Geriatric Education Medicine Ariana Aoun MS RD CSR LD Gabrielle Sherer

1. The Influence of Nutritional Supplement Drinks on Providing Adequate Calorie and Protein Intake in Older Adults With Dementia Geriatric Education Medicine ArianaAoun MS RD CSR LD Gabrielle Sherer

2. Citation Allen V, Methven L, Gosney M. The Influence of Nutritional Supplement Drinks on Providing Adequate Calorie and Protein Intake in Older Adults With Dementia. Journal of Nutrition, Health & Aging. 2013; 17: 752-755.

3. Background • Indvs with dementia –malnourishment prevalence of 44% • Age matched indvswho are cognitively intact 25% • decreased functional ability • increased dependence on others • decreased oral intake • ONS - avg wt gain 2.2% across 3058 elderly people • challenged if oral food intake is decreased • Cognitively intact healthy adults (aged 18 to 58) • lunch consumption/appetite significantly decreased with consumption of products similar to ONS prior to lunch • Clinical areas -ten studies (n=371) in systematic review • compared energy intake from food at baseline w/ energy intake from food at end of supplement period • no significant difference in energy intake from food • None looked exclusively at people with cognitive impairment • oral intake may be more directly influenced by appetite • less likely than cognitively intact adults to change behavior when participating in a study

4. Objective of Study • Investigate whether providing ONS reduces protein and energy intake from food in elderly people with cognitive impairment compared to when ONS are not given • Investigate whether providing ONS is beneficial in achieving adequate protein and calorie intake in elderly people with cognitive impairment

5. Participants & Setting • N=26 • The Royal Berkshire Hospital, St Thomas’ Hospital and The John Radcliffe Hospital (UK) • Hospital (8) and nursing home (18) setting • 69% female • >65 years old (75-93) • Cognitive impairment (MMSE 4.95 - 21.21) • Weight 43.2 – 70.2 kg (95.04 - 154.44 lbs) • Exclusion Factors : • acute confusion • unstable diabetes • swallowing difficulties • lactose intolerant • allergic to products within long-life dairy (UHT) beverages • less than a 1 liter fluid restriction • already taking ONS

6. Design • Nursing home care managers screened residents • next of kin contacted by letter • Researcher visited elderly care wards of hospitals daily and ensured nurses or doctors screened patients • information sheets provided to next of kin • Collected: • Demographic details • Height • Nutritional status(current weight and Mini nutritional assessment short form, MNA – SF) • Cognitive ability (Mini mental state examination, MMSE)

7. Intervention • Each participant provided three ONS - alternate days over one week • ONS given btw meals and removed 1 hr before meal service (finished or not) • ONS from a variety of manufacturers • Abbott Ensure US • Nestle Boost US • Nestle Resource EU • NutriciaFortimel EU • Abbott Ensure Plus • Abbott Ensure Plus Juice EU • 200-237ml (6.8-8 oz) • 196.5 – 280.1 Kcal • 9.1 – 18.5g of protein

8. Main Outcome Measures Total energyand pro intake- each day Energyand pro intake from food vsONS- intervention days • Meal intake assessed by nursing and care staff using quartile method • none, quarter, half, three quarters, all • converted into calories (kcal) and protein (g) based on avg total kcal and protein for meals given to patients • ONS drink consumed- calculated by weighing remnants

9. Statistical Analysis • Energy and Pro intake • Wilcoxon signed-rank test for paired data • Number of participants meeting energy and protein requirements • Z test of two proportions • Protein requirements: 1g/kg/day • Energy: Harris Benedict x activity level 1.51(people with dementia)

10. Results Consumption of ONS - 69.5 +/-29.0% per day Energy: • Significantly more Kcal consumed on intervention days vs control days • (1755.4 +/- 644.2 vs 1238.9+/-511.7, V = 200, p<0.001) • No significant difference btw Kcal consumed from food on intervention days vs control days • (1273.7 +/- 558.7 vs 1238.9 +/- 511.7, V = 880, p=0.641) • 55.8% met caloric goals on intervention days vs 17.3% on control days • (z=1.96, p<0.0001) Protein: • Significantly more total protein consumed on intervention days vs control days • (73.4 +/-29.5 vs 47.5 +/- 20.4, V = 145, p<0.0001) • g pro consumed from food on intervention days vs control days-not significantly different • (49.1 +/- 22.3 vs 47.5 +/- 20.4, V=838.5, p=0.576) • 74.2% met RDA on intervention vs 33.9% on control days • (z = 1.96, p<0.0001)

11. Conclusions In elderly pts with dementia • Use of ONS did not significantly influence energy or protein intake from food • When given btw meals • ONS had an additive effect on intake

12. Study Limitations • ONS compliance lower than comparable studies • Short study period • Only recruited pts that had visitors in hospital- limiting • Method of calculating intake • Delivering ONS every other day • Habit forming?

13. Implications for Clinical Practice • For geriatric patients with dementia who are malnourished, oral nutrition supplements can be used without fear of reducing intake from food and they are likely to increase total calorie and protein intake toward meeting total needs.