AimThis paper considers the challenges of delivering effective palliative care to older people with dementia and the possible strategies to overcome barriers to end-of-life care in these patients.

ObjectiveBioelectrical impedance vector analysis (BIVA) and phase angle (PA) have been shown previously to indicate relative nutritional status in patients. The aim of this study was to investigate the application of BIVA and PA assessments in a cohort of frail older hospital patients and compare these assessments with malnutrition risk screening by MUST (Malnutrition Universal Screening Tool), and the MNA-SF® (Mini-Nutritional Assessment-Short Form). MethodsSixty-nine patients (n = 44 men; n = 25 women; age 82.1 ± 7.6 y [range 62-96 y]; body mass index 25.8 ± 5.4 kg/m2 [range 16.6-45.1 kg/m2]) were recruited from hospital wards specializing in the care of frail older individuals from the United Kingdom. Bioelectrical impedance assessment was performed at 50 khz frequency, BIVA was performed using raw impedance data, PA was calculated, and data were compared against reference population groups. Patients were categorized by malnutrition risk by MUST and MNA-SF.

s u m m a r yBackground & aims: This cohort study aimed to investigate and compare the ability to predict malnutrition in a group of frail older hospital patients in the United Kingdom using the nutritional risk screening tools, MUST (malnutrition universal screening tool), MNA-SF Ò (mini nutritional assessment-short form) and bioelectrical impedance assessment (BIA) of body composition. Methods: MUST and MNA-SF was performed on 78 patients (49 males and 29 females, age: 82 y AE 7.9, body mass index (BMI): 25.5 kg/m 2 AE 5.4), categorised by nutritional risk, and statistical comparison and test reliability performed. BIA was performed in 66 patients and fat free mass (FFM), fat mass (FM) and body cell mass (BCM) and index values (kg/m 2 ) calculated and compared against reference values. Results: MUST scored 77% patients 'low risk', 9% 'medium risk' and 14% 'high risk', compared to MNA-SF categorisation: 9%, 46% and 45%, respectively (P < 0.000001). Reliability assessment found poor reliability between the screening tools (coefficient, r ¼ 0.4). Significant positive correlations were found between most variables (P < 0.05e<0.001); although females exhibited greater variation. FFM index analysis found 40% of males low/depleted, 21% borderline/at risk with 96% categorised by MNA-SF as either malnourished or at risk (MUST-35%). 29% males had low FM index and all appropriately classified by MNA-SF. 30% females had low FFM index or borderline, MNA-SF screening appropriately categorised 86% (compared to MUST-29%).Conclusions: This preliminary data may have significant clinical implications and highlights the potential ability of the MNA-SF and BIA to accurately assess malnutrition risk over MUST in frail older hospital patients.

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This article considers the role of palliative care in the management of patients with dementia. It aims to broaden the knowledge of nurses providing general care as well as specialist palliative and end of life care to patients with dementia in all settings. The article helps nurses to identify the characteristics of end-stage dementia and meet the associated challenges that this diagnosis poses. Nurses should then be in a better position to recognise and support patients and their families and ensure that palliative care is included in care planning for this group of patients.

Skeletal muscle mass (SMM) has a dual functional role in illness and disease acting as a dynamic repository of amino acids which may be utilised to support the acute phase response 1 . This nutritional role of SMM may be important in frail older people who suffer from acute and chronic illness and are admitted to hospital. Specific guidelines have been developed for the assessment of sarcopenia/low SMM in older people 2 . We previously showed that frail older hospital patients may be under-categorised for malnutrition risk using the current UK routine screening tool (MUST) 3 . Patient participants (n = 69 (44 males, 25 females), age: 82 ± 7·5y (62-96), BMI: 26·0 ± 5·4 kg/m 2 (16·6-45·1)) were recruited from two hospital wards specialising in care of frail older patients in Lincoln. Full ethical approval was obtained from NHS East Midlands Research Ethics Committee prior to study commencement, ethical guidelines followed and informed consent sought from all patients. Bioelectrical impedance assessment (BIA) of SMM was determined using a Maltron ® 916S BIA device at 50 khz frequency. SMM was converted into skeletal muscle index values (SMI, kg/m2) and compared and correlated against BMI and mini nutritional assessment short-form (MNA-SF ® ) scores. SMI reference cut-points were utilised to determine prevalence of sarcopenia/low SMI 2 .Table 1 and Figure 1 shows that males had a particularly high prevalence of severe/low (50%, n = 22) and moderate (45%, n = 20) SMI and corresponding 'malnourished' and 'at risk' MNA-SF scores (6·9 ± 2·9 and 8·9 ± 2·2, respectively), despite being within normal and overweight BMI ranges (21·2 ± 2·8 and 27·7 ± 3·1 kg/m 2 , respectively). Females were mostly within normal (56%, n = 14) and moderate (40%, n = 10) SMI and within 'at risk' MNA-SF scores (8·6 ± 2·2 and 8·7 ± 3·3, respectively). Correlations for SMI and BMI were: Group (r = 0·53; P < 0·0001), males (r = 0·90, P < 0·0001), females (r = 0·81, P < 0·0001); SMI and MNA-SF score (0-14): Group (r = 0·32; P = 0·008), males (r = 0·49, P = 0·001), female (r = 0·33, P = 0·11).Male patients may be suffering from the potential coexistence of sarcopenia, cachexia and malnutrition which is not being highlighted by conventional screening tools routinely used in the UK. This preliminary data may have important nutritional and clinical implications for care of frail older people and requires further study in larger cohorts of patients. We further recommend validation of the Maltron ® BIA equation for SMM estimation with a gold standard technique to confirm BIA accuracy.

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