Abstract
Backgrounds
Malnutrition is common among hospitalised older adults, and weight may continue to decline after discharge without nutritional support. Post-discharge home visit programmes by dieticians show positive outcomes, but not all participants experience improvement of their nutritional status. We compared participant’s characteristics according to weight change groups in a 3-month public community programme of dietician home visits.
Methods
This observational retrospective study included older adults at risk of malnutrition or malnourished in geriatric acute care wards and discharged home. Hospital data included pre-hospital basic (ADL) and instrumental (IADL) activities of daily living, comorbidity (Cumulative Illness Rating Scale-Geriatric), plasma albumin and CRP, and oral nutritional supplement prescription at discharge. The programme consisted in four or five home visits over three months, depending on the first full home Mini Nutritional Assessment (MNA) score. Dieticians provided individualised counselling and recorded weight, appetite, energy and protein intake, ADL, IADL, handgrip strength (HS), self-perceived health status (SPHS), and quality of life (QoL). The number of family or professional caregivers was noted. Participants were classified according to weight change between the first and last visit: gain > 1 kg, loss > 1 kg, or stability.
Results
Among 351 participants (mean age 87.3 ± 6.1), 197 (56%) completed ≥ 2 visits, weight change was available for 189 (54%), and 149 (42%) completed all planned visits. A higher number of caregivers at home was associated with completing ≥ 2 visits (1.9 ± 1.3 vs. 1.6 ± 1.1; p = 0.01). Between the first and last visit, 46% gained weight, 33% remained stable, and 21% lost weight. No baseline characteristic was significantly different between weight change groups. Over time, weight (median + 0.9 kg; Q1–Q3 [0.5–1.2]), appetite, QoL, SPHS, MNA, and HS improved significantly (all p < 0.01).
Conclusions
Almost half of participants gained weight during the dietician-led home visit programme. Baseline geriatric assessment did not allow discrimination between weight change groups. In older adults discharged from geriatric acute care, factors influencing dietary counselling efficacy remains to be identified in order to support individualised care plans.
Trial registration
(ClinicalTrials.gov):NCT04016532
Keywords: Home-based intervention, Older Adults, Malnutrition, Dietician, Weight
Introduction
Malnutrition impacts both individual health trajectories and healthcare expenditure in older adults. Malnutrition may affect up to half of the older patients in acute care wards [1], is associated with in-hospital complications, functional decline and mortality [2, 3] and, after discharge, impairs functional recovery and increases the risk of readmissions and death [4–7]. The length of stays in the hospital being usually short, most patients still need nutritional support after discharge. Without this nutritional support, most of older patients continue to lose weight after discharge [8–13]. International guidelines indicate that older adults with malnutrition or at risk of malnutrition should be offered individualised nutritional counselling to support adequate dietary intake and improve or maintain nutritional status [14]. Nutritional information and education should also be given by a nutritional expert, e.g. a dietician, should consist of several (at least two) individual sessions and should be maintained over a longer period of time [14]. Dietary counselling aims to adapt nutritional support to the individual’s nutritional requirements, food preferences and feeding capacity and propose an individualised range of measures such as meal enrichment, food modification, snacks and oral nutritional supplements (ONS).
Individualised nutritional care plans aiming to improve nutritional status in older adults post-discharge have shown positive results, including improvements in body weight, appetite, food intake and other outcomes such as physical performance and quality of life [12, 13, 15]. The inconsistency in the results may be due to differences in care plans and study populations. In addition, the ability of older post-discharge patients to comply to a nutritional care plan that includes home visits seems to be an issue [16]. Identifying patient-related factors associated with changes in nutritional status during a post-discharge nutritional support programme can help to target specific issues and develop more individualised care plans.
In 2018, the French Hauts-de-Seine and Yvelines departments funded a 3-month community programme of home consultations by dieticians after discharge from geriatric acute care wards as part of its policy to prevent disability. The aims of this study was to compare baseline participants’ baseline characteristics according to weight change during follow-up. We also examined changes in appetite, protein and energy intake, handgrip strength, full MNA→, ability to perform basic and instrumental activities of daily living, self-reported health status and quality of life.
Materials and methods
Study design
In 2018, a 3-month community programme of home consultations by dieticians after discharge from geriatric acute care wards was launched by the French Hauts-de-Seine and Yvelines departments. This programme had been proposed by Saveurs&Vie (S&V), a meals-on-wheels provider that separately offers home visits by trained dieticians for nutritional assessment and dietary counselling. Patients were screened in geriatric acute care wards in eight hospitals located in the Hauts-de-Seine and Yvelines departments and were offered the programme at discharge. The evaluation of this programme was done retrospectively by the Gérontopôle d’Ile-de-France (Gérond’if), a public research and innovation structure dedicated to the study of ageing.
This multicentre retrospective observational study included patients who participated in the programme of home visits by dieticians for 3 months, and was conducted between August 2018 and December 2023.
Description of the community programme
Patients were screened by hospital dieticians and medical doctors. Inclusion criteria were age 60 and older, hospitalised in a geriatric acute care ward, at risk of malnutrition or malnourished (as assessed by healthcare professionals with regard to nutritional status and malnutrition risk factors) and planned to be discharged. Non-inclusion criteria were severe major cognitive disorder (as defined by the Diagnostic and Statistical Manual of Mental Disorders-5), active cancer, end-stage organ failure, long-term corticosteroid therapy (≥ 10 mg prednisone or equivalent) and enteral or parenteral nutrition.
If the patient (and the patient’s caregiver, if there was one) accepted to participate in the programme, the acute care geriatric ward sent a notification to the S&V dieticians and forwarded information on nutritional status (weight, BMI) and ONS prescription (if it was the case). After discharge, the dieticians phoned the participants to make appointments for home visits. Dieticians attempted to contact participants by phone up to three times to schedule one home visit. In case of refusal to continue the program or no response after three phone calls, participants were considered lost to follow-up. The dietician home visits were free of charge for the participants and no meals-on-wheels from S&V were proposed. If dieticians thought that a participant would benefit from meals-on-wheels, they referred the participant to the local public structures.
Figure 1 shows the design of the programme. The first home visit by the dietician (V0) took place within 7 days of hospital discharge. The full MNA→ [17] was performed at home. For participants at risk for malnutrition (17 ≤ MNA < 24) at V0, the next visit (V1) was scheduled 1 month later. For malnourished participants (MNA < 17) at V0, an additional visit was scheduled at 15 days post-discharge (V0bis) followed by the V1 one month after discharge. All participants were then scheduled for a home visit 2 months (V2) and 3 months (V3) after discharge from the hospital. Thus, participants that fully completed the programme received four or five home visits in 3 months, depending on their initial MNA score. Slight adjustments in the timing of the visits based on participant availability were tolerated. For participants that completed at least 2 visits, the latest visit was described as the final visit, whether or not they had completed the full number of planned visits.
Fig. 1.
Design of the community programme
During home visits, dieticians provided individualised dietary counselling to participants and, when applicable, to their caregivers. The participants were educated about the importance of eating food of high nutritional value, targeting calculated protein and energy and requirements and favouring food diversity [14]. Food fortification and snacks were proposed. Dieticians took into account the food supply at home. If ONS had been prescribed in the hospital, dieticians encouraged their consumption. Physical activity was also encouraged.
Data collection
Hospital data
Hospital data was collected retrospectively by reviewing medical records one by one. Routinely collected data in the acute care geriatric wards included: weight, BMI, and plasma albumin and C-reactive protein (CRP) concentrations. Hospital data also included functional status which was assessed with the basic (ADL) [18] and instrumental (IADL) [19] activities of daily living scores, referring to functional status prior to hospitalisation, before becoming acutely ill, as was reported by the patient and caregivers. The Cumulative Illness Rating Scale-Geriatric (CIRS-G) total score and the number of severe comorbidities (defined by a category sub-score > 2) were calculated retrospectively to assess comorbidity [20]. ONS prescriptions at discharge (yes/no) and the number and type (family or professional) of caregivers included in the care plan at home were also collected.
Data collected at home by the dieticians
Each participant was cared for and monitored by the same dietician. At each visit, the dietician brought a scale and measured weight (each participant was weighted with the same scale). Collected data also included daily energy and protein intake as assessed by diet history interviews [21], appetite (using a verbal numeric scale from 0, no appetite, to 10, very good appetite), self-perceived quality of life (QoL, using a verbal numeric scale from 0, very poor, to 10, very good) and self-perceived health status (SPHS, using a verbal numeric scale from 0, very poor, to 10, very good). At V0 and V3, dieticians completed the MNA. At V3, dieticians completed the ADL and IADL rating scales. Handgrip dynamometers were provided in 2021: dieticians measured handgrip strength (HS) at each visit in newly included participants from this date.
Outcomes
Compliance to the programme was assessed by the number of visits completed by the patients. Weight change between the first and the last visit was defined as “weight loss” if the patient had lost strictly more than 1 kg, “weight gain” if the patient had gained strictly more 1 kg or “stable weight” if weight change was less than 1 kg.
Ethics
The protocol received approval from the ethic comity Comité de Protection des Personnes Ile de France III on April 18th 2019 (n° 2018-A03458-47) and the database was declared to the French authority Commission Nationale Informatique et Libertés (CNIL). Retrospectively, participants were asked to declare by postal letter if they did object to the analysis of the data (collected both in the hospital and during the home visits) for the study. After a one-month waiting period, in the absence of written opposition, patients were included.
Statistical analysis
Participants who completed two or more visits were considered for analysis of factors associated to weight change. Participants who completed only one visit or none were analysed as one group.
Categorical variables were expressed as numbers and percentages, n (%).The Shapiro-Wilk test was performed to check the normal distribution of continuous variables. In case of normal distribution, variables were presented as mean ± standard deviation (SD). In case of skewed distribution variables were described using median and interquartile range (IQR). Group comparisons according to the number of completed visits (0 or 1 visits vs. 2 to 5 visits) or according to weight change groups (weight loss, stable weight or weight gain) were conducted using the Chi-square test for categorical variables. For continuous variables, showing normal distribution and when heteroscedasticity was ruled out (Levene test), we used Student’s t-test or ANOVA. If not, we used Wilcoxon or Kruskal-Wallis tests. Comparisons between the first and the last visit used the McNemar test (categorical variables) and paired Student’s t-test (continuous variables). Mean variations with 95% confidence intervals (CI) were calculated for continuous variables. The alpha risk was set at 0.05. Statistical analyses were conducted using JMP software (SAS Institute®, version 9.0.1). Missing data were not implemented.
Results
Of the 404 older adults screened in the eight geriatric acute care wards and offered the post-discharge programme of home visits by a dietician, 351 met the inclusion criteria. They were aged 87.3 ± 6.1 years, 62% were women, 82% had one or two severe conditions, the ability to perform activities of daily living (ADL and IADL) was moderately impaired and 85% of the participants had a family or professional caregiver at home for the post-discharge care plan. At discharge, ONS were prescribed for 64% of the participants (Table 1).
Table 1.
Participants’ characteristics by the number of subsequent home visits (n = 351)
| MD (%) |
All (N = 351) |
Number of home visits | P | ||
|---|---|---|---|---|---|
| 0–1 (N = 154) |
2–5 (N = 197) |
||||
| Age (years) | - | 87.3 ± 6.1 | 88.3 ± 6.0 | 86.5 ± 6.1 | < 0.01 |
| Female sex | - | 219 (62) | 90 (58) | 129 (65) | 0.18 |
| Prior to hospitalisation | |||||
| ADL (/6) | 11 (3) | 5.5 (5.0 ; 6.0) | 6.0 (5.0 ; 6.0) | 5.5 (4.5 ; 6.0) | 0.16 |
| IADL (/4) | 9 (3) | 3.0 (2.0 ; 4.0) | 3.0 (2.0 ; 4.0) | 3.0 (2.0 ; 4.0) | 0.38 |
| At hospitalisation admission | |||||
| Weight (kg) | 9 (3) | 63 (52 ; 73) | 63 (52 ; 72) | 62 (52 ; 73) | 0.68 |
| BMI | 58 (17) | 23 (21 ; 27) | 23 (21 ; 26) | 23 (21 ; 28) | 0.20 |
| < 22 | 106 (36) | 45 (37) | 61 (35) | 0.16 | |
| 22-29.9 | 147 (50) | 65 (54) | 82 (48) | ||
| ≥ 30 | 40 (14) | 11 (9) | 29 (17) | ||
| CIRS-G | |||||
| Score (/56) | 10 (3) | 12 (9 ; 15) | 12 (9 ; 15) | 12 (9 ; 16) | 0.74 |
| Number of severe conditions | |||||
| 0 | 58 (18) | 25 (17) | 33 (19) | 0.65 | |
| 1 | 100 (31) | 50 (34) | 50 (29) | ||
| ≥ 2 | 161 (51) | 73 (49) | 88 (52) | ||
| Albuminemia (g/L) | 11 (3) | 32 (28 ; 34) | 31 (28 ; 34) | 32 (28 ; 35) | 0.43 |
| CRP (mg/L) | 18 (5) | 17 (4 ; 55) | 16 (4 ; 51) | 17 (5 ; 57) | 0.65 |
| Care plan at discharge | |||||
| Caregivers | 4 (1) | ||||
| None | 52 (15) | 27 (19) | 25 (13) | < 0.01 | |
| Professional only | 97 (29) | 57 (39) | 40 (21) | ||
| Family only | 62 (18) | 24 (16) | 38 (20) | ||
| Professional and family | 127 (38) | 37 (26) | 90 (46) | ||
| Total number | 2 (1 ; 2) | 2 (1 ; 2) | 2 (1; 3) | 0.03 | |
| ONS | 14 (4) | 191 (64) | 72 (59) | 119 (67) | 0.12 |
Results are presented as mean (± standard deviation) or median (1st ; 3rd quartile) for continuous variables depending on the distribution. Continuous variables were compared using the Wilcoxon test except for age for which the student-t test was used. Categorical variables are presented by the number (%) and compared using the Chi2 test
MD Missing data, ADL Activities of daily living, IADL Instrumental activities of daily living, CIRS-G Cumulative Illness Rating Scale-Geriatric, ONS Oral nutritional supplement
Of the 351 included participants, 197 (56%) completed ≥ 2 visits, weight change could be calculated in 189 (54%) and 149 (42%) completed all planned visits (Fig. 2). The proportion of participants that completed each programmed visit is given in supplemental Fig. 1. The median time from discharge to each visit was 7 days (IQR 5; 8) for V0, 17 days (13; 22) for V0bis, 29 days (26; 36) for V1, 61 days (55; 68) for V2 and 91 days (84; 103) for V3.
Fig. 2.
Flow-chart
Table 1 shows the baseline characteristics of participants that completed two visits or more, as compared to those who completed one visit or none. Participants who completed two visits or more were significantly younger and had significantly more caregivers than participants who completed only one visit or none.
For participants that completed two visits or more, 86 (46%) gained weight [mean (95% CI) + 3.0 (2.7; 3.4) kg or 5.1 (4.4; 5.8) % of body weight], 63 (33%) had stable weight and 40 (21%) lost weight (-2.5 (-2.8; -2.2) kg or -4.0 (-4.6; -3.4) %). None of the participants’ baseline characteristics were significantly different according to subsequent weight change groups (Table 2).
Table 2.
Participants’ characteristics by weight change between the first and the last home visit (n = 189)
| MD (%) | Weight change | P | |||
|---|---|---|---|---|---|
| Weight loss > 1 kg (N = 40) |
Stable Weight (N = 63) |
Weight gain > 1 kg (N = 86) |
|||
| Age (years) | 86.8 ± 6.4 | 86.6 ± 5.6 | 86.4 ± 6.2 | 0.94 | |
| Female sex | 26 (65) | 46 (73) | 54 (62) | 0.41 | |
| Prior to hospitalisation | |||||
| ADL (/6) | 6 (3) | 5.0 (4.5 ; 6.0) | 5.5 (4.5 ; 6.0) | 5.8 (5.0 ; 6.0) | 0.23 |
| IADL (/4) | 8 (4) | 3.0 (1.0 ; 4.0) | 3.0 (2.0 ; 4.0) | 3.0 (2.0 ; 4.0) | 0.33 |
| At hospitalisation admission | |||||
| Weight (kg) | 22 (12) | 65 (52 ; 76) | 60 (53 ; 74) | 62 (51 ; 72) | 0.57 |
| BMI | 24 (13) | 25 (21 ; 28) | 23 (21 ; 28) | 23 (20 ; 28) | 0.69 |
| < 22 | 12 (32) | 20 (38) | 27 (36) | 0.91 | |
| 22-29.9 | 17 (46) | 24 (45) | 37 (49) | ||
| ≥ 30 | 8 (22) | 9 (17) | 11 (15) | ||
| CIRS-G | |||||
| Score (/56) | 24 (13) | 12 (10 ; 14) | 13 (9 ; 17) | 12 (9 ; 15) | 0.95 |
| Number of severe conditions | 6 (17) | 11 (21) | 15 (20) | 0.91 | |
| 0 | 10 (28) | 16 (30) | 23 (31) | ||
| 1 | 20 (55) | 26 (49) | 37 (49) | ||
| ≥ 2 | |||||
| Albuminemia (g/L) | 27 (14) | 32 (29 ; 35) | 32 (29 ; 36) | 31 (27 ; 34) | 0.44 |
| CRP (mg/L) | 36 (19) | 15 (6 ; 63) | 10 (2 ; 52) | 21 (6 ; 59) | 0.39 |
| Post discharge care plan | |||||
| Caregivers at home | 4 (2) | ||||
| None | 8 (20) | 6 (10) | 11 (13) | 0.87 | |
| Professional only | 9 (22) | 13 (21) | 18 (21) | ||
| Family member only | 8 (20) | 13 (21) | 16 (19) | ||
| Professional and family | 15 (38) | 29 (48) | 39 (47) | ||
| Total number | 2.0 (1.0 ; 2.0) | 2.0 (1.0 ; 2.0) | 2.0 (1.0 ; 3.0) | 0.35 | |
| ONS prescription | 8 (4) | 24 (67) | 36 (62) | 52 (68) | 0.74 |
| Nutritional evaluation at V0 | |||||
| Weight (kg) | 67 (54 ; 74) | 61 (54 ; 74) | 64 (51 ; 73) | 0.51 | |
| Grip Strength (kg) | 103 (54) | 18 (14 ; 19) | 20 (13 ; 25) | 19 (12 ; 26) | 0.68 |
| Appetite (/10) | 12 (6) | 6.0 (5.0 ; 8.0) | 6.0 (5.0 ; 8.0) | 6.0 (5.0 ; 7.0) | 0.75 |
| Energy intake (kcal/day) | 32 (17) | 1390 ± 459 | 1570 ± 563 | 1579 ± 460 | 0.16 |
| Protein intake (g/day) | 22 (12) | 62 (48 ; 76) | 58 (47 ; 82) | 68 (56 ; 82) | 0.24 |
| Mini Nutritional Assessment (MNA/30) | 26 (14) | 21 (17 ; 24) | 20 (16 ; 23) | 21 (19 ; 24) | 0.33 |
| MNA categories | |||||
| Normal nutritional status | 9 (28) | 13 (22) | 17 (23) | 0.20 | |
| At risk for malnutrition | 15 (47) | 28 (49) | 46 (63) | ||
| Malnourished | 8 (25) | 17 (29) | 10 (14) | ||
Results are presented as mean (± standard deviation) or median (1st ; 3rd quartile) for continuous variables depending on the distribution. Continuous variables were compared using the Kruskal-Wallis test except for age and energy intake for which the ANOVA test was used. Categorical variables are presented by the number (%) and compared using the Chi2 test
MD Missing data, ADL Activities of daily living, IADL Instrumental activities of daily living, CIRS-G Cumulative Illness Rating Scale-Geriatric, CRP C-reactive protein, ONS Oral nutritional supplement
Figure 3 shows each individual’s body weight change between the first and last home visit. The higher the number of completed visits, the better the weight change: median weight change was − 0.1 (IQR − 1.5 ; 0.8) kg when only two visits were completed, 0.2 (-0.5 ; 1.5) kg for three visits, 0.4 (-1.0 ; 2.0) kg for four visits, and + 1.5 (-1.0 ; +3.0) kg for five visits (p for trend = 0.046). Table 3 shows the changes in nutritional and functional parameters between the first and the last visit. For all participants that completed two visits or more, the mean (95% CI) weight change was + 0.9 (0.5 ; 1.2) kg or (+ 1.5 (0.9 ; 2.2) %). Significant improvements in appetite, QoL, SHS, and MNA, were observed. ADLs and IADL scores on the last visit were not different from that reflecting functional status prior to hospitalisation.
Fig. 3.
Weight change between the first and the last visit for each patient (n = 197)
Table 3.
Changes in participants’ parameters between the first and the last home visit (n = 197)
| MD | First visit | Last visit | Mean diff | P | |
|---|---|---|---|---|---|
| Weight (kg) | 8 (4) | 64.5 ± 15.1 | 65.4 ± 15.3 | 0.9 [0.5 ; 1.2] | < 0.01 |
| Energy intake (kcal/day) | 31 (16) | 1452 ± 455 | 1481 ± 471 | 29 [-36 ; 95] | 0.38 |
| Protein intake (g/day) | 28 (14) | 66± 23 | 67 ± 23 | 1 [-4 ; 4) | 0.64 |
| Appetite (/10) | 10 (5) | 6.1 ± 2.1 | 6.9 ± 1.9 | 0.8 [0.5 ; 1.0] | < 0.01 |
| MNA (/30) | 81 (41) | 20.7 ± 4.5 | 23.7 ± 4.4 | 2.9 [2.3 ; 3.6] | < 0.01 |
| Handgrip strength (kg) | 130 (66) | 18.1 ± 8.6 | 19.4± 7.8 | 1.3 [0.4 ; 2.1] | < 0.01 |
| QoL (/10) | 39 (20) | 6.6 ± 1.8 | 7.0 ± 1.6 | 0.5 [0.3 ; 0.7] | < 0.01 |
| SR-Health Status (/10) | 23 (12) | 5.8 ± 1.7 | 6.4 ± 1.8 | 0.7 [0.5 ; 0.9] | < 0.01 |
| ADL (/6)* | 92 (47) | 6.0 (4.5 ; 6.0) | 6.0 (5.0 ; 6.0) | 0.0 [-0.2 ; 0.2] | 0.83 |
| IADL (/4)* | 93 (47) | 3.0 (2.0 ; 4.0) | 3.0 (2.0 ; 3.0) | 0.0 [-0.1 ; 0.2] | 0.76 |
For variables, results are presented as the mean (± SD) or the median (Q1 ; Q3) depending of the distribution. The mean difference is given with 95% confidence interval [95%CI]. Student-t or Wilcoxon tests for paired data compared the variables between the first and the last visit
MD Missing data, MNA full Mini Nutritional Assessment, QoL Quality of life, SR-Health status Self-reported health status, ADL Activities of daily living, IADL Instrumental activities of daily living
*Changes in ADL and IADL scores were compared between level prior to hospitalisation and level at the last visit
Discussion
This observational retrospective study shows that in older participants who completed at least two visits as part of a 3-month public community programme of home visits by dieticians after discharge from geriatric acute care wards, 46% gained weight, 33% had stable weight and 21% lost weight. Participants’ characteristics, ONS prescription and number of caregivers at home were not significantly different between weight change groups. However, a higher number of caregivers (family + professional) at home was associated with a better chance to succeed in completing at least two home visits. Furthermore, significant improvements between the first and the last visit were observed for weight, appetite, MNA score, quality of life, self-perceived health status, and handgrip strength.
To the best of our knowledge, only one previously published study described weight changes in categories of loss, stable or gain in community post-discharge programme of home visits by dieticians. In the HOMEFOOD randomized controlled study [13], only one patient out of 53 participants (2%) in the intervention group and 42 (79%) in the control group had lost > 1 kg at the end of a 6-month follow-up; in our study, the proportion of weight loss > 1 kg was 21%. Of note, the HOMEFOOD intervention included 5 home visits by a dietician in 3 months, but also included three telephone calls between the home visits and free supplemental energy- and protein-rich foods (one hot meal/day and two in-between meals/day). This suggests that more comprehensive protocols may be more efficacious in reducing post-discharge weight loss in older patients, albeit more expensive. In our study, weight change for all participants that completed two or more visits was + 0.9 kg, which is consistent with randomized controlled studies that reported weight changes of + 0.7 to + 1.4 kg in the intervention groups after three or four months [8, 10, 12], and comparable to + 0,4 kg six weeks after a 4-week post-discharge dietician follow-up programme [22]. In the Transitional Aged Care programme, the MNA increased by 3 points in 3 months, but weight change was not described [23].
We aimed to identify the participants’ characteristics that differ between weight change groups during the follow-up. Interestingly, none of the participants’ baseline characteristics (age, sex, BMI, comorbidity, disability, albuminemia and CRP levels), nor the number of caregivers at home, were significantly different between weight change groups. This suggests that these criteria should not be used to exclude participants from programmes of home-visits by dieticians. However, it is important to keep in mind that participants with severe major cognitive disorder, active cancer and end-stage organ failure were not included in this study, as in most previously published studies. Other studies will be needed to explore the feasibility and effect on nutritional status of home visits by dieticians in participants affected with these very severe diseases.
Only 56% of the participants who had accepted the programme of home visits while being in the hospital and who were called by the dietician post-discharge actually accepted the first and second home visit and only 42% of the participants completed all planned visits. We did not record the reasons for the visits not being completed. Some of these participants may have accepted readily to participate in the programme when in the hospital, being informed that the home visits were offered free of charge by the public stakeholders and not having to commit in writing. When back at home, a number of reasons may have led to non-completion of the visits, such as difficulty in answering the phone or getting up to open the door, fatigue or reluctance to let someone they don’t know into their home. Furthermore, older patients hospitalised in geriatric care wards are at risk for early readmissions [24] and some patients may not have been at home when the dieticians called. Of note, the number of home caregivers was significantly higher in participants who completed at least 2 home visits: 46% in participants with both family and professional caregivers and 13% in participants with no caregiver at all (Table 1). This suggests that caregivers can remove a number of barriers to participation in a nutritional support programme at home.
In our study, ADL and IADL scores at the last visit were not significantly different from the scores prior to hospitalisation, before becoming acutely ill. In contrast, previous studies have highlighted that 6 to 12 months following hospital discharge, fewer than half of the older adults had recovered to their pre illness levels of functioning [25, 26]. Thus, in our study, the ADL and IADL scores being similar to scores prior to hospitalisation may be interpreted as a positive result. Consistently, handgrip strength, quality of life and self-perceived health status significantly increased between the first and the last home visit. Encouraging physical activity, as was done by the dieticians in our study, appears as mandatory in order to favour improvement in functional status [12, 14, 16, 23].
Our study has several limitations. The absence of a control group constrains the interpretation of the programme’s efficacy. Nevertheless, previous randomised controlled trials of post-discharge home visits by dietitians have demonstrated favourable outcomes, although not all participants experience improvements in nutritional status. Our objective was to compare participants’ characteristics according to subsequent weight change within a similar programme. The retrospective design of our study did not allow to collect information on possible fluid retention (e.g. related to heart or renal failure) or dehydration, (e.g. low fluid intake or diuretic therapy). These may have participated in some of the participants’ weight change during the follow-up. Self-perceived QoL and health status were evaluated using a pragmatic, 0 to 10 method to minimize assessment time and increase feasibility for both participants and dieticians during home visits, rather than longer questionnaires, which may limit the precision of these outcomes. Missing data, particularly for handgrip strength, may also have limited the interpretation of changes in muscle strength.
In conclusion, participation on this public community programme of post-discharge home visits by dieticians is associated with improvement of appetite, MNA, quality of life and self-perceived health status in older patients discharged from acute care geriatric wards. Almost half of the participants gained weight, but baseline geriatric assessment did not distinguish between participants that subsequently gained, stabilised or lost weight during the programme. Interestingly, family and professional caregivers favoured compliance to the programme. Future programmes should include strategies to optimize inclusion and compliance of socially isolated older adults.
Acknowledgements
The Départements des Hauts-de-Seine and des Yvelines, through the Commission des Financeurs pour la prévention de la perte d’autonomie, have supported the Nutrivitalité – DIETADOM programme since 2020. This programme, led by the home dietary counselling company Saveurs & Vie Conseils, is part of public actions aimed at preventing and combating undernutrition among older adults. Participants were screened by geriatricians and dietitians in geriatric acute care wards across eight hospitals: Rive-de-Seine Hospital (Dr Chansiaux Bucalo), La Porte Verte Hospital (Dr Harboun), Beaujon University Hospital (Pr Raynaud-Simon), Louis Mourier University Hospital (Dr Haguenauer), Ambroise Paré University Hospital (Pr Teillet), Foch Hospital (Dr Bizard), Stell Hospital (Dr Galopin), and Quatre-Villes Hospital (Dr Charpentier).
Authors’ contributions
MS, PCA, CCB and ARS designed the study. MS, KG, SL and SR collected data. MS performed statistical analysis. MS, PCA KG, SL, and ARS contributed in writing the manuscript. All authors read and approved the final manuscript.
Funding
The French Hauts-de-Seine and Yvelines departments funded the 3-month community programme of home consultations by dieticians with 700.000 euros since 2018. The evaluation of the programme was done retrospectively by the Gérontopôle d’Ile-de-France (Gérond’if), a public research and innovation structure dedicated to the study of ageing.
Data availability
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
The protocol received approval from the ethic comity Comité de Protection des Personnes Ile de France III on April 18th 2019 (n° 2018-A03458-47) and the database was declared to the French authority Commission Nationale Informatique et Libertés (CNIL). Retrospectively, participants were asked to declare by postal letter if they did object to the analysis of the data (collected both in the hospital and during the home visits) for the study. After a one-month waiting period, in the absence of written opposition, patients were included.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.