Malnutrition in the older Australian rural rehabilitation community : indentification, patient outcomes and the role of informal caregivers,

Abstract

Background and literature review Enhancing the effectiveness of nutritional care to improve the overall health of older adults will be key in reducing hospital and aged care facility demand, a priority target of current health service research and policy. Engaging informal caregivers as part of the nutrition care team presents an opportunity for improving the nutrition status of older Australians in rehabilitation and the community. Rehabilitation facilities have the highest prevalence of malnutrition (5 – 68%); which is negatively associated with physical function and quality of life, and positively associated with risk of admission to residential aged care (RAC), hospitalisation and mortality following discharge to the community. However, there is insufficient evidence for informing best practice in identifying malnutrition in the rehabilitation setting and providing nutrition support to patients as they transition back to the community. Importantly, it is not known if patients remain malnourished followingdischarge from rehabilitation. The aim of this thesis is to increase the evidence-base for improving the nutrition status of older adults in rural Australia across the continuum of care and exploring the role of caregivers in supporting nutrition-related care during the transition from rehabilitation to home. Methods Therefore, the MARRC Study (Malnutrition in the Rural Rehabilitation Community) was undertaken, which comprised a prospective observational cohort study and a qualitative study. The cohort study recruited 57 malnourished older adults with informal caregivers from two rural rehabilitation units, and followed patients throughout rehabilitation and three months post-discharge. The prospective data was used to evaluate the criterion (concurrent and predictive) validity of two nutrition screening tools and two nutrition assessment tools compared to the ICD-10-AM classification of malnutrition. The prevalence of malnutrition and associated long-term patient outcomes were also reported. The change in nutrition status, quality of life and physical function of the malnourished patients over the study period was reported using a linear mixed model. The qualitative study recruited four female informal caregivers of malnourished older rehabilitation patients, who were interviewed during their care-recipients’ rehabilitation admission and two weeks post-discharge. The interviews were analysed reflecting an interpretative phenomenological approach and a series of “drivers” relevant to the research question were discussed. Results and conclusions The Malnutrition Screening Tool and the Scored Patient-Generated Subjective Global Assessment tool have strong criterion validity and are appropriate for use in geriatric rehabilitation. Other nutrition screening tools and nutrition assessment tools require further examination or modification before they can be recommended. The prevalence of malnutrition was 46%, which is similar to metropolitan facilities. However, malnourished rehabilitation patients were more likely to be discharged to RAC and readmitted to hospital. These patients were found to have continuing malnutrition, low quality of life and worsening physical function for at least three months in their homes following their discharge from rehabilitation. The qualitative study identified three drivers: “responsibility”, “caregiver nutrition ethos”, and “quality of life”, and concluded that rehabilitation dietitians should recognise and support informal caregivers of malnourished patients. The current thesis provides evidence to improve malnutrition screening, assessment, diagnosis and resource allocation in rehabilitation facilities. It also makes recommendations to improve nutrition intervention in practice, and for how intervention studies should be designed in this setting. The thesis concludes with a call to action: for dietitians to advocate for malnutrition to be of higher consideration on the rehabilitation agenda, so that patient outcomes may be improved in the long term.

Date of Award	8 Oct 2016
Original language	English
Supervisor	Elizabeth Isenring (Supervisor), Adrienne M Young (Supervisor) & Judith Dorothea Bauer (Supervisor)