Abstract:There is increasing awareness of the detrimental health impact of frailty on older adults and of the high prevalence of malnutrition in this segment of the population. Experts in these 2 arenas need to be cognizant of the overlap in constructs, diagnosis, and treatment of frailty and malnutrition. There is a lack of consensus regarding the definition of malnutrition and how it should be assessed. While there is consensus on the definition of frailty, there is no agreement on how it should be measured. Separate assessment tools exist for both malnutrition and frailty; however, there is intersection between concepts and measures. This narrative review highlights some of the intersections within these screening/assessment tools, including weight loss/decreased body mass, functional capacity, and weakness (handgrip strength). The potential for identification of a minimal set of objective measures to identify, or at least consider risk for both conditions, is proposed. Frailty and malnutrition have also been shown to result in similar negative health outcomes and consequently common treatment strategies have been studied, including oral nutritional supplements. While many of the outcomes of treatment relate to both concepts of frailty and malnutrition, research questions are typically focused on the frailty concept, leading to possible gaps or missed opportunities in understanding the effect of complementary interventions on malnutrition. A better understanding of how these conditions overlap may improve treatment strategies for frail, malnourished, older adults.Key words: frailty, malnutrition, screening, assessment, diagnosis, handgrip strength, oral nutritional supplements, older adult.Résumé : Les effets néfastes de la fragilité des personnes âgées sur leur santé ainsi que la forte prévalence de malnutrition dans cette strate de la population suscitent une prise de conscience grandissante. Les experts dans ces deux domaines doivent être au fait du chevauchement des construits, du diagnostic et du traitement de la fragilité et de la malnutrition. Il n'y a pas encore de consensus au sujet de la définition de la malnutrition et de son évaluation. Concernant la fragilité, on s'entend sur sa définition, mais pas sur sa mesure. Il existe pourtant des outils distincts de mesure de la malnutrition et de la fragilité et, d'ailleurs, les concepts et mesures présentent une intersection. Cette revue narrative souligne les intersections entre les outils de dépistage et d'évaluation comme la perte de poids/diminution de la masse corporelle, de la capacité fonctionnelle et la faiblesse (force de préhension manuelle). En guise de tentative, on propose un ensemble minimal de mesures objectives pour la détermination ou, à tout le moins, l'identification d'un risque dans les deux conditions. La fragilité et la malnutrition aboutissent, études à l'appui, à des problèmes de santé similaires justifiant des stratégies communes de traitement tels les suppléments nutritionnels oraux. Alors que plusieurs résultats du traitement c...

BackgroundMany patients are admitted to hospital and are already malnourished. Gaps in practice have identified that care processes for these patients can be improved. Hospital staff, including management, needs to work towards optimizing nutrition care in hospitals to improve the prevention, detection and treatment of malnutrition. The objective of this study was to understand how staff members perceived and described the necessary ingredients to support change efforts required to improve nutrition care in their hospital.MethodsA qualitative study was conducted using purposive sampling techniques to recruit participants for focus groups (FG) (n = 11) and key informant interviews (n = 40) with a variety of hospital staff and management. Discussions based on a semi-structured schedule were conducted at five diverse hospitals from four provinces in Canada as part of the More-2-Eat implementation project. One researcher conducted 2-day site visits over a two-month period to complete all interviews and FGs. Interviews were transcribed verbatim while key points and quotes were taken from FGs. Transcripts were coded line-by-line with initial thematic analysis completed by the primary author. Other authors (n = 3) confirmed the themes by reviewing a subset of transcripts and the draft themes. Themes were then refined and further detailed. Member checking of site summaries was completed with site champions.ResultsParticipants (n = 133) included nurses, physicians, food service workers, dietitians, and hospital management, among others. Discussion regarding ways to improve nutrition care in each specific site facilitated the thought process during FG and interviews. Five main themes were identified: building a reason to change; involving relevant people in the change process; embedding change into current practice; accounting for climate; and building strong relationships within the hospital team.ConclusionsHospital staff need a reason to change their nutrition care practices and a significant change driver is perceived and experienced benefit to the patient. Participants described key ingredients to support successful change and specifically engaging the interdisciplinary team to effect sustainable improvements in nutrition care.Trial registrationRetrospectively registered ClinicalTrials.gov Identifier: NCT02800304, June 7, 2016.

BackgroundSuccessful improvements in health care practice need to be sustained and spread to have maximum benefit. The rationale for embedding sustainability from the beginning of implementation is well recognized; however, strategies to sustain and spread successful initiatives are less clearly described. The aim of this study is to identify strategies used by hospital staff and management to sustain and spread successful nutrition care improvements in Canadian hospitals.MethodsThe More-2-Eat project used participatory action research to improve nutrition care practices. Five hospital units in four Canadian provinces had one year to improve the detection, treatment, and monitoring of malnourished patients. Each hospital had a champion and interdisciplinary site implementation team to drive changes. After the year (2016) of implementing new practices, site visits were completed at each hospital to conduct key informant interviews (n = 45), small group discussions (4 groups; n = 10), and focus groups (FG) (11 FG; n = 71) (total n = 126) with staff and management to identify enablers and barriers to implementing and sustaining the initiative. A year after project completion (early 2018) another round of interviews (n = 12) were conducted to further understand sustaining and spreading the initiative to other units or hospitals. Verbatim transcription was completed for interviews. Thematic analysis of interview transcripts, FG notes, and context memos was completed.ResultsAfter implementation, sites described a culture change with respect to nutrition care, where new activities were viewed as the expected norm and best practice. Strategies to sustain changes included: maintaining the new routine; building intrinsic motivation; continuing to collect and report data; and engaging new staff and management. Strategies to spread included: being responsive to opportunities; considering local context and readiness; and making it easy to spread. Strategies that supported both sustaining and spreading included: being and staying visible; and maintaining roles and supporting new champions.ConclusionsThe More-2-Eat project led to a culture of nutrition care that encouraged lasting positive impact on patient care. Strategies to spread and sustain these improvements are summarized in the Sustain and Spread Framework, which has potential for use in other settings and implementation initiatives.Trial registrationRetrospectively registered ClinicalTrials.gov Identifier: NCT02800304, June 7, 2016.

Background: Nutrition care in hospitals is often haphazard, and malnourished patients are not always readily identified and do not receive the care they require. The Integrated Nutrition Pathway for Acute Care (INPAC) is an algorithm designed to improve the prevention, detection and treatment of malnutrition in medical and surgical patients. More-2-Eat is an evaluation of the implementation of INPAC care activities (e.g. screening) in five diverse medical units from different hospitals in Canada. The primary purpose is to understand how tailored implementation affects INPAC uptake and factors that impact this implementation. The principal outcome is a toolkit that can provide guidance to others.

Retrospectively registered ClinicalTrials.gov Identifier: NCT02800304, June 7, 2016.