Elsevier

Maturitas

Volume 111, May 2018, Pages 31-46
Maturitas

Is telehealth effective in managing malnutrition in community-dwelling older adults? A systematic review and meta-analysis

https://doi.org/10.1016/j.maturitas.2018.02.012Get rights and content

Highlights

  • Malnutrition-focused telephone consultations for older adults appear feasible.

  • Telehealth interventions can improve quality of life for malnourished older adults.

  • Telehealth can improve protein intake by 0.13 g/kg in malnourished older adults.

  • Compared with usual care, malnutrition-focused telehealth appears cost-effective.

  • Larger well designed randomised controlled trials are needed to strengthen evidence.

Abstract

Telehealth offers a feasible method to provide nutrition support to malnourished older adults. This systematic review and meta-analysis aims to determine the efficacy of telehealth methods in delivering malnutrition-related interventions to community-dwelling older adults. Studies in any language were searched in five electronic databases from inception to 2nd November 2017. Quality of the evidence was assessed using the Cochrane Risk of Bias tool and the GRADE approach. Nine studies were identified, with results published across 13 included publications, which had mostly low to unclear risk of bias. There were two interventions delivered to disease-specific groups, one with kidney disease and one with cancer; the remaining seven interventions were delivered to patients with mixed morbidities following discharge from an inpatient facility. Seven studies delivered telehealth via telephone consultations and two used internet-enabled telemedicine devices. Ten meta-analyses were performed. Malnutrition-focused telehealth interventions were found to improve protein intake in older adults by 0.13 g/kg body weight per day ([95%CI: 0.01–0.25]; P = .03; n = 2 studies; n = 200 participants; I2 = 41%; GRADE level: low) and to improve quality of life (standardised mean difference: 0.55 [95%CI: 0.11–0.99]; P = .01; n = 4 studies with n = 9 quality-of-life tools; n = 248 participants; I2 = 84%: GRADE level: very low). There were also trends towards improved nutrition status, physical function, energy intake, hospital readmission rates and mortality in the intervention groups. Overall, this review found telehealth is an effective method to deliver malnutrition-related interventions to older adults living at home, and is likely to result in clinical improvements compared with usual care or no intervention. However, further research with larger samples and stronger study designs are required to strengthen the body of evidence.

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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