EAL

UWL: Nutritional Status (2009)

Citation:

Study Design:

Class:

- Click here for explanation of classification scheme.

Quality Rating:

Research Purpose:

The aim of the study was to determine changes over a three-month period among the older people with dementia living in long-term care settings, related to:

Changes in BMI
Health outcomes and associated factors.

Inclusion Criteria:

Older people with dementia living in two long-term care facilities in Taiwan
None specifically mentioned.

Exclusion Criteria:

None specifically mentioned.

Description of Study Protocol:

Recruitment

In 2003, a convenience sample of 55 residents was recruited from two long-term care facilities for older people with dementia. Both settings had special units and areas for older residents with a confirmed diagnosis of dementia.

Design: Trend study; cross-sectional study with repeated measurements.

Statistical Analysis

Due to small sample size, non-parametric statistical methods such as Wilcoxon matched paired signed ranks test, Mann-Whitney U test and chi-square test were used to analyze the data.

Data Collection Summary:

Timing of Measurements

Repeat measures of individuals' weight were taken at roughly the same time of the day each month. Measurements were made over a three-month period.

Dependent Variables

Body weight was measured with portable or mechanical chair scale
Height was measured with standing upright scale
BMI
Medical records were reviewed for information on demographics, number of medications currently used, number of medical diagnoses, eating ability, type of diet and frequency of family visits
Functional status determined by Barthel Index
Common adverse health events were also recorded: Death, emergency room visits, falls, fever, hospital admissions and new pressure ulcers.

Independent Variables

Dementia.

Description of Actual Data Sample:

Initial N: 55 residents participated (29 males, 26 females)
Attrition (final N): 42 residents completed all four assessments during the study period. 47 were available at the first measurement, 43 were available for the second measurement, and 45 for the third measurement.
Age: Mean 80.2±6.6 years (range 64 to 97)
Ethnicity: Not mentioned, assumed Asian
Location: Taiwan.

Summary of Results:

Characteristics and Eating Ability of Participants

Variables
Length of stay (months)	18.6±15.1 (one to 54)
Physical function (Barthel score)	47.6±35.1 (zero to 100)
Number of diagnoses in addition to dementia	1.6±1.5 (one to six)
Number of medications	3.6±3.0 (zero to 11)
Family visits, less than one a week	43.6%
Family visits, one to two a week	20.0%
Family visits, three to four a week	16.4%
Family visits, more than five a week	20.0%
Self-fed	47.3%
Minor assistance in oral feeding	3.6%
Major assistance in oral feeding	27.3%
Total assistance (naso-gastric feeding)	21.8%
Tube-feeding diet	21.8%
Soft diet	72.7%
Liquid diet	5.5%
Initial BMI, less than 18.5	18.2%
Initial BMI, 18.5 to less than 20.0	18.2%
Initial BMI, 20.0 to less than 24.0	43.6%
Initial BMI, 24.0 and above	20.0%

Other Findings

18% of the residents were undernourished (BMI less than 18.5)
Although there was no statistical significance, there was a trend toward decreasing BMI over the three-month study period (baseline BMI 21.8±3.3, three-month BMI 21.5±3.6, P=0.06)
There was a trend toward residents with low BMI needing assistance during mealtime (P=0.056)
19 residents, many receiving naso-gastric tube feeding, experienced adverse health effects during the study period
Dependency in eating was the major factor differentiating residents with normal or low BMI values, and also in distinguishing those who experienced adverse health outcomes.

Author Conclusion:

Careful identification of residents at risk of malnutrition and poor health outcomes is necessary to deliver effective interventions. To obtain better outcomes for residents, nurses' skills in assessing eating ability, identifying problems and providing appropriate help during mealtimes should be improved. In addition, basic anthropometric measures, such as body weight, are non-invasive, not overly time-consuming and can assist early identification of problems in nutritional status of older people with dementia. We also suggest that educating nurses about nutrition and assessment skills should be a priority in this area to ensure better quality of care. In addition, in this era of globalization, it is increasingly common for people to be cared for by foreign healthcare personnel. Strategies for understanding and improving communication and interactions may benefit both residents and healthcare workers. Future studies should include evaluating such programs and testing interventions, such as modifying the environmental and behavioural context at mealtimes, and enhancing the knowledge level and assessment skills of nurses related to the nutritional status of older people with dementia.

Funding Source:

Government:

National Science Council of the Republic of China

Reviewer Comments:

Recruitment methods and inclusion and exclusion criteria were not well described. Monthly measurements were not made in all subjects. Authors note the following limitations:

Sample limited to two long-term care facilities for older people with dementia
Small sample size
Follow-up period was too short to observe significant changes
Some data were retrieved from nursing records and were thus dependent on quality of the records
BMI was only indicator of nutritional status
Certain factors related to nutritional status were not assessed, such as chewing and swallowing ability, depression and social support, staff-resident interaction and communication patterns.

Quality Criteria Checklist: Primary Research
Relevance Questions
	1.	Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies)	N/A
	2.	Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about?	Yes
	3.	Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice?	Yes
	4.	Is the intervention or procedure feasible? (NA for some epidemiological studies)	N/A

Validity Questions
1.	Was the research question clearly stated?		Yes
	1.1.	Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified?	Yes
	1.2.	Was (were) the outcome(s) [dependent variable(s)] clearly indicated?	Yes
	1.3.	Were the target population and setting specified?	Yes
2.	Was the selection of study subjects/patients free from bias?		???
	2.1.	Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study?	No
	2.2.	Were criteria applied equally to all study groups?	???
	2.3.	Were health, demographics, and other characteristics of subjects described?	Yes
	2.4.	Were the subjects/patients a representative sample of the relevant population?	???
3.	Were study groups comparable?		Yes
	3.1.	Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT)	Yes
	3.2.	Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline?	Yes
	3.3.	Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.)	Yes
	3.4.	If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis?	Yes
	3.5.	If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.)	Yes
	3.6.	If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")?	N/A
4.	Was method of handling withdrawals described?		Yes
	4.1.	Were follow-up methods described and the same for all groups?	Yes
	4.2.	Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.)	Yes
	4.3.	Were all enrolled subjects/patients (in the original sample) accounted for?	Yes
	4.4.	Were reasons for withdrawals similar across groups?	N/A
	4.5.	If diagnostic test, was decision to perform reference test not dependent on results of test under study?	N/A
5.	Was blinding used to prevent introduction of bias?		Yes
	5.1.	In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate?	N/A
	5.2.	Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.)	Yes
	5.3.	In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded?	Yes
	5.4.	In case control study, was case definition explicit and case ascertainment not influenced by exposure status?	N/A
	5.5.	In diagnostic study, were test results blinded to patient history and other test results?	N/A
6.	Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described?		Yes
	6.1.	In RCT or other intervention trial, were protocols described for all regimens studied?	N/A
	6.2.	In observational study, were interventions, study settings, and clinicians/provider described?	Yes
	6.3.	Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect?	N/A
	6.4.	Was the amount of exposure and, if relevant, subject/patient compliance measured?	N/A
	6.5.	Were co-interventions (e.g., ancillary treatments, other therapies) described?	N/A
	6.6.	Were extra or unplanned treatments described?	N/A
	6.7.	Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups?	N/A
	6.8.	In diagnostic study, were details of test administration and replication sufficient?	N/A
7.	Were outcomes clearly defined and the measurements valid and reliable?		???
	7.1.	Were primary and secondary endpoints described and relevant to the question?	Yes
	7.2.	Were nutrition measures appropriate to question and outcomes of concern?	Yes
	7.3.	Was the period of follow-up long enough for important outcome(s) to occur?	???
	7.4.	Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures?	Yes
	7.5.	Was the measurement of effect at an appropriate level of precision?	???
	7.6.	Were other factors accounted for (measured) that could affect outcomes?	???
	7.7.	Were the measurements conducted consistently across groups?	Yes
8.	Was the statistical analysis appropriate for the study design and type of outcome indicators?		???
	8.1.	Were statistical analyses adequately described and the results reported appropriately?	Yes
	8.2.	Were correct statistical tests used and assumptions of test not violated?	Yes
	8.3.	Were statistics reported with levels of significance and/or confidence intervals?	Yes
	8.4.	Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)?	N/A
	8.5.	Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)?	N/A
	8.6.	Was clinical significance as well as statistical significance reported?	Yes
	8.7.	If negative findings, was a power calculation reported to address type 2 error?	No
9.	Are conclusions supported by results with biases and limitations taken into consideration?		Yes
	9.1.	Is there a discussion of findings?	Yes
	9.2.	Are biases and study limitations identified and discussed?	Yes
10.	Is bias due to study's funding or sponsorship unlikely?		Yes
	10.1.	Were sources of funding and investigators' affiliations described?	Yes
	10.2.	Was the study free from apparent conflict of interest?	Yes