Prevalence of protein-energy malnutrition risk in European older adults in community, residential and hospital settings, according to 22 malnutrition screening tools validated for use in adults ≥65 years: A systematic review and meta-analysis
Introduction
The European population is estimated at 515 million inhabitants, of which 19% is currently aged 65 years and older. This is expected to increase to 29% in 2060 [1,2]. Longevity is one of the main causes for the increasing number of people aged 65 years and older in Europe. Ageing is both wonderful and problematic, the latter because increased longevity often brings health-related issues [3], among which protein-energy malnutrition (PEM) is frequently observed [4,5]. PEM is associated with delayed recovery from disease, poorer quality of life and increased risk of morbidity and mortality [6]. The condition appears to be more prevalent among fragile elderly and in those having higher care needs, with prevalence rates dependent on age, the functional and marital status of participants, the health care setting and the tools or parameters used to determine malnutrition risk [[7], [8], [9], [10]]. Crichton et al. recently reported PEM prevalence rates between 2.5 and 16.5% among European community-dwelling adults, depending on the European region [11].
Screening is advised as a first step prior to a diagnosis of malnutrition [12], in order to identify persons at risk of malnutrition. Screening should be a standardized procedure, intended for application in a large number of persons, be quick, easy and practical, have high validity, and screening parameters should be easily accessible [13]. Identification of risk is the first step to starting timely, tailored nutritional interventions. Systematically screening medical inpatients on hospital admission for risk of malnutrition, independent of their medical condition, followed by individualised nutritional support in patients identified at risk of malnutrition improved important clinical outcomes, including survival, in a recent large Swiss study [14].
Numerous malnutrition screening tools have been designed over the past decades. However, most malnutrition screening tools are aimed at a specific target population, such as patients in a particular health care- or community setting [[15], [16], [17]]. In addition, malnutrition screening tools for younger adults are often used in older populations. Of all existing malnutrition screening tools worldwide, only 34 have been validated for use with older adults, and only 22 of these demonstrated acceptable validity for older adults in the specific setting in which they were tested [13]. Existing estimates of the prevalence of PEM risk among European older adults are generally restricted to specific settings, with non- and poorly validated malnutrition screening tools frequently included in analyses. Consequently, an accurate estimate of PEM risk in older adults across all health care and community settings is timely given the beneficial effects of systematic screening for malnutrition and early nutrition intervention in the recent Swiss study [14].
The current study aimed to estimate the prevalence of malnutrition risk in older adults in Europe across different health care settings by performing a systematic review and pooled meta-analysis using data based on the 22 malnutrition screening tools recently selected for best validity in adults >65 years.
Section snippets
Methods
This review describes the results of work package 2.3 of the Joint Programming Initiative Healthy Diet for a Healthy Life MalNutrition in the ELderly (MaNuEL) Knowledge Hub [1]. The Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) statement was followed [18]. The project was registered in the PROSPERO database of systematic reviews with number CRD42017073246 [19].
Study characteristics
From a total of 21,465 articles, 196 studies were included for data extraction and analyses (Fig. 1). Within studies, multiple samples could be described and several malnutrition screening tools had been applied. Therefore, 196 studies resulted in 223 unique samples, providing data for 252 sub-samples, i.e. when a study reported on the same sample with either two (n = 25), three (n = 5) or four (n = 1) malnutrition screening tools. Samples were included from a single setting (n = 188) or from
Discussion
To our knowledge, this is the first meta-analysis that provides general prevalence data for protein-energy malnutrition risk in older adults across Europe as well as prevalence data within different health care settings, based on the identification of risk by malnutrition screening tools validated for use in older adults. Our systematic review shows that as many as 23% of European older adults are at high risk of malnutrition and that more than double this number (48.4%) is at some malnutrition
Conflict of interest
The authors declare that they have no conflict of interest.
Funding
The preparation of this paper was supported by the MalNutrition in the ELderly (MaNuEL) knowledge hub. This work is supported by the Joint Programming Initiative ‘A Healthy Diet for a Healthy Life’. The funding agencies supporting this work are (in alphabetical order of participating Member State): France: Agence Nationale de la Recherche (ANR); Germany: German Federal Ministry of Food and Agriculture (BMEL) through the Federal Office for Agriculture and Food (BLE), grant number 2815ERA079E;
Provenance and peer review
This article has undergone peer review.
CRediT authorship contribution statement
Susanne Leij-Halfwerk: Conceptualization, Methodology, Investigation, Data curation, Project administration, Writing - original draft, Writing - review & editing, Visualization, Formal analysis, Resources. Marije H. Verwijs: Investigation, Writing - original draft, Writing - review & editing, Visualization, Formal analysis. Sofie van Houdt: Investigation, Writing - original draft, Writing - review & editing, Visualization. Jos W. Borkent: Methodology, Validation, Software, Data curation,
Acknowledgements
Cas Claessens
Laura Claessens
Joline Michels
Corien Stakenkamp
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