Nutritional interventions and related efforts addressing undernutrition during rehabilitation after acquired brain injury: a scoping review protocol

Abstract

Introduction

Patients with an acquired brain injury (ABI) are at an increased risk of undernutrition due to the disease-related inflammation and other numerous symptoms that impact their nutrition. Unfortunately, recommendations related to nutritional interventions and related efforts vary. The objective of this scoping review is to map the body of literature on nutritional interventions and related efforts provided by health professionals, such as screening or assessments, addressing undernutrition in adults with a moderate to severe ABI during the subacute rehabilitation pathway.

Methods and analysis

The review follows the Joanna Briggs Institute methodology for scoping reviews. The librarian-assisted search strategy will be conducted in the bibliographical databases: MEDLINE (PubMed), Embase, CINAHL, Web of Science and OpenGrey. Indexed and grey literature in English, German or Scandinavian languages from January 2010 will be considered for inclusion. Two independent reviewers will conduct the iterative process of screening the identified literature, paper selection and data extraction. Disagreements will be resolved by discussion until a consensus is reached. A template will be used to guide the data extraction. This scoping review will include research articles, methodological papers and clinical guidelines reporting on nutritional interventions or related efforts to prevent or address undernutrition in adult patients (≥18 years) with moderate to severe ABI within the first year after admission to rehabilitation hospital. We will map all kinds of nutritional efforts provided by professionals in different settings within high-income countries, including interventions targeting relatives.

Ethics and dissemination

This review will involve the collection and analysis of secondary sources that have been published and/or are publicly available. Therefore, ethics approval is not required. The results will be published in an international peer-reviewed journal, presented at scientific conferences and disseminated through digital science communication platforms.

Study registration

Open Science Framework: https://doi.org/10.17605/OSF.IO/H5GJX.

Strengths and limitations of this study.

• The use of the Joanna Briggs Institute methodology for the conduct of scoping review ensures a systematic approach involving at least two independent researchers to identify, retrieve, review and map the evidence of relevance.

• A limitation of the scoping review is the restriction to English, German and Scandinavian languages and to publications after 2010, potentially resulting in some relevant evidence not being identified.

• A further limitation is that patients’ specific interests have not been examined and no patients or members of the public have been involved in the protocol design.

Introduction

Acquired brain injury (ABI) is an umbrella term referring to any brain injury occurring after birth and which is not a result of a progressive disorder or degenerative disease.¹ Patients with moderate to severe ABI are at high risk of disease-related undernutrition due to increased production of corticosteroids, counter-regulatory hormones and cytokines resulting in increased metabolism.^{2 3} The risk of undernutrition is further increased as the changes after an ABI can cause difficulties in buying, preparing, chewing, swallowing and delivering food to the mouth in conjunction with confusion, fatigue and depression.^2–5 At admission, nearly half of patients fulfil the Global Leadership Initiative on Malnutrition (GLIM) criteria^{6 7} and 10% remain undernourished after 4 weeks of rehabilitation.⁸ Upon referral to in-hospital rehabilitation, a majority of patients with ABI experience weight loss relative to their weight at admission. Long-term undernutrition is known to persist in about one-third of community-dwelling patients with ABI.^{9 10} Undernutrition not only leads to weight loss and prolonged muscle tissue-associated hospitalisation due to the increase in infectious complications and pressure ulcers, but also a decrease in functional outcomes preceding the dependency on public services even after discharge.^{6 10 11}

Nutritional treatment includes several components involving relatives and different professionals, but nutritional care is perceived as a core purview for nurses.^{12 13} This includes identifying eating-related problems; drawing up, monitoring and coordinating care plans; ensuring meal aesthetics and providing needed support in meal situations.^{14 15} However, it is claimed that the nursing staff in both primary and secondary healthcare sectors have neither sufficient knowledge nor routines or attitudes to identify and support the patients’ nutritional needs.^{14 16} Several clinical guidelines exist, but the main focus is on acute care, while the nursing staff’s contributions and responsibilities during the rehabilitation trajectory remain unclear.^{4 17 18} Clear recommendations for nutritional interventions to support the nutrition care of patients with ABI during the rehabilitation trajectory are required in order to prevent undernutrition and complications and reduce rehabilitation outcomes.¹⁹ A preliminary search of MEDLINE, the Cochrane Database of Systematic Reviews and Joanna Briggs Institute (JBI) Evidence Synthesis reveals no current or underway systematic reviews or scoping reviews on the topic. The aim of this scoping review is to identify and map best practices described in clinical guidelines and evidence concerning nutritional interventions and efforts such as screening or assessments to prevent or address undernutrition during the first year of subacute in-hospital and municipal rehabilitation in adults with moderate to severe ABI.

Methods and analysis

Study design and protocol registration

The proposed study is conducted in accordance with the JBI methodology for scoping reviews^20–22 and will be reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping reviews (PRISMA-ScR) checklist.²³ The protocol is registered in Open Science Framework (https://doi.org/10.17605/OSF.IO/H5GJX). A team of nurse researchers within the field of neurorehabilitation will systematically identify, retrieve, review and map international evidence of relevance.

Review questions

The purpose of this study is to map a body of literature and identify knowledge gaps in accordance with the research questions below. The research questions are based on the Population, Concept and Context framework for scoping reviews as defined by the JBI.²⁴

1. What nutritional interventions and related efforts provided by healthcare professionals are available to address undernutrition in patients with a moderate to severe ABI (≥18 years) during the subacute rehabilitation pathway from admission to rehabilitation hospital and 1 year onwards?

2. What are the characteristics, that is, content, intensity, duration, context of use and professional responsibilities of the nutritional interventions and related efforts, such as screening or assessments, mapped within the following categories: nutritional screening, nutritional assessment, nutritional care plans, nutritional education of patients, involvement of relatives in nutritional tasks, compensatory strategies as delivery of meals as well as support to prepare or consume meals?

Inclusion and exclusion criteria

This scoping review includes reports from any research methodology and grey literature, including research studies, methodological papers, clinical guidelines and opinion papers reporting on nutritional efforts provided by healthcare professionals (including dietitians, nurses, physiotherapists, occupational therapists, etc) to prevent or address undernutrition during the rehabilitation pathway (eg, in-hospital rehabilitation, nursing homes, primary care in the municipalities or other care facilities) in high-income countries. Examples of nutritional interventions could be nutritional screening and assessment, nutritional care plans, nutritional education, or compensatory strategies of purchasing, preparing or consuming meals.¹⁵ Systematic reviews that meet the inclusion criteria will be analysed for additional references. Materials published in English, German or Scandinavian languages from January 2010 to the present are considered in accordance with present language competencies of the research team and the expected feasibility of efforts in healthcare systems with distribution of responsibilities between primary and secondary sectors in high-income countries. The population includes adult patients (≥18 years) undergoing cross-sectional rehabilitation after a moderate to severe ABI and/or their relatives from admission to rehabilitation hospital and 1 year onwards. The group with ABI is heterogeneous with varying sensorimotor, perceptive, cognitive dysfunctions or impaired consciousness. Hence, we define severity of rehabilitation needs following a moderate to severe brain injury as National Institutes of Health Stroke Scale standard score of 5–45 in patients who had a stroke²⁵; a Glasgow Coma Scale score of 12 or lower within the first 24 hours after injury in patients with traumatic brain injury²⁶; or complex changes of functions following an ABI which require in-hospital rehabilitation conducted by an interdisciplinary team of specialists²⁷ in order to delineate minor need for rehabilitation. This study uses malnutrition as a synonym for undernutrition, as per the European Society for Clinical Nutrition. The GLIM criteria to diagnose malnutrition⁶ consist of three phenotypical criteria (non-voluntary weight loss, low body mass index and low muscle mass) and two aetiological criteria (reduced food intake or assimilation, and inflammation or disease burden).⁶

Search strategy

The search strategy aims to locate both published and unpublished studies. A three-step search strategy is used as recommended by the JBI.²⁰ The first step consists of an initial preliminary search of PubMed/MEDLINE. Analysis of the text contained in titles and abstracts informs the development of a search strategy, including the identification of search terms and index terms. Development of the search strategy requires a close collaboration between the first author and an experienced university hospital librarian. This strategises the step two search, including all identified keywords and index terms, adjusted for each of the additional databases Embase and CINAHL, and for unpublished or grey literature OpenGrey. In step three, the reference lists of all included studies will be screened for additional evidence. The fully developed search strategies are provided in online supplemental appendix I.

Data extraction

Following the search, all identified citations will be collated and uploaded into EndNote V.20 (Clarivate Analytics, Pennsylvania, USA) and duplicates will be removed. Assessments will be performed by two authors independently in two steps using Covidence (Veritas Health Innovation, Melbourne, Australia). Following a pilot test, titles and abstracts will be screened against the inclusion criteria. Then, the full text of included sources will be assessed. Any disagreements that arise between the reviewers at each stage of the selection process will be resolved through a discussion or consensus with an additional reviewer. Reasons for exclusion of sources of evidence will be recorded. The results of the search and the study inclusion process will be reported as a flow diagram in accordance with the PRISMA-ScR.²³

The Covidence extraction template V.2.0 software will be used and a data extraction form will be developed a priori, as per the JBI methodology.^20–22 The draft data extraction form is provided (online supplemental appendix II). Key information includes each study’s authors, year of publication, country of origin, setting, population, methodology/methods, and findings related to professional efforts to screen, assess, monitor or reduce undernutrition following an ABI. The template will be modified as necessary during a pilot process. Two authors will independently extract data from a sample of the included evidence sources. A cross-check will be conducted by two authors to ensure the analogy of the extracted data. Finally, the developed template will be used to extract data from all included sources. Any disagreements between the reviewers will be resolved through a discussion or consensus with an additional reviewer.

Data analysis and presentation

Data from the extraction process will be mapped and presented in a tabular form divided into appropriate categories fitting the review questions (eg, screening, monitoring and interventions to improve the nutritional state) including a basic numerical account of the amount, type and distribution of the evidence included in the review. Data analysis will be conducted by two independent researchers followed by discussions involving all authors. A descriptive narrative summary will accompany the tabulated results.

Patient and public involvement

None.

Ethics and dissemination

This review will involve the collection and analysis of secondary sources that have been published and/or are publicly available. Therefore, ethics approval is not required. The results will be published in an international peer-reviewed journal, presented at scientific conferences and disseminated through digital science communication platforms. The protocol is registered with Open Science Framework (https://doi.org/10.17605/OSF.IO/H5GJX).

Ethics statements

Patient consent for publication

Not applicable.