Community optimized management for better eating after hospital sTay among geriatric patients of poor socio-economic status - The COMEAT study

Summary

Introduction

In patients suffering from disease-related and socioeconomic malnutrition and being discharged from hospital, continuity of care is challenging. Lack of adequate nutrition may lead to increase in morbidity and mortality. The aim of this study was to overcome the handicap of limited nutrition access in this category of patients and to study its consequences on clinical outcome.

Methods

Hospitalized patients screened to be at risk of malnutrition were approached and if diagnosed as suffering from malnutrition and from limited financial resources, they were randomized to receive a delivered daily dinner tray for 6 months and an assistance during the meal by a philanthropic association, or to regular food. At entry to the study, patients were assessed by indirect calorimetry, bioimpedance, Hospital Anxiety and Depression Scale (HADS), Functional independence measure (FIM) and SF 36 quality of life questionnaire. The latest questionnaires were reproduced after 3 and 6 months. Survival was followed at 6 months. The student t-test, the paired t-test, ANOVA were used. 180 days survival curves were expressed using the Kaplan-Meier method.

Results

631 patients were screened and 60 patients were randomized. There was no difference between groups. Survival at 6 months was improved significantly in the intervention group (87%) compared to the control group (65%, p<005). HADS did significantly improve at 3 months and other parameters (FIM, SF 36) were not changed significantly.

Conclusions

In hospitalized patients at nutritional risk, lunch home delivery, supported by a physical company after hospital discharge was associated with significantly lower mortality rates and improved depression and anxiety scores in elderly patients suffering from socioeconomic related malnutrition

Introduction

Malnutrition affects health outcomes and survival mainly among the geriatric population [1,2].

A study surveying 16,290 hospitalized patients indicated that on the day of data collection (NutritionDay) and during the week prior to inclusion more than half of the patients did not eat more than half the meal provided. Insufficient food intake is an independent risk factor for mortality, regardless of the patient's diagnosis [3]. Various physical, mental and social conditions contribute to the development of malnutrition in older adults [4,5]. A model called DoMAP (Determinants of Malnutrition in Aged Persons ((4) has been defined out of 122 potential causes for malnutrition, including 3 main factors: low intake, increased requirements, and impaired nutrient bioavailability, but other parameters were also included such as demographics, financial, food, appetite, longevity, psychological function, physical function, comorbidities and therapies. In addition, direct and indirect causes that contribute to malnutrition, such as low income, poverty, lack of ability to prepare meals and solitude, i.e., the absence of company with the feeling of loneliness, play important roles as well. Other studies confirm that in adult malnutrition patients that are discharged from the hospital, social, economic and environmental factors increase the incidence and severity of depression and anxiety and are related to impaired quality of life [[5], [6], [7], [8], [9]].

Schorr et al. [6] revealed that appropriate food supply to the geriatric population may overcome two main hindrances: lack of money to buy food and the depression and anxiety impairing food preparation. In the hospital, between 30% and 85% of hospitalized patients suffer from malnutrition according to different surveys [10]. Eating adequately while being hospitalized is often a matter of necessity rather than pleasure as means to reduce hospital stays, malaise and even mortality [11]. During the hospitalization course, patients' nutritional conditions deteriorate, a phenomenon that was given the name “hospital malnutrition” [12]. Hospital malnutrition usually persists in the patients' home environment following hospitalization [13]. Hospitalized patients consume lower amounts of food due to various causes, not the least the underlying disease and screening tools have been developed to diagnose patients at risk of malnutrition [14]. A vicious cycle that begins with a decrease in food consumption prior to hospitalization, worsens during the hospital stay, and continues after discharge from the hospital back to the patient's natural environment, for reasons such as anorexia, depression, cognitive impairment, lack of access to food and increased risk of post-hospitalization complications [[15], [16], [17]].

The aim of this research was to evaluate the effects of provision of adequate nutrition and company support in patients' homes after hospital discharge in a population of patients with malnutrition related to the aforementioned socio-economic factors. The endpoints were 6 months survival, patients’ quality of life, including the improved level of anxiety and depression, functional independence measure (FIM) and the rate of resources utilization (outpatient clinic visits, hospital readmissions).