Is telehealth effective in managing malnutrition in community-dwelling older adults? A systematic review and meta-analysis
Introduction
Despite being preventable and treatable, malnutrition is highly prevalent and a strong independent contributor to poor health in the older adult population [[1], [2], [3], [4]]. Malnutrition is defined as the unintentional and preventable loss of lean tissues such as muscle, with or without fat loss, due to prolonged inadequate dietary intake of protein and energy, increased requirements and/or excessive losses [[1], [5]]. A sufficient increase in dietary protein and energy intake to meet individualized requirements and cease the loss of lean tissues will reverse malnutrition [[3], [5]]. However, encouraging malnourished patients to consume appropriate types and quantities of foods to meet their nutritional requirements encounters many diverse barriers due to its complex physiological, socio-economic, and environmental risk factors, as well as unique presentation in each individual [5]. Individualised and long-term nutrition support is required to overcome these barriers and enable the older adult to meet their energy and protein requirements; thus, the current usual care of short term treatment during a health care admission is insufficient to properly treat malnutrition in many cases [[5], [6]]. Therefore, it is now essential to look to alternative methods of healthcare delivery which facilitate patient-centred care across the continuum and reduce barriers patients face, while also maximising current healthcare resources.
For this reason, healthcare providers have increasingly been using telehealth, which enhances patient access to long-term care. With the use of technology growing rapidly around the world, [7], telehealth methods have demonstrated a credibility in overcoming typical logistical challenges in modern healthcare delivery [8]. Telehealth can be defined as the delivery of healthcare services from a distance using telecommunication techniques synchronously (i.e. same time, different location) and/or asynchronously (i.e. different time, different location) [8]. As such, telehealth may allow for specialised nutrition care to be delivered more cost-effectively and to more patients in need.
Telehealth strategies have been shown to be effective at improving dietary behaviour in chronic disease [[9], [10]] and in primary care [[11], [12]]. Older adults suffering from chronic conditions have also shown improvements in areas of their self-management and confidence in using telehealth modalities [13]. Therefore, telehealth offers a feasible method to provide regular and long-term nutrition support to malnourished older adults living at home; a population group who may find it difficult to access health services, particularly in rural areas [[6], [14], [15], [16]]. However, this age group may also have limitations related to lack of internet accessibility, hearing difficulties, and familiarity and acceptance of technology, which may limit the effectiveness of telehealth interventions. Consequently, the effectiveness of telehealth with older adults to improve malnutrition warrants examination so that healthcare resources may be directed appropriately. This study aims to determine the efficacy of telehealth methods in delivering malnutrition-related interventions to community-dwelling older adults.
Section snippets
Methods
A systematic review and meta-analysis of the literature was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [17] and was registered with the International Prospective Register of Systematic Reviews (PROSPERO number: CRD42017080922).
Search results and study quality
The search identified 2993 records, with 2164 remaining after deduplication (Fig. 1). Forty-six publications were assessed for eligibility via full text, and 13 were included. Of these 13 publications, six papers were used to report outcomes from two studies, leading to nine intervention studies included (Table 1). Seven studies were randomised controlled trials (RCTs), where the study by Lim et al. [27] was pre-test post-test, and the study by Lindhardt et al. [28] was a non-randomised
Discussion
This systematic review and meta analysis found that telephone consultations are feasible and cost-effective methods to deliver interventions to older adults at risk of malnutrition. Compared with usual care, this review found evidence that malnutrition-related interventions delivered via telehealth are effective in improving quality of life and protein-intake, although confidence in the estimated effect sizes for these outcomes is low to very low. While pooled data did not find statistical
Conclusion
Malnutrition-related telehealth interventions to older adults living at home are likely to result in improvements to quality of life and dietary intake, and appear feasible and cost-effective. Evidence suggests telehealth may also improve nutrition status, physical function, hospital readmission and mortality; however, further research is required to strengthen the body of evidence.
Contributors
MC, HM, DC and SM contributed to eligibility screening. DC, JC and SM contributed to review of study quality. WM and SM contributed to data extraction, and JK and SM contributed to the meta-analyses. SM lead the drafting of the manuscript. All authors contributed to study concept, interpretation of results, and revision of the manuscript.
Conflict of interest
The authors declare no actual or potential conflicts of interest. Elizabeth Isenring has consulted to companies including those that manufacture nutritional oral supplements; however, declares these consultations are unrelated to the current study and has not influenced this study in any way.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Provenance and peer review
This article has undergone peer review.
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2022, Primary Care - Clinics in Office PracticeCitation Excerpt :Telehealth interventions varied and included telephone calls by dieticians and providers at regular intervals; use of a telemonitoring device in which patients entered data about body weight and answered questions about appetite, supplements, wellbeing, and fluid intake; and use of a tablet-based app to order energy- and protein-enriched meals for delivery to patients following hospital discharge. The interventions resulted in improved protein intake by 0.13 g/kg/d as well as improvements in quality of life, with trends toward improved nutrition status, energy intake, physical function, and clinical outcomes.19 Medicare Annual Wellness Visits (AWV) are an important touchpoint to conduct health risk assessments, provide preventive health recommendations, and update screenings for seniors.20
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2022, Clinical Nutrition ESPENCitation Excerpt :This is supported by observational evidence from a recent systematic review [71] which reported the convenience of telehealth in bringing together multiple healthcare professionals whilst minimising direct patient contact during the COVID-19 pandemic. Multiple expertise combined in this way can be an effective tool in tackling malnutrition as reported by a meta-analysis [72]; there was a significant improvement in protein intakes (2 studies; 200 participants) and quality of life (4 studies; 248 participants) in malnutrition focussed telehealth interventions when compared to usual care, in older adults living at home. However, limited practical guidance was provided by the papers in this review.
A multimodal nutritional intervention after discharge improves quality of life and physical function in older patients – a randomized controlled trial
2021, Clinical NutritionCitation Excerpt :The PP analysis (patients receiving the full intervention) in this study, suggested that telephone consultations with dieticians could though be effective for reducing readmission rate, LOS and mortality [17]. The use of telephone consultations is supported by a recent systematic review, which concluded that telephone consultation seems to be an effective method to deliver malnutrition-related interventions to older adults living at home, and that this method is likely to result in clinical improvements compared with usual care or no intervention [29]. It should also be mentioned that the point estimate in both the exploratory analysis revealed an approximately 30% decrease in proportion of readmissions at 6 months.