9 (2.2) 0.26a
Mean MMSE scores (SD) 22.7 (5.9) 24.8 (5.8) 0.03a
Mean functional comorbidity index (SD) 3.0 (1.9) 3.4 (2.0) 0.44a
Coronary artery disease, n (%) 41 (50.0) 41 (53.2) 0.68
Dementia, n (%) 32 (37.8) 24 (31.0) 0.45
Frailty status
Frail 21 (25.6) 19 (24.7) 0.97
Pre-frail 50 (61.0) 47 (61.0)
BMI = body mass index (kg/m2); 1ADL = instrumental activities of daily living; MMSE = mini-mental state examination; MNA = mini nutritional assessment; SD = standard deviation. a t test, the others are c2 tests.
Several studies have shown the positive effects of interventions in frail older people. These interventions include exercise programs without nutritional intervention.6-9 To our knowledge, this is the first study to evaluate the effects of multidisciplinary geriatric intervention with dietary advice without nutrition supplements on frailty status among community-dwelling older people. A previous multifactorial intervention study8 showed some evidence of the positive effects of nutrition supplements in frail older persons. Payette et al8 reported that nutritional intervention alone does not constitute adequate therapy to reverse the process of functional impairment in the participants.
1n the present study, the positive effect of the nutritional intervention could have resulted from better nutritional status according to MNA-test and it may even possibly have stopped the deterioration of the participants' frailty status. The positive effect
Table 2
Frailty status and MNA scores at baseline and at 1-year follow-up.
Outcomes 1ntervention group (n = 77) Control group (n = 82)
Frailty status
Robust Pre-frail Frail Robust Pre-frail Frail
n (%) n (%) n (%) n (%) n (%) n (%)
Baseline 11 (14.3) 47(61.0) 19(24.7) 11(13.4) 50(61.0) 21 (25.6)
1-year 11 (15.1) 43(58.9) 19(26.0) 9 (12.5) 36 (50.0) 27 (37.5)
follow-upa
Mean of MNA scores (SD) Mean of MNA scores (SD)
Baseline 21.4 (1.6) 21.6(1.7)
1-year 23.9 (12.2) 20.9 (3.5)
follow-upb
MNA = mini nutritional assessment. a Missing data n = 4. b Missing data n = 10.
Table 3
Adjusted odds ratio (95% CI) on frailty status and MNA in relation to intervention and multivariate associations between the changes of frailty status and MNA scores.
Same Improved Deterioration
n (%) OR (95% CI) n (%) OR (95% CI) n (%) OR (95% CI)
Frailty status
Intervention 47 (64.4) 1 12 (16.4) 1.89 14(19.2) 1.12
(1.08-3.54) (0.57-2.55)
Control 46 (63.8) 1 6 (8.2) 1 20 (27.8) 1
Intervention 48 (65.8) 1 22 (30.1) 2.61 3(4.1) 0.23
(1.67-5.56) (0.14-0.87)
Control 51 (70.8) 1 12 (16.7) 1 9(12.5) 1
Frailty status (intervention)
MNA change 47 (64.4) 1 12 (16.4) 1.12 14(19.2) 1.03
(1.03-1.31) (0.91-1.21)
MNA = mini nutritional assessment.
Adjusted age, gender; FC1 (functional comorbidy index), 1ADL (instrumental activities of daily living) and MMSE (mini mental state examination).
on nutritional status might be explained by the individually tailored interventions among persons who are at risk of malnutrition. The intervention included individually tailored personal guidance on nutrition, so it may be assumed that dietary advice was more likely to be adopted by the participants. Furthermore, the same authorized nutritionist performed the nutrition intervention. However, the participants in this study took part in other interventions at the same time, and it is thus possible that these interventions had an effect on their frailty and nutritional status. 1n our study, 91.2% (145) of the participants completed the nutrition intervention and followed the nutritionist's recommendations after referral. In earlier studies, compliance rates for community-based CGA programs range from 46% to 76%.19 The good compliance rate may have improved the effectiveness of the nutrition advice.
Previous studies have reported that frailty was associated with low cognitive decline, the incidence of Alzheimer's disease, and mild cognitive impairment (MCI).20-22 The frail participants had a 1.3-fold higher risk of cognition decline over a 10-year period, and the decline was more severe in frail participants compared with robust or pre-frail ones.23 For nutritional status, Chen et al24 showed that for every point increase in MNA score, the chances of having cognitive impairment decreased by 17%. The overall prevalence of frailty and cognitive impairment in community-dwelling populations was greater in women than in men.3,25,26 Nevertheless, Johansson et al27 showed cognition decline to be the most important risk factor for decreased nutritional status in men, but not in women. For many older women, preparing food is a part of daily life and something they have always done, while for men preparing food may be something they have learned when older, which is why good cognitive function is necessary if they are to manage preparing meals.
The findings of the present study are important from a clinical perspective, in terms of comprehensive clinical evaluation of an older person's health and ability to live at home. The vast majority of older people are community dwelling, and the promotion of their nutritional health might help to prevent adverse health outcomes such as institutionalization. Nutritional screening and nutritional invention should be part of standard care among community-dwelling older people. Furthermore, prevention of frailty requires continuous comprehensive geriatric assessment and individualized intervention.
The strengths of the present study were the population-based design, the fact that the participants underwent comprehensive
interviews and assessments, as well as the fact that a multiprofessional research team conducted the study design and data collection. Furthermore, all the nutritional screens with the MNA, sociodemographic factors, health status and cognitive functioning were carried out by the same two nurses and the nutrition intervention was performed by the same authorized nutritionist. A limitation of this study is that the nutritional intervention is one of several health promotion interventions (medical, oral health and physical), which can lead to difficulties in drawing conclusions. The results of the analyses should be interpreted with caution because the other interventions expected to have an effect on nutritional status and thereby creating the risk of bias in the study outcomes. The design of the present study is weaker than that of a traditional randomized controlled study, owing to the performance of randomization before the baseline measurements. Randomized controlled trials are needed to confirm whether individualized nutritional interventions have on influence frailty status. Another limitation of our study is the relatively small sample size. Even so, the association of nutritional intervention with improved frailty and nutritional status was quite clear.
In conclusion, it seems that the multidisciplinary geriatric assessment including individual dietary counseling has positive effects on frailty status. More emphasis on good nutrition in the older population might have a preventive effect on the incidence of frailty.
Acknowledgments
The authors wish to acknowledge the GeMS study personnel: physicians Marja-Liisa Laitinen, Sirpa Pikkarainen and Jarmo Alander; nurses Anu Hanninen, Paula lire and Marja-Leena Keka-lainen; and physiotherapists Aila Makela and Jarmo Seppanen; for their dedicated work in collecting data for this project. The Social Insurance of Institute of Finland and the City of Kuopio financially supported this study.
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