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Cited by 516Nutrition and Health in AgingClinical Nutrition and GastroenterologyDysphagia Assessment and Management

ESPEN practical guideline: Clinical nutrition and hydration in geriatrics

Open access
Volkert, Dorothee, Beck, Anne Marie, Cederholm, Tommy, Cruz-Jentoft, Alfonso, Hooper, Lee, Kiesswetter, Eva, Maggio, Marcello, Raynaud-Simon, Agathe +5 more·2022·Clinical Nutrition
DOI 10.1016/j.clnu.2022.01.024
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Abstract

BACKGROUND Malnutrition and dehydration are widespread in older people, and obesity is an increasing problem. In clinical practice, it is often unclear which strategies are suitable and effective in counteracting these key health threats. AIM To provide evidence-based recommendations for clinical nutrition and hydration in older persons in order to prevent and/or treat malnutrition and dehydration. Further, to address whether weight-reducing interventions are appropriate for overweight or obese older persons. METHODS This guideline was developed according to the standard operating procedure for ESPEN guidelines and consensus papers. A systematic literature search for systematic reviews and primary studies was performed based on 33 clinical questions in PICO format. Existing evidence was graded according to the SIGN grading system. Recommendations were developed and agreed in a multistage consensus process. RESULTS We provide eighty-two evidence-based recommendations for nutritional care in older persons, covering four main topics: Basic questions and general principles, recommendations for older persons with malnutrition or at risk of malnutrition, recommendations for older patients with specific diseases, and recommendations to prevent, identify and treat dehydration. Overall, we recommend that all older persons shall routinely be screened for malnutrition in order to identify an existing risk early. Oral nutrition can be supported by nursing interventions, education, nutritional counselling, food modification and oral nutritional supplements. Enteral nutrition should be initiated if oral, and parenteral if enteral nutrition is insufficient or impossible and the general prognosis is altogether favorable. Dietary restrictions should generally be avoided, and weight-reducing diets shall only be considered in obese older persons with weight-related health problems and combined with physical exercise. All older persons should be considered to be at risk of low-intake dehydration and encouraged to consume adequate amounts of drinks. Generally, interventions shall be individualized, comprehensive and part of a multimodal and multidisciplinary team approach. CONCLUSION A range of effective interventions is available to support adequate nutrition and hydration in older persons in order to maintain or improve nutritional status and improve clinical course and quality of life. These interventions should be implemented in clinical practice and routinely used.

AI snapshot

Written from the paper’s full text.

TL;DR

This ESPEN practical guideline presents 82 recommendations for clinical nutrition and hydration in older persons, covering malnutrition, dehydration, and obesity management. It condenses the 2019 ESPEN geriatrics guideline into a practical/graphical format without changing the original recommendations.

Key findings

  • A general energy guiding value is 30 kcal/kg body weight/day, individually adjusted; protein intake should be at least 1 g/kg BW/day, with 1.0–1.2 g/kg suggested for healthy older persons, 1.2–1.5 g/kg in acute or chronic illness, and up to 2.0 g/kg in severe illness, injury, or malnutrition.
  • Older women should be offered at least 1.6 L of drinks/day and older men at least 2.0 L/day unless a clinical condition requires a different approach; this is based on EFSA adequate intake of 2.0 L/day for women and 2.5 L/day for men, assuming 80% comes from drinks.
  • ONS should provide at least 400 kcal/day including 30 g or more protein/day, be continued for at least one month, and have efficacy/expected benefit assessed monthly; in 46 trials, overall ONS compliance was 78%, better in the community (81%) than in hospital (67%).
  • Low-intake dehydration should be identified using directly measured serum/plasma osmolality >300 mOsm/kg, or calculated osmolarity >295 mmol/L if direct measurement is unavailable; simple signs/tests and bioelectrical impedance should not be used to assess hydration status in older adults.

Methods

  • This practical guideline consists of 82 recommendations based on the 2019 ESPEN guideline on clinical nutrition and hydration in geriatrics; the original was shortened, commentaries focused on the underlying evidence/literature, recommendations were not changed, and content was transformed into a graphical presentation.
  • The original guideline was developed according to the ESPEN standard operating procedure; a comprehensive systematic literature search was performed on 4 July 2016 based on 33 clinical questions in PICO format, with evidence graded by SIGN and recommendations graded A/B/0/GPP.
  • Recommendations were agreed through a multistage consensus process with percentage agreement reported; funding was exclusively from ESPEN, with guideline shortage and dissemination funded in part by UEG and ESPEN.

Limitations

  • The paper states that evidence is often poor, heterogeneous, or limited: for example, multimodal/multidisciplinary evidence grade was reduced from A to B, home-delivered meals was downgraded to B, nutritional counseling was downgraded to B, and pressure ulcer recommendation was downgraded to B because only one RCT documented benefit.
  • The paper states that the original guideline was shortened and recommendations were not changed; for further methodology details it refers readers to the full ESPEN guideline and ESPEN SOP.
  • Evident from the text: the systematic search date was 2016, so later evidence is not incorporated; many recommendations are GPP/consensus-based rather than high-grade evidence, and some guidance relies on clinical experience or common sense (e.g., counseling duration, the four-week EN time frame described as “somehow arbitrary”).

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1016/j.clnu.2022.01.024

Cites

289 of 289 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

165 of 427 cited sources checked · 91 supported · 2 flagged · accuracy not yet measured

  • Premisecitation

    Meta-analyses indicate that the mortality risk of healthy older people is lowest in the overweight range.

    “as meta-analyses indicate that the mortality risk of healthy older people is lowest in the overweight range (279-281).”
    Quote in the paperSubstantial claim3 of 3 sources checked
    • cites [279] Di Angelantonio, 2016, Body-mass index and all-cause mortality: individual-participant-data meta-analysis of 239 prospective studies in four continents, Lancet source

      The Results report that mortality was lowest at BMI 20–<25 kg/m², below the overweight range. For participants aged 70–89, the reported nadir was BMI 24 kg/m², also below the overweight threshold of 25 kg/m². The Discussion explicitly challenges earlier claims that overweight is associated with lower mortality. (LLM, conf=0.94)

      Checked by a reasoning model — may be wrong.

      Experimental — accuracy not yet measured
    • cites [280] Winter, 2014, BMI and all-cause mortality in older adults: a meta-analysis, Am J Clin Nutr source

      Table 2 and the Discussion (page not supplied) place the lowest estimated mortality risk in the overweight BMI range for adults aged 65 or older. The meta-analysis studied community-dwelling older adults, not a population restricted to healthy people, so the claim's health qualifier is not established by this source. (LLM, conf=0.84)

      Experimental — accuracy not yet measured
    • cites [281] Flegal, 2013, Association of all-cause mortality with overweight and obesity using standard body mass index categories: a systematic review and meta-analysis, JAMA source

      Table 2 reports lower all-cause mortality for the overweight category among adults aged 65 or older (HR 0.90, 95% CI 0.86–0.95, relative to normal weight). But the review does not establish that risk is lowest specifically among healthy older people: its age subgroup is not restricted to healthy participants, and it does not establish a definitive lowest-risk BMI range. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
  • Premisecitation

    Malnutrition is regarded as one important contributing factor in the complex etiology of sarcopenia and frailty.

    “and is regarded as one important contributing factor in the complex etiology of sarcopenia and frailty (1,3,4).”
    Quote in the paperNot a substantial claim3 of 3 sources checked
    • cites [1] Morley, 2017, Anorexia of ageing: a key component in the pathogenesis of both sarcopenia and cachexia, J Cachexia Sarcopenia Muscle source
    • cites [3] Cruz-Jentoft, 2010, European working group on sarcopenia in older people: sarcopenia: European consensus on definition and diagnosis. Report of the European workign group on sarcopenia in older people, Age Ageing source

      In “Sarcopenia as a geriatric syndrome” (page not provided), the paper lists less-than-optimal diet among several contributing factors to sarcopenia. Its “Frailty” section (page not provided) describes overlap with sarcopenia and includes unintended weight loss in a frailty definition, but does not identify malnutrition as a contributing cause of frailty. (LLM, conf=0.84)

      Experimental — accuracy not yet measured
    • cites [4] Clegg, 2013, Frailty in elderly people, Lancet source
  • Premisecitation

    In healthy and sick elderly persons, measurements of resting energy expenditure resulted in about 20 kcal/kg body weight and day.

    “In healthy and sick elderly persons, measurements of REE resulted in about 20 kcal/kg body weight (BW) and day (14)(15)(16).”
    Quote in the paperSubstantial claim1 of 3 sources checked
    • cites [14] Alix, 2007, Energy requirements in hospitalized elderly people, J Am Geriatr Soc source
    • cites [15] Gaillard, 2008, A practical approach to estimate resting energy expenditure in frail elderly people, J Nutr Health Aging source

      The Results (Predicted resting energy expenditure; page unavailable) report measured weight-adjusted REE close to 20 kcal/kg/day in the study’s sick elderly patients: 19.1 in normal-weight patients and 22.4 in underweight patients. The paper does not establish that figure for healthy elderly people, so the claim extends beyond the population studied. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
    • cites [16] Gaillard, 2007, Energy requirements in frail elderly people: a review of the literature, Clin Nutr source
  • Findingcitation

    One study in malnourished community-dwelling older adults failed to show any effect of individual nutritional advice and physical training.

    “One study in malnourished community-dwelling older adults failed to show any effect of individual nutritional advice and physical training (83).”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [83] Lammes, 2012, Effects of nutritional intervention and physical training on energy intake, resting metabolic rate and body composition in frail elderly. a randomised, controlled pilot study, J Nutr Health Aging source

      The Abstract conclusion reports no effect of individual nutrition counselling and physical exercise on energy intake, resting metabolic rate or fat-free mass in community-dwelling frail adults aged 75 and older. But the Results say only three of 93 participants were classified as malnourished, so the claim mischaracterizes the study population. The Discussion also reports a small, statistically significant increase in resting metabolic rate in the training group, making “any effect” too broad. (LLM, conf=0.90)

      Experimental — accuracy not yet measured
  • Findingcitation

    Five RCTs were identified comparing combined exercise and nutrition interventions to singular exercise interventions in older people with malnutrition or at risk of malnutrition.

    “Five RCTs were identified comparing combined exercise and nutrition interventions to singular exercise interventions in older people with malnutrition or at risk of J o u r n a l P r e -p r o o f malnutrition (83,87,(94)(95)(96).”
    Quote in the paperSubstantial claim2 of 3 sources checked
    • cites [83] Lammes, 2012, Effects of nutritional intervention and physical training on energy intake, resting metabolic rate and body composition in frail elderly. a randomised, controlled pilot study, J Nutr Health Aging source
    • cites [87] Miller, 2006, Nutritional supplementation and resistance training in nutritionally at risk older adults following lower limb fracture: a randomized controlled trial, Clin Rehabil source
    • cites [94] Sugawara, 2012, Effect of anti-inflammatory supplementation with whey peptide and exercise therapy in patients with COPD, Respir Med source
  • May combine two claims. 90
  • Classified as probably not a substantial claim. 49
  • The quote only partly states this claim. 1

  • May combine two claims.

    Premisecitation

    Prevalence rates of dehydration are low in independent, community-dwelling older persons but increase to more than one third in more frail and vulnerable older adults and those in need of care.

    “Prevalence rates are also low in independent, community-dwelling older persons but increase to more than one third in more frail and vulnerable older adults and those in need of care (9).”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [9] Hooper, 2015, Which frail older people are dehydrated? The UK DRIE study, J Gerontol- Series A Biol Sci Med Sci source

      The Abstract reports that 20% of the 188 UK long-term-care residents were dehydrated, contrary to the claim that prevalence in older adults needing care exceeds one third. Figure 2 in the Discussion separately reports 28% with impending dehydration; it does not classify them as currently dehydrated. The study does not establish a prevalence rate for independent, community-dwelling older people. (LLM, conf=0.88)

      Checked by a reasoning model — may be wrong.

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    In advanced age and in acute and chronic illness, nutritional problems are widespread, and reduced dietary intake combined with catabolic disease rapidly leads to malnutrition.

    “Particularly in advanced age and in the case of acute and chronic illness, nutritional problems are widespread, and a reduced dietary intake in combination with the effects of catabolic disease rapidly leads to malnutrition (1,2).”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites [1] Morley, 2017, Anorexia of ageing: a key component in the pathogenesis of both sarcopenia and cachexia, J Cachexia Sarcopenia Muscle source

      The paper’s Abstract (page unavailable) says that food intake decreases with ageing and that illness-associated inflammation can worsen anorexia and weight loss in older people. It does not establish that nutritional problems are widespread across acute and chronic illness, or that reduced intake combined with catabolic disease rapidly causes malnutrition. (LLM, conf=0.84)

      Experimental — accuracy not yet measured
    • cites [2] Agarwal, 2013, Malnutrition in the elderly: a narrative review, Maturitas source

  • May combine two claims.

    Premisecitation

    Older persons are at increased risk of dehydration for various reasons, and dehydration is related to serious health consequences.

    “Besides malnutrition, older persons are at increased risk of dehydration for various reasons, which is also related to serious health consequences (7,8).”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites [7] Hooper, 2014, Water-loss dehydration and aging, Mech Ageing Dev source
    • cites [8] Hodgkinson, 2003, Maintaining oral hydration in older adults: a systematic review, Int J Nurs Pract source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Obesity is an increasing problem in older people, currently affecting between 18 and 30% of the worldwide population aged 65 years and older.

    “obesity with its well-known negative health consequences is an increasing problem also in older people, currently affecting between 18 and 30% of the worldwide population aged 65 years and older (10,11).”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites [10] Gallus, 2015, Overweight and obesity in 16 European countries, Eur J Nutr source
    • cites [11] Porter Starr, 2016, Challenges in the management of geriatric obesity in high risk populations, Nutrients source

      Section 1, “Overview of the Obesity Challenge in High-Risk Populations,” describes obesity as an increasing global challenge among older adults. It does not give an 18–30% prevalence for the worldwide population aged 65 and older; its figures concern U.S. adults aged 60 and older, other age groups, or a worldwide change in prevalence rather than current prevalence. (LLM, conf=0.90)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Daily amounts of 1.2-1.5 g/kg have been suggested for older persons with acute or chronic illness, and up to 2.0 g/kg body weight and day in case of severe illness, injury or malnutrition.

    “Daily amounts of 1.2 -1.5 g/kg have been suggested for older persons with acute or chronic illness (17,18) and up to 2.0 g/kg BW and day in case of severe illness, injury or malnutrition (17).”
    Quote in the paperSubstantial claim2 of 2 sources checked
    • cites [17] Bauer, 2013, Evidence-based recommendations for optimal dietary protein intake in older people: a position paper from the PROT-AGE Study Group, J Am Med Dir Assoc source

      The Key PROT-AGE recommendations state that most older adults with acute or chronic disease need 1.2–1.5 g/kg body weight per day, and that those with severe illness or injury or with marked malnutrition may need as much as 2.0 g/kg. The citing sentence omits the qualification that malnutrition is marked, making that part broader than the source’s recommendation. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites [18] Deutz, 2014, Protein intake and exercise for optimal muscle function with aging: recommendations from the ESPEN Expert Group, Clin Nutr source

      The Abstract recommends 1.2–1.5 g protein/kg body weight/day for older people who are malnourished or at risk of malnutrition because of acute or chronic illness. It also recommends higher intake for severe illness or injury, but the passages in our copy do not specify an upper amount of 2.0 g/kg/day. (LLM, conf=0.87)

      Experimental — accuracy not yet measured

  • Classified as probably not a substantial claim.

    Premisecitation

    Daily amounts of 1.0-1.2 g/kg body weight have been suggested for healthy older persons by several expert groups.

    “Daily amounts of 1.0 -1.2 g/kg BW have been suggested for healthy older persons by several expert groups (17)(18)(19).”
    Quote in the paperSubstantial claim2 of 3 sources checked
    • cites [17] Bauer, 2013, Evidence-based recommendations for optimal dietary protein intake in older people: a position paper from the PROT-AGE Study Group, J Am Med Dir Assoc source
    • cites [18] Deutz, 2014, Protein intake and exercise for optimal muscle function with aging: recommendations from the ESPEN Expert Group, Clin Nutr source
    • cites [19] Rizzoli, 2014, The role of dietary protein and vitamin D in maintaining musculoskeletal health in postmenopausal women: a consensus statement from the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO), Maturitas source

  • May combine two claims.

    Findingcitation

    Three relevant systematic literature reviews of high or average quality were identified, examining training for staff in residential care, people with dementia and/or their formal or informal care-givers, and informal carers and community care workers.

    “Three relevant systematic literature reviews (SLRs) of high (63,64) or average quality (65) were identified, which examined the effectiveness of training for staff in residential care (64), people with dementia and/or their formal or informal care-givers (63) and informal carers and community care workers (65).”
    Quote in the paperSubstantial claim2 of 3 sources checked
    • cites [63] Bunn, 2016, Effectiveness of interventions to indirectly support food and drink intake in people with dementia: eating and Drinking Well IN dementiA (EDWINA) systematic review, BMC Geriatr source
    • cites [64] Abbott, 2013, Effectiveness of mealtime interventions on nutritional outcomes for the elderly living in residential care: a systematic review and meta-analysis, Ageing Res Rev source
    • cites [65] Marshall, 2013, Are informal carers and community care workers effective in managing malnutrition in the older adult community? A systematic review of current evidence, J Nutr Health Aging source

  • May combine two claims.

    Findingcitation

    The SLR by Bunn et al. included interventions with an educational and/or awareness component for persons with dementia and/or their formal or informal care-givers; the overall effect on nutritional status in the three RCTs included was very limited.

    “The SLR by Bunn et al. (63) included interventions with an educational and/or awareness component for persons J o u r n a l P r e -p r o o f with dementia and/or their formal or informal care-givers.The overall effect on nutritional status in the three RCTs included was very limited.”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [63] Bunn, 2016, Effectiveness of interventions to indirectly support food and drink intake in people with dementia: eating and Drinking Well IN dementiA (EDWINA) systematic review, BMC Geriatr source

  • May combine two claims.

    Findingcitation

    In that study, independent of the interventions, participants who needed to increase energy intake by at least 20% but failed lost weight and fat-free mass, whereas no changes were observed in those reaching this goal.

    “However, in this study independent of the interventions, participants who needed to increase their energy intake by ≥ 20% to reach their energy requirements but failed this goal lost weight and fat-free mass during the intervention period whereas no changes were observed in those reaching this goal (83).”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [83] Lammes, 2012, Effects of nutritional intervention and physical training on energy intake, resting metabolic rate and body composition in frail elderly. a randomised, controlled pilot study, J Nutr Health Aging source

  • May combine two claims.

    Premisecitation

    In older people, weight loss occurs at the expense of muscle mass and is associated with impaired physical function.

    “In older people weight loss occurs at the expense of muscle mass (78) and is associated with impaired physical function (79).”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites [78] Newman, 2005, Weight change and the conservation of lean mass in old age: the Health, Aging and Body Composition Study, Am J Clin Nutr source
    • cites [79] Ritchie, 2008, Unintentional weight loss predicts decline in activities of daily living function and life-space mobility over 4 years among community-dwelling older adults, J Gerontol Series A: Biol Sci Med Sci source

  • Classified as probably not a substantial claim.

    Premisecitation

    Due to heterogeneity, small numbers of participants and poor quality of some studies, further high-quality studies are required to provide reliable evidence on food fortification.

    “Due to the heterogeneity of the studies, small numbers of participants and poor quality of some studies, the authors concluded that further high-quality studies are required to provide reliable evidence (101).”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [101] Morilla-Herrera, 2016, Effectiveness of food-based fortification in older people. A systematic review and meta-analysis, J Nutr Health Aging source

  • May combine two claims.

    Premisecitation

    In individual patients, both nasogastric tube feeding and PEG feeding may be harmful.

    “Complication rates of EN are reported to be generally low (160), but in individual patients, both nasogastric tube feeding and PEG feeding may be harmful (136, 161).”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites [136] Wirth, 2012, Complications and mortality after percutaneous endoscopic gastrostomy in geriatrics: a prospective multicenter observational trial, J Am Med Dir Assoc source
    • cites [161] Sparks, 2011, Pulmonary complications of 9931 narrow-bore nasoenteric tubes during blind placement, J Parenter Enteral Nutr source

  • May combine two claims.

    Premisecitation

    Within this review, three studies suggested improved mortality outcomes with PEG feeding while two out of three studies reported PEG feeding to be better from a nutritional perspective.

    “Within this review, a meta-analysis was not possible for mortality and nutritional outcomes, but three studies suggested improved mortality outcomes with PEG feeding while two out of three studies reported PEG feeding to be better from a nutritional perspective.”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [166] Jaafar, 2015, Percutaneous endoscopic gastrostomy versus nasogastric feeding in older individuals with non-stroke dysphagia: a systematic review, J Nutr Health Aging source

  • May combine two claims.

    Premisecitation

    A RCT observed an increase of 17% mean volume of fluid and tube feed given in the nasal loop group, without any differences in outcome after three months.

    “A RCT observed an increase of 17% mean volume of fluid and tube feed given in the nasal loop group, without any differences in outcome after three months (169).”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [169] Beavan, 2010, Does looped nasogastric tube feeding improve nutritional delivery for patients with dysphagia after acute stroke? A randomised controlled trial, Age Ageing source

      The Results (page not available in our copy) report that the nasal-loop group received a 17-percentage-point higher proportion of prescribed feed and fluids, not a 17% increase in mean volume; mean volumes were 17.0 L versus 11.4 L. The Results describe three-month outcomes as similarly poor, and Table 2 shows no statistically significant differences in the three-month outcomes reported. (LLM, conf=0.88)

      Experimental — accuracy not yet measured

  • Classified as probably not a substantial claim.

    Interpretationcitation

    In patients with severe dementia, the risk-benefit ratio of enteral nutrition is generally unfavorable.

    “In patients with severe dementia, the risk-benefit ratio of EN is generally unfavorable and EN thus not recommended.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [163] Volkert, 2015, ESPEN guidelines on nutrition in dementia, Clin Nutr source

  • May combine two claims.

    Premisecitation

    Two studies on nasal loops in tube-fed stroke patients demonstrated that nasal loops are safe, well-tolerated and effective in delivering full enteral nutrition.

    “Two studies on nasal loops in tube-fed stroke patients demonstrated that nasal loops are safe, well-tolerated and effective in delivering full EN (167-169).”
    Quote in the paperSubstantial claim2 of 3 sources checked
    • cites [167] Anderson, 2004, The nasal loop provides an alternative to percutaneous endoscopic gastrostomy in high-risk dysphagic stroke patients, Clin Nutr source
    • cites [168] Beavan, 2007, Is looped nasogastric tube feeding more effective than conventional nasogastric tube feeding for dysphagia in acute stroke?, Trials source

      The Background (page not provided) says early reports suggest nasal loops secure tubes and may allow more reliable feeding without compromising patient acceptability. But this paper is a trial protocol: its Abstract Methods lists feed delivery, adverse events and tolerability as outcomes to be measured, not findings. It does not demonstrate safety, good tolerability or delivery of full enteral nutrition. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites [169] Beavan, 2010, Does looped nasogastric tube feeding improve nutritional delivery for patients with dysphagia after acute stroke? A randomised controlled trial, Age Ageing source

      The Discussion reports that nasal loops increased delivery of prescribed feed and fluids from 57% to 75%, not that they delivered full enteral nutrition. The Results report no significant difference in measured tolerability, but minor nasal problems were more common with loops (37% versus 15%); none required medical intervention. These findings support improved delivery and some reassurance about tolerability, but not the unqualified claims of full delivery and safety. (LLM, conf=0.88)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Most trials aiming to increase fluid intake in older adults assessed fluid intake, hydration status and health outcomes poorly, so success in increasing fluid intake is unclear.

    “Unfortunately, most trials assessed fluid intake hydration status and health outcomes poorly, so success in increasing fluid intake is unclear.”
    Quote in the paperSubstantial claim2 of 2 sources checked
    • cites [219] Abdelhamid, 2016, Effectiveness of interventions to directly improve, maintain or facilitate food and drink intake in people with dementia: eating and Drinking Well IN dementiA (EDWINA) systematic review and meta-analysis, BMC Geriatr source

      The Discussion reports insufficient high-quality evidence to establish whether the interventions were effective and calls for more robust hydration and health outcomes. The Strengths and limitations section also notes a lack of clear hydration-status data. These findings support the concern about poor assessment and uncertain effectiveness, but the review concerns people with dementia, not older adults generally, and does not establish that most trials poorly assessed all three named outcomes. (LLM, conf=0.85)

      Experimental — accuracy not yet measured
    • cites [220] Bunn, 2015, Increasing fluid intake and reducing dehydration risk in older people living in long-term care: a systematic review, J Am Med Dir Assoc source

      The Discussion (page unavailable) says most studies had considerable risk of bias and that, without 24-hour measurement, a change in overall fluid intake cannot be determined. The Risk of Bias section (page unavailable) finds fluid-intake or hydration assessment at high risk of bias in 16 of 23 studies. The copy supports uncertainty about increasing fluid intake, but does not specifically establish that most trials assessed health outcomes poorly. (LLM, conf=0.84)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Combined analysis of eleven trials using standard ONS indicated a reduced risk of postoperative complications, whereas for high-protein ONS (two RCTs) no such effect was found.

    “Combined analysis of eleven trials using standard ONS indicated a reduced risk of postoperative complications, whereas for high-protein ONS (two RCTs) no such effect was found (182).”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [182] Avenell, 2016, Nutritional supplementation for hip fracture aftercare in older people, Cochrane Database Syst Rev source

  • May combine two claims.

    Premisecitation

    A range of positive effects are reported after six to twelve months for nutritional interventions in orthogeriatric patients, e.g. reduced length of hospital stay, improved independence in activities of daily living, improved mobility, reduced in-hospital falls and fall-related injuries, decreased emergency department visits, significantly fewer days of delirium, fewer pressure ulcers, reduced-nut

    “A range of positive effects are reported after six to twelve months, e.g.reduced length of hospital stay (55,56), improved independence in activities of daily living (56,192,193), improved mobility (56), reduced in-hospital falls and fall-related injuries (57), decreased emergency department visits (192) significantly fewer days of delirium (55), fewer pressure ulcers (55), reduced nursing home ad”
    Quote in the paperSubstantial claim1 of 5 sources checked
    • cites [55] Olofsson, 2007, Malnutrition in hip fracture patients: an intervention study, J Clin Nurs source
    • cites [56] Stenvall, 2007, A multidisciplinary, multifactorial intervention program reduces postoperative falls and injuries after femoral neck fracture, Osteoporos Int source

      Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

      Experimental — accuracy not yet measured
    • cites [192] Shyu, 2016, Enhanced interdisciplinary care improves self-care ability and decreases emergency department visits for older Taiwanese patients over 2 years after hip-fracture surgery: a randomised controlled trial, Int J Nurs Stud source
    • cites [193] Singh, 2012, Effects of high-intensity progressive resistance training and targeted multidisciplinary treatment of frailty on mortality and nursing home admissions after hip fracture: a randomized controlled trial, J Am Med Dir Assoc source
    • cites [57] Stenvall, 2007, Improved performance in activities of daily living and mobility after a multidisciplinary postoperative rehabilitation in older people with femoral neck fracture: a randomized controlled trial with 1-year follow-up, J Rehabil Med source

  • May combine two claims.

    Premisecitation

    Hypophosphatemia was associated with an increased length of hospital stay and mortality rate, which was however no longer significant in a multivariate analysis.

    “Hypophosphatemia was also associated with an increased length of hospital stay and mortality rate, which was however no longer significant in a multivariate analysis (176).”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [176] Kagansky, 2005, Hypophosphataemia in old patients is associated with the refeeding syndrome and reduced survival, J Intern Med source

  • May combine two claims.

    Premisecitation

    Memory problems may cause older adults to forget to drink and forget that they haven't drunk.

    “Memory problems may cause older adults to forget to drink and forget that they haven't drunk (7)(8)(9)252).”
    Quote in the paperNot a substantial claim3 of 4 sources checked
    • cites [7] Hooper, 2014, Water-loss dehydration and aging, Mech Ageing Dev source
    • cites [8] Hodgkinson, 2003, Maintaining oral hydration in older adults: a systematic review, Int J Nurs Pract source
    • cites [9] Hooper, 2015, Which frail older people are dehydrated? The UK DRIE study, J Gerontol- Series A Biol Sci Med Sci source

      The paper’s introductory passage says people with dementia may forget to drink when daily routines are lost, and the Discussion says dementia can disrupt drinking habits. It does not say they forget that they have not drunk; the study also cautions that its cross-sectional findings cannot establish causation. No page numbers are available in our copy. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites [252] Marra, 2016, Elevated serum osmolality and total water deficit indicate impaired hydration status in residents of long-term care facilities regardless of low or high body mass index, J Acad Nutr Diet source

      The Introduction (page not provided) says residents with cognitive impairment may be unaware of their needs and forget to drink or request beverages. It does not say they forget whether they have already drunk, so that part of the claim is not supported. (LLM, conf=0.85)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Reduced thirst and reduced urine concentration by the kidney increase dehydration risk in older adults.

    “Among age-related physiological changes, reduced thirst and reduced urine concentration by the kidney increase dehydration risk (9,(243)(244)(245)(246).”
    Quote in the paperSubstantial claim1 of 5 sources checked
    • cites [9] Hooper, 2015, Which frail older people are dehydrated? The UK DRIE study, J Gerontol- Series A Biol Sci Med Sci source

      The paper’s introductory passage says older people are thought to face greater dehydration risk because thirst sensation and urinary concentrating ability frequently decline with age. The Discussion cautions that DRIE was cross-sectional and could not establish whether poor renal function causes dehydration or the reverse. The citing sentence presents the risk increase as established rather than qualified. (LLM, conf=0.83)

      Experimental — accuracy not yet measured
    • cites [243] Davies, 1995, Age-associated alterations in thirst and arginine vasopressin in response to a water or sodium load, Age Ageing source
    • cites [244] de Castro, 1992, Age-related changes in natural spontaneous fluid ingestion and thirst in humans, J Gerontol: Psychol Sci source
    • cites [245] Lindeman, 1985, Longitudinal studies on the rate of decline in renal function with age, J Am Geriatr Soc source
    • cites [246] Rowe, 1976, The influence of age on the renal response to water deprivation in man, Nephron source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    A small short term RCT in older adults with severe cognitive impairment suggested that cervical spine manipulation may increase dysphagia limit for those with swallowing problems, but effects on hydration were not assessed.

    “A small short term RCT in older adults with severe cognitive impairment J o u r n a l P r e -p r o o f suggested that cervical spine manipulation may increase dysphagia limit for those with swallowing problems, but effects on hydration were not assessed (265).”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [265] Bautmans, 2008, Dysphagia in elderly nursing home residents with severe cognitive impairment can be attenuated by cervical spine mobilization, J Rehabil Med source

  • Classified as probably not a substantial claim.

    Premisecitation

    Maintaining stable body weight is considered desirable for overweight older adults.

    “Therefore, and to avoid a progression to obesity, maintaining stable BW is considered desirable for overweight older adults (11).”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [11] Porter Starr, 2016, Challenges in the management of geriatric obesity in high risk populations, Nutrients source

  • May combine two claims.

    Premisecitation

    In people following stroke, thickened fluids alongside access to free water compared to thickened liquids alone was effective at protecting against aspiration and increasing fluid intake.

    “A recent systematic review and guidelines report RCTs showing that in people following stroke, thickened fluids alongside access to free water (no other drinks) compared to thickened liquids alone was effective at protecting against aspiration and increasing fluid intake.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [110] Burgos, 2017, ESPEN guideline on clinical nutrition in Neurology, Clin Nutr source

      In the Recommendation 61 commentary (page unavailable), the guideline describes stroke trials comparing thickened liquids plus free water with thickened liquids alone, and reports no pneumonia in either group. But the reported RCT found identical mean total beverage intake in both groups; the guideline does not establish that free water increased intake or protected against aspiration compared with thickened liquids alone. (LLM, conf=0.87)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Obesity, especially severe obesity (BMI ≥35 kg/m2), increases metabolic and cardiovascular risk as well as the risk of mobility limitations and frailty in older persons, particularly when marked muscle loss has already occurred.

    “Obesity, especially severe obesity (BMI ≥35 kg/m²), increases metabolic and cardiovascular risk as well as the risk of mobility limitations and frailty in older persons (277,278,285), particularly when marked muscle loss has already occurred (283).”
    Quote in the paperNot a substantial claim1 of 4 sources checked
    • cites [277] Visvanathan, 2012, Australian and New Zealand Society for Geriatric Medicine: position statement-obesity and the older person, Australas J Ageing source
    • cites [278] Villareal, 2005, Obesity in older adults: technical review and position statement of the American Society for Nutrition and NAASO, the Obesity Society, Obesity source
    • cites [285] Batsis, 2018, Addressing obesity in aging patients, Med Clin source

      The sections “Impact of Obesity on Physical Function/Disability” and “Sarcopenic Obesity – a subset of high-risk individuals” link obesity to disability and reduced function in older adults, with greater risk when low muscle mass or strength coexists. “Defining Obesity in Older Adults” discusses cardiometabolic risk, but does not establish that BMI ≥35 specifically increases that risk; it also does not establish that obesity increases frailty risk. Page numbers are unavailable in our copy. (LLM, conf=0.84)

      Experimental — accuracy not yet measured
    • cites [283] Parr, 2013, ‘Sarcobesity’: a metabolic conundrum, Maturitas source

  • May combine two claims.

    Premisecitation

    In cases of obesity with comorbidities, positive effects of intended weight loss on orthopedic problems, cardiovascular and metabolic risk, insulin sensitivity, chronic inflammation, and functional limitations have been reported, partly in combination with physical exercise.

    “In these cases, positive effects of intended weight loss on orthopedic problems, cardiovascular and metabolic risk, insulin sensitivity, chronic inflammation, and functional limitations have been reported, partly in combination with physical exercise (11,274,276,278,285,286).”
    Quote in the paperSubstantial claim3 of 6 sources checked
    • cites [11] Porter Starr, 2016, Challenges in the management of geriatric obesity in high risk populations, Nutrients source

      The Overview section (page unavailable) reports that planned, supervised weight reduction in obese older adults can improve type 2 diabetes, coronary heart disease, osteoarthritis symptoms, and physical function. It also describes weight reduction combined with exercise. The copy does not report improved insulin sensitivity or reduced chronic inflammation from weight loss; its discussion of inflammation concerns obesity’s contribution to a chronic inflammatory state. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites [274] Garvey, 2016, American Association of Clinical Endocrinologists and American College of Endocrinology comprehensive clinical practice guidelines for medical care of patients with obesity, Endocr Pract source
    • cites [276] Mathus-Vliegen, 2012, Prevalence, pathophysiology, health consequences and treatment options of obesity in the elderly: a guideline, Obes Facts source
    • cites [278] Villareal, 2005, Obesity in older adults: technical review and position statement of the American Society for Nutrition and NAASO, the Obesity Society, Obesity source
    • cites [285] Batsis, 2018, Addressing obesity in aging patients, Med Clin source

      The “Evidence for Weight Loss in Older Adults?” section reports improved physical performance when intentional weight loss was combined with exercise, and “Cautions of Losing Weight in Older Adults” describes improvements in cardiometabolic risk and physical function. The copy does not report benefits for orthopedic problems, insulin sensitivity, or chronic inflammation; its evidence also concerns older adults rather than all people with obesity and comorbidities. No page numbers are available in our copy. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites [286] Gill, 2015, Weight management in older adults, Curr Obes Rep source

  • May combine two claims.

    Premisecitation

    Studies with a strong social element, where socializing around food and drink was supported, tended to improve quality of life, nutritional status and fluid intake.

    “but a key suggestion from assessments of nutrition more generally was that studies with a strong social element, where socializing around food and drink was supported, tended to improve quality of life, nutritional status and fluid intake (219).”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [219] Abdelhamid, 2016, Effectiveness of interventions to directly improve, maintain or facilitate food and drink intake in people with dementia: eating and Drinking Well IN dementiA (EDWINA) systematic review and meta-analysis, BMC Geriatr source

      The Results section reports that small studies of social activities around meals found improvements in interaction and enjoyment, and one family-style-meal study found increased weight. The Discussion says social interventions consistently suggested possible improvements in aspects of quality of life. It does not report improved fluid intake from those interventions, and the nutritional finding is limited to one study; no page numbers were provided in our copy. (LLM, conf=0.88)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    The combination with exercise training had comparable if not greater effects than the singular weight-reducing diets regarding the reduction of body weight and fat mass, while often preserving lean mass better than diet alone.

    “The combination with J o u r n a l P r e -p r o o f exercise training had comparable if not greater effects than the singular weight-reducing diets regarding the reduction of BW and fat mass, while often preserving lean mass better than diet alone (289-291, 295-297, 299).”
    Quote in the paperSubstantial claim6 of 7 sources checked
    • cites [289] Villareal, 2011, Weight loss, exercise, or both and physical function in obese older adults, N Engl J Med source
    • cites [290] Avila, 2010, Effect of moderate intensity resistance training during weight loss on body composition and physical performance in overweight older adults, Eur J Appl Physiol source
    • cites [291] Frimel, 2008, Exercise attenuates the weight-loss-induced reduction in muscle mass in frail obese older adults, Med Sci Sports Exerc source
    • cites [295] Chomentowski, 2009, Moderate exercise attenuates the loss of skeletal muscle mass that occurs with intentional caloric restriction-induced weight loss in older, overweight to obese adults, J Gerontol A Biol Sci Med Sci source
    • cites [296] Campbell, 2009, Resistance training preserves fat-free mass without impacting changes in protein metabolism after weight loss in older women, Obesity (Silver Spring) source
    • cites [297] Dunstan, 2002, High-intensity resistance training improves glycemic control in older patients with type 2 diabetes, Diabetes Care source
    • cites [299] Amati, 2008, Separate and combined effects of exercise training and weight loss on exercise efficiency and substrate oxidation, J Appl Physiol (1985) source

  • May combine two claims.

    Premisecitation

    Treatment for low-intake dehydration involves the administration of hypotonic fluids, which will help correct the fluid deficit while diluting down the raised osmolality.

    “Treatment for low-intake dehydration involves the administration of hypotonic fluids (222-224), which will help correct the fluid deficit while diluting down the raised osmolality.”
    Quote in the paperSubstantial claim2 of 3 sources checked
    • cites [222] Cheuvront, 2013, Physiologic basis for understanding quantitative dehydration assessment, Am J Clin Nutr source

      The Introduction (page unavailable) says that fluid acquisition is necessary to restore body-water balance, and the section on AVP and thirst responses says water loading lowers plasma osmolality. The paper does not recommend administering hypotonic fluids as treatment for low-intake dehydration, so it supports the underlying physiology but not the cited treatment claim. (LLM, conf=0.78)

      Experimental — accuracy not yet measured
    • cites [223] Nadal, 1941, A comparison between dehydration from salt loss and from water deprivation, J Clin Invest source

      The Procedure and Results (pages unavailable) show that subjects dehydrated by water deprivation recovered after receiving distilled water, supporting replacement of a water deficit with salt-free fluid. The paper does not recommend hypotonic-fluid administration as a clinical treatment or show that it lowers raised osmolality; the Results report no significant change in serum sodium in Experiment IIA. (LLM, conf=0.84)

      Experimental — accuracy not yet measured
    • cites [224] Thomas, 2008, Understanding clinical dehydration and its treatment, JAMDA source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The review suggested that overall the studies were at high risk of bias.

    “but suggested that overall the studies were at high risk of bias.”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [220] Bunn, 2015, Increasing fluid intake and reducing dehydration risk in older people living in long-term care: a systematic review, J Am Med Dir Assoc source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The introduction of the US Resident Assessment Instrument (which requires mandatory monitoring and reporting of hydration risks) reduced dehydration in older adults.

    “It was also suggested that the introduction of the US Resident Assessment Instrument (which requires mandatory monitoring and reporting of hydration risks) reduced dehydration in older adults(220, 261).”
    Quote in the paperNot a substantial claim2 of 2 sources checked
    • cites [220] Bunn, 2015, Increasing fluid intake and reducing dehydration risk in older people living in long-term care: a systematic review, J Am Med Dir Assoc source

      The RAI-MDS section (page unavailable) reports that dehydration prevalence in US nursing-home residents fell from 3% to 1% after compulsory implementation, supporting the suggested reduction. It does not say that the instrument requires mandatory monitoring and reporting of hydration risks, and the finding is specific to long-term-care residents rather than older adults generally. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites [261] Fries, 1997, Effect of the national resident assessment instrument on selected health conditions and problems, J Am Geriatr Soc source

      The Results and Discussion report that dehydration prevalence fell after RAI implementation among US nursing-home residents, and the authors suggest the RAI contributed while acknowledging other possible causes. The paper describes required resident assessments and guidelines for identifying dehydration risks, but does not establish a requirement to report those risks; its findings also concern nursing-home residents, not older adults generally. (LLM, conf=0.84)

      Experimental — accuracy not yet measured

  • Classified as probably not a substantial claim.

    Premisecitation

    A recent systematic review suggested that multiple strategies including involvement and input from older adults, staff, management, and policymakers will be needed to address problems with drinking in residential care.

    “A recent systematic review (see recommendations 67, 68) suggested that multiple strategies including involvement and input from older adults, staff, management, and policymakers will be needed to address problems with drinking in residential care (220).”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [220] Bunn, 2015, Increasing fluid intake and reducing dehydration risk in older people living in long-term care: a systematic review, J Am Med Dir Assoc source

      The Abstract says reducing dehydration in long-term care is likely to require multiple strategies involving policymakers, management, and care staff. The Conclusion calls for work at resident, institutional, and policy levels and for person-centered approaches to drinking barriers, but it does not specifically call for older adults’ involvement and input. (LLM, conf=0.83)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Sample sizes were small (between 18 and 140 participants), the interventions were always started within five days from surgery and usually continued until discharge or until oral intake was sufficient.

    “Sample sizes were small (between 18 and 140 participants), the interventions were always started within five days from surgery and usually continued until discharge or until oral intake was sufficient.”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [182] Avenell, 2016, Nutritional supplementation for hip fracture aftercare in older people, Cochrane Database Syst Rev source

  • May combine two claims.

    Premisecitation

    Regarding mortality and complication risk, the meta-analysis of EN only studies as well as the RCT using EN followed by ONS showed no evidence of an effect.

    “Regarding mortality and complication risk, the meta-analysis of EN only studies as well as the RCT using EN followed by ONS showed no evidence of an effect.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [182] Avenell, 2016, Nutritional supplementation for hip fracture aftercare in older people, Cochrane Database Syst Rev source

  • May combine two claims.

    Premisecitation

    The Cochrane analysis from Avenell et al. found three RCTs and one quasi-randomized trial that tested the effects of supplementary overnight EN alone and one additional RCT that tested overnight EN followed by ONS.

    “The Cochrane analysis from Avenell et al. (182) found three RCTs and one quasirandomized trial that tested the effects of supplementary overnight EN alone and oneadditional RCT that tested overnight EN followed by ONS.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [182] Avenell, 2016, Nutritional supplementation for hip fracture aftercare in older people, Cochrane Database Syst Rev source

      The Nasogastric tube feeding section identifies four studies of tube feeding, and the Nasogastric tube feeding and oral supplements section identifies one additional study (Sullivan 2004) using nightly tube feeding followed by oral supplements. The retrieved passages do not establish that the first four comprised exactly three RCTs and one quasi-randomized trial, or that all four used overnight feeding. (LLM, conf=0.78)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Weight loss increases the risk of sarcopenia, frailty, functional decline, fractures, and malnutrition.

    “and consequently increases the risk of sarcopenia, frailty, functional decline, fractures, and malnutrition (276, 282, 283).”
    Quote in the paperSubstantial claim2 of 3 sources checked
    • cites [276] Mathus-Vliegen, 2012, Prevalence, pathophysiology, health consequences and treatment options of obesity in the elderly: a guideline, Obes Facts source

      In “Nutrition and Diet” (page not specified), the guideline says diet-induced weight loss could worsen age-related muscle loss and impair physical function. In “Who Should Lose Weight and What Are the Concerns?” (page not specified), it identifies sarcopenic obesity and hip fractures as potential adverse effects, but limits the fracture association to non-overweight elderly people. It does not say weight loss increases malnutrition risk, and it links frailty to sarcopenic obesity rather than directly to weight loss; the claim also states as certain what the guideline presents as a risk. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
    • cites [282] Cetin, 2014, Obesity in the elderly: more complicated than you think, Cleve Clin J Med source

      The “CETIN AND NASR” section says intentional weight loss also reduces skeletal muscle, and “SARCOPENIA: LOSS OF MUSCLE WITH AGE” links muscle loss to frailty and loss of physical function. But Table 2 lists improved physical function with intentional weight loss, while the treatment discussion names protection from fractures as a potential benefit. The paper does not establish that weight loss increases fracture or malnutrition risk. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
    • cites [283] Parr, 2013, ‘Sarcobesity’: a metabolic conundrum, Maturitas source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Volume depletion follows medical conditions resulting in excessive losses of fluid and electrolytes, such as excessive blood loss, vomiting, and diarrhea.

    “and following medical conditions resulting in excessive losses of fluid and electrolytes, such as excessive blood loss, vomiting, and diarrhea (221-224).”
    Quote in the paperNot a substantial claim2 of 4 sources checked
    • cites [221] Cheuvront, 2010, Biological variation and diagnostic accuracy of dehydration assessment markers, Am J Clin Nutr source
    • cites [222] Cheuvront, 2013, Physiologic basis for understanding quantitative dehydration assessment, Am J Clin Nutr source

      In “Two Critical Caveats to Understanding Osmotic Responses to Dehydration” (pp. 1–4), the paper identifies vomiting and secretory diarrhea as causes of isotonic hypovolemia, also called volume depletion because solute is lost along with water. It discusses blood-volume loss when assessing volume depletion, but does not explicitly identify excessive blood loss as a cause in the same way. (LLM, conf=0.79)

      Experimental — accuracy not yet measured
    • cites [223] Nadal, 1941, A comparison between dehydration from salt loss and from water deprivation, J Clin Invest source

      The Results (page not specified) state that loss of extracellular electrolyte reduces extracellular and plasma volume. The “Mixed type of dehydration” section (page not specified) identifies vomiting and diarrhea as causes of dehydration, but the paper does not identify excessive blood loss as a cause in this discussion. (LLM, conf=0.85)

      Experimental — accuracy not yet measured
    • cites [224] Thomas, 2008, Understanding clinical dehydration and its treatment, JAMDA source

  • May combine two claims.

    Findingcitation

    In an RCT of acceptable quality, additional individual nutritional support by dietetic assistants in older hospitalized patients with hip fractures increased energy intake and decreased mortality in the trauma unit and within four months after discharge compared to standard care.

    “The study reported increased energy intake and decreased mortality in the trauma unit and within four months after discharge in the intervention group compared to the group with standard care.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [46] Duncan, 2005, Using dietetic assistants to improve the outcome of hip fracture: a randomised controlled trial of nutritional support in an acute trauma ward, Age Ageing source

  • May combine two claims.

    Findingcitation

    In Feldblum et al., there were no intervention effects on energy or protein intake, body weight, and functional measures.

    “however, no intervention effects on energy or protein intake, BW, and functional measures.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [47] Feldblum, 2011, Individualized nutritional intervention during and after hospitalization: the nutrition intervention study clinical trial, J Am Geriatr Soc source

  • May combine two claims.

    Findingcitation

    Feldblum et al. extended an individualized nutritional intervention in older internal medical patients to six months after hospitalization and reported an improved Mini Nutritional Assessment score and reduced mortality in the intervention compared to the control group.

    “Feldblum et al. (47) extended an individualized nutritional intervention in older internal medical patients to six months after hospitalization and reported an improved Mini Nutritional Assessment (MNA) score and reduced mortality in the intervention compared to the control group”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [47] Feldblum, 2011, Individualized nutritional intervention during and after hospitalization: the nutrition intervention study clinical trial, J Am Geriatr Soc source

  • May combine two claims.

    Findingcitation

    In that RCT, bodyweight, grip strength, complications, and length of hospital stay were unaffected.

    “Bodyweight, grip strength, complications, and length of hospital stay were however unaffected.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [46] Duncan, 2005, Using dietetic assistants to improve the outcome of hip fracture: a randomised controlled trial of nutritional support in an acute trauma ward, Age Ageing source

  • May combine two claims.

    Findingcitation

    Multidisciplinary nutritional care concepts including regular team meetings increased dietary intake and improved quality of life in hip fracture patients.

    “Multidisciplinary nutritional care concepts including regular team meetings increased dietary intake and improved quality of life in hip fracture patients (41)”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [41] Hoekstra, 2011, Effectiveness of multidisciplinary nutritional care on nutritional intake, nutritional status and quality of life in patients with hip fractures: a controlled prospective cohort study, Clin Nutr source

  • May combine two claims.

    Findingcitation

    Positive effects on various outcome parameters were reported in multimodal and multidisciplinary intervention studies, but results were not always consistent.

    “Positive effects on various outcome parameter were reported (e.g.dietary intake (49,50,53), nutritional status, the incidence of falls (53,56), fall-related injuries (56), health status (55), physical performance (48)(49)(50)(51)57), social activity (49,50), costeffectiveness (52) and quality of life (48,51)), results were however not always consistent.”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [48] Beck, 2016, Multidisciplinary nutritional support for undernutrition in nursing home and home-care: a cluster randomized controlled trial, Nutrition source
    • cites [49] Beck, 2008, Multifaceted nutritional intervention among nursing-home residents has a positive influence on nutrition and function, Nutrition source
    • cites [50] Beck, 2010, Physical and social functional abilities seem to be maintained by a multifaceted randomized controlled nutritional intervention among old (>65 years) Danish nursing home residents, Arch Gerontol Geriatr source

  • May combine two claims.

    Findingcitation

    Three RCTs of low to acceptable quality in older hospitalized patients at nutritional risk with various diagnoses or after acute stroke reported positive effects on energy and protein intake, body weight, complications, antibiotic use, readmissions, and functional measures.

    “Three RCTs of low to acceptable quality investigated the effects of comprehensive individualized nutritional interventions in older hospitalized patients at nutritional risk with various diagnoses (43,44) or after acute stroke (45), and reported positive effects on energy and protein intake (43,44), BW (44,45), complications, antibiotic use, readmissions (44) and functional measures (44,45).”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [43] Rufenacht, 2010, Nutritional counseling improves quality of life and nutrient intake in hospitalized undernourished patients, Nutrition source
    • cites [44] Starke, 2011, Short-term individual nutritional care as part of routine clinical setting improves outcome and quality of life in malnourished medical patients, Clin Nutr source
    • cites [45] Ha, 2010, Individual, nutritional support prevents undernutrition, increases muscle strength and improves QoL among elderly at nutritional risk hospitalized for acute stroke: a randomized, controlled trial, Clin Nutr source

  • May combine two claims.

    Findingcitation

    The narrative summation and meta-analysis did not find any significant effects, but trends in favor of individualized dietary counseling were reported for most outcomes considered.

    “The narrative summation and meta-analysis did not find any significant effects, but trends in favor of individualized dietary counseling were reported for most outcomes considered (99).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [99] 2016, National Clinical Guideline for exercise and nutrition to old people with geriatric problems, DHMA

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    Meta-analysis results were in favor of dining environment alteration regarding body weight (all three RCTs) and energy intake (two RCTs) but were not significant.

    “Meta-analysis results were in favor of the intervention regarding BW (all three RCTs) and energy intake (two RCTs) but not J o u r n a l P r e -p r o o f significant.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [64] Abbott, 2013, Effectiveness of mealtime interventions on nutritional outcomes for the elderly living in residential care: a systematic review and meta-analysis, Ageing Res Rev source

  • May combine two claims.

    Findingcitation

    Abbott et al. included six feeding assistance studies; two RCTs and three pre-post comparisons described positive effects on dietary intake.

    “Abbott et al. (64) included six feeding assistance studies.Two RCTs and three pre-post comparisons described positive effects on dietary intake.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [64] Abbott, 2013, Effectiveness of mealtime interventions on nutritional outcomes for the elderly living in residential care: a systematic review and meta-analysis, Ageing Res Rev source

  • May combine two claims. The quote only partly states this claim.

    Findingcitation

    Quality of life was examined in two studies which both found beneficial effects of dining environment alteration.

    “Quality of life was examined in two studies which both found beneficial effects.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [64] Abbott, 2013, Effectiveness of mealtime interventions on nutritional outcomes for the elderly living in residential care: a systematic review and meta-analysis, Ageing Res Rev source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingcitation

    Young et al. reviewed evidence on nutritional education or advice in people over 65 years living at home; five studies had nutritional education as the sole constituent, while the rest included it as part of a more complex intervention.

    “Young et al. (77) reviewed the evidence regarding the effectiveness of nutritional education or advice in people over 65 years of age living at home.Five studies (of 23) had nutritional education as the sole constituent of the program, whilst the rest included it as part of a more complex intervention.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [77] Young, 2011, Nutritional education for community dwelling older people: a systematic review of randomised controlled trials, Int J Nurs Stud source

  • May combine two claims.

    Findingreasoning

    Study designs and results of included studies were heterogeneous with partly positive effects on dietary intake and nutritional status.

    “Study designs and results of included studies were heterogeneous with partly positive effects on dietary intake and nutritional status.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Findingnone given

    No intervention studies have been performed among old people in home-care where malnutrition and risk of malnutrition are also prevalent.

    “No intervention studies have been performed among old people in home-care where malnutrition and risk of malnutrition are also prevalent.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    Meta-analysis found positive effects of individualized dietary counseling on body weight, energy, and protein intake but no effect on handgrip strength or mortality compared to brief dietary advice or no intervention.

    “Meta-analysis found positive effects on BW, energy, and protein intake but no effect on handgrip strength or mortality compared to brief dietary advice or no intervention (100).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [100] Munk, 2016, Individualised dietary counselling for nutritionally at-risk older patients following discharge from acute hospital to home: a systematic review and meta-analysis, J Hum Nutr Diet source

  • May combine two claims.

    Premisecitation

    Malnutrition is related to poor outcomes including increased rates of infections, length of hospital stay, duration of convalescence after acute illness, and mortality risk.

    “Malnutrition is related to poor outcome, e.g.increased rates of infections, length of hospital stay, duration of convalescence after acute illness as well as mortality risk (2)”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [2] Agarwal, 2013, Malnutrition in the elderly: a narrative review, Maturitas source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Reported prevalence rates of malnutrition are generally below 10% in independently living older persons and increase up to two thirds in hospitalized older patients.

    “Reported prevalence rates are generally below 10% in independently living older persons and increase up to two thirds in hospitalized older patients (5,6).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [5] Kaiser, 2010, Frequency of malnutrition in older adults: a multinational perspective using the mini nutritional assessment, J Am Geriatr Soc source
    • cites [6] Cereda, 2016, Nutritional status in older persons according to healthcare setting: a systematic review and meta-analysis of prevalence data using MNA®, Clin Nutr source

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    Given the variation in minimal drinks recommendations, the use of the EFSA fluid recommendation seems appropriately cautious in older adults.

    “Given this variation, the use of the EFSA fluid recommendation seems appropriately cautious in older adults.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    Daily amounts of 25 g of dietary fiber are considered adequate for normal laxation in adults of all ages and can be regarded as a guiding value also for older patients.

    “Daily amounts of 25 g are considered adequate for normal laxation in adults of ages (23) and can be regarded as guiding value also for older patients.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [23] European Food Safety Authority (EFSA), 2010, Scientific opinion on dietary reference values for carbohydrates and dietary fibre, EFSA J

      Not checked in the free run.

  • May combine two claims.

    Premisereasoning

    Basal energy requirements are influenced by gender and nutritional status; REE/kg body weight is higher for men than for women and increases with decreasing BMI.

    “Due to their strong relation to fat-free mass, basal energy requirements are also influenced by gender and by nutritional status; in fact, REE/kg BW is higher for men than for women and increases with decreasing body mass index (BMI).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Existing evidence was graded according to the SIGN grading system.

    “Existing evidence was graded according to the SIGN (Scottish Intercollegiate Guidelines Network) grading system.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    All recommendations were agreed in a multistage consensus process, which resulted in a percentage of agreement.

    “All recommendations were agreed in a multistage consensus process, which resulted in a percentage of agreement (%).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    As reviewed by Darmon et al., restrictive diets seem to be less effective with increasing age, although data about their effects in older persons are rare.

    “As recently reviewed by Darmon et al. (59), restrictive diets furthermore seem to be less effective with increasing age, albeit data about their effects in older persons are rare.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [59] Darmon, 2010, Restrictive diets in the elderly: never say never again?, Clin Nutr source

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    A comprehensive, systematic literature search was performed on 4 July 2016 based on 33 clinical questions in PICO format.

    “A comprehensive, systematic literature search was performed on 4th July 2016 based on 33 clinical questions in PICO (population of interest, interventions, comparisons, outcomes) format.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Interpretationreasoning

    Assuming 80% of fluid needs come from drinks, women would require 1.6 L/day of drinks and men 2.0 L/day.

    “Assuming 80% of these fluid needs to come from drinks then women would require 1.6 L/d of drinks, and men 2.0 L/d.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductreasoning

    Because of partly inconsistent results, the evidence grade was reduced from A to B.

    “Because of partly inconsistent results, the evidence grade was reduced from A to B.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    Nutritional counseling by a health care professional is regarded as the first line of nutrition therapy.

    “Nutritional counseling by a health care professional is regarded as the first line of nutrition therapy.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Eating is a social act, and eating in company is known to stimulate dietary intake, also in older persons.

    “Eating is a social act, and eating in company is known to stimulate dietary intake, also in older persons (70,71).”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [70] Stroebele, 2004, Effect of ambience on food intake and food choice, Nutrition source
    • cites [71] De Castro, 1992, The amount eaten in meals by humans is a power function of the number of people present, Physiol Behav source

  • Classified as probably not a substantial claim.

    Premisecitation

    In a position statement, the American Dietetic Association concludes that liberalization of diet prescriptions for older adults in long-term care may enhance nutritional status and quality of life.

    “In a position statement, the American Dietetic Association concludes that the liberalization of diet prescriptions for older adults in longterm care may enhance the nutritional status and quality of life (61).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [61] Niedert, 2005, Position of the American Dietetic Association: liberalization of the diet prescription improves quality of life for older adults in long-term care, J Am Diet Assoc source

  • May combine two claims.

    Interpretationreasoning

    Scientific evidence is presently poor, but education and support for formal and informal caregivers are rated as one promising strategy among others to support adequate dietary intake of older persons with malnutrition or at risk of malnutrition.

    “Altogether, scientific evidence is presently poor, but education and support for formal and informal caregivers are rated as one promising strategy among others to support the adequate dietary intake of older persons with malnutrition or at risk of malnutrition.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Enteral nutrition is frequently commenced late after substantial weight loss has already developed, which is in the stage of severe malnutrition and hampers effective nutritional therapy.

    “EN is frequently commenced late after substantial weight loss has already developed, which is in the stage of severe malnutrition (128, 129) and which hampers effective nutritional therapy (130).”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [128] Loser, 1998, Enteral long-term nutrition via percutaneous endoscopic gastrostomy (PEG) in 210 patients a four-year prospective study, Dig Dis Sci source
    • cites [129] Klose, 2003, Nutritional status and quality of life in patients with percutaneous endoscopic gastrostomy (PEG) in practice: prospective one-year follow-up, Dig Dis Sci source
    • cites [130] Donini, 2009, Predicting the outcome of artificial nutrition by clinical and functional indices, Nutrition source

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Premisenone given

    Rigorous prospective RCTs comparing enteral nutrition with no feeding are not feasible for ethical reasons.

    “Rigorous prospective RCTs comparing EN with no feeding are not feasible for ethical reasons.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    One systematic literature review focusing on the time after hospital discharge included six trials and found evidence for increased dietary intake and body weight with ONS, but not concerning mortality or readmission risk.

    “One SLR focusing on the time following hospital discharge (116) included six trials and found evidence for increased dietary intake and BW with ONS, but not concerning mortality or readmission risk.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [116] Beck, 2013, Oral nutritional support of older (65 years+) medical and surgical patients after discharge from hospital: systematic review and meta-analysis of randomized controlled trials, Clin Rehabil source

  • May combine two claims.

    Premisecitation

    Older malnourished patients need a higher energy supply than younger adults to gain weight, and the increase in body weight and fat-free mass in response to equal energy supply is slower in older patients.

    “Furthermore, older malnourished patients need a higher energy supply than younger adults to gain weight, and the increase in BW and fat-free mass in response to equal energy supply is slower in older patients (126).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [126] Hébuterne, 1997, Effects of refeeding by cyclic enteral nutrition on body composition: comparative study of elderly and younger patients, Clin Nutr source

  • Classified as probably not a substantial claim.

    Study design and conductreasoning

    Due to the limited quality of the original studies, restriction to hospital discharge in some studies, and only rare involvement of caregivers, the recommendation was downgraded to B.

    “Due to the limited quality of the original studies, restriction to hospital discharge in some of the studies and only rare involvement of caregivers, the recommendation was downgraded to B.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    In 46 clinical trials in mostly older participants across healthcare settings (mean age 74 years), overall compliance with ONS was 78%, better in the community (81%) than in the hospital (67%).

    “In 46 clinical trials in mostly older participants across healthcare settings (mean age 74 years), overall compliance was 78%, better in the community (81%) than in the hospital (67%) (127).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [127] Hubbard, 2012, A systematic review of compliance to oral nutritional supplements, Clin Nutr source
    • Rests on an assumption: Compliance is crucial to achieve beneficial effects of ONS.

  • May combine two claims.

    Premisecitation

    In a systematic literature review of nine studies, energy intake increased in seven out of nine studies using energy enrichment and protein intake increased in three out of five studies using protein enrichment.

    “Energy intake increased in seven out of nine studies using energy enrichment and protein intake increased in three out of five J o u r n a l P r e -p r o o f studies using protein enrichment.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [102] Trabal, 2015, Effects of dietary enrichment with conventional foods on energy and protein intake in older adults: a systematic review, Nutr Rev source

  • May combine two claims.

    Premisecitation

    Two other RCTs reported that combined dietary counseling and ONS after hospital discharge prevented weight loss and improved activities of daily living and decreased functional limitations.

    “Two other RCTs (not included in this systematic review) studied the effects of a combined dietary counseling and ONS intervention after hospital discharge and reported prevention of weight loss and improved activities of daily living functions (124) and decreased functional limitations (52,125).”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [124] Persson, 2007, Nutritional supplementation and dietary advice in geriatric patients at risk of malnutrition, Clin Nutr source
    • cites [52] Neelemaat, 2012, Oral nutritional support in malnourished elderly decreases functional limitations with no extra costs, Clin Nutr source
    • cites [125] Neelemaat, 2011, Post-discharge nutritional support in malnourished elderly individuals improves functional limitations, J Am Med Dir Assoc source

  • May combine two claims.

    Premisecitation

    There was a significant positive correlation between compliance and total energy intake, showing that ONS consumption has little effect on usual food intake.

    “There was also a significant positive correlation between compliance and total energy intake (energy intake from food plus ONS energy intake), showing that ONS consumption has little effect on the usual food intake.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [127] Hubbard, 2012, A systematic review of compliance to oral nutritional supplements, Clin Nutr source

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based).

    Premisenone given

    Enteral nutrition is in principle a life-prolonging procedure.

    “EN is in principle a life-prolonging procedure.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Premisenone given

    Oral intake is associated with sensory input and training of swallowing, increased quality of life and enhances the cleaning of the oropharynx.

    “Oral intake of the safe texture should be encouraged as far as safely possible because oral intake is associated with sensory input and training of swallowing, increased quality of life and enhances the cleaning of the oropharynx.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Oral intake is associated with sensory input and training of swallowing, increased quality of life and enhances cleaning of the oropharynx.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisereasoning

    Enteral nutrition and parenteral nutrition are medical treatments because they require the insertion of a feeding tube or intravenous cannulation and a physician's prescription.

    “EN and PN are medical treatments because they require the insertion of a feeding tube or intravenous cannulation and a physician's prescription.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Interpretationcitation

    In patients where death is imminent, e.g. within the next four weeks, or in patients with an incurable disease which cannot be improved by any treatment including nutritional support, the patient's comfort is the highest priority.

    “Especially in patients where death is imminent, e.g.within the next four weeks, or in patients with an incurable disease which cannot be improved by any treatment including nutritional support (e.g.advanced dementia, terminal phase of malignant cancer disease), the patient´s comfort is the highest priority (162).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [162] Druml, 2016, ESPEN guideline on ethical aspects of artificial nutrition and hydration, Clin Nutr source

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Premisenone given

    Clinical improvement, as well as prevention of further clinical deterioration, can both be relevant goals for an individual patient.

    “Clinical improvement, as well as prevention of further clinical deterioration, can both be relevant goals for an individual patient.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisenone given

    Even patients with dysphagia and nil-by-mouth have to swallow more than 500 ml of saliva per day which alone is a risk factor for aspiration pneumonia.

    “It has to be kept in mind that even patients with dysphagia and nil-by-mouth have to swallow more than 500 ml of saliva per day which alone is a risk factor for aspiration pneumonia.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Even patients with dysphagia and nil-by-mouth have to swallow more than 500 ml of saliva per day which alone is a risk factor for aspiration pneumonia.

  • Probably not a substantial claim: may not pass S4 (based). May combine two claims.

    Premisenone given

    In geriatric patients, nasogastric tubes are frequently not well tolerated but are also often not fixed adequately.

    “In geriatric patients, nasogastric tubes are frequently not well tolerated but are also often not fixed adequately.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationcitation

    In the palliative situation, covering a patient's nutritional requirements is entirely irrelevant.

    “In this situation, covering a patient's nutritional requirements is entirely irrelevant (162).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [162] Druml, 2016, ESPEN guideline on ethical aspects of artificial nutrition and hydration, Clin Nutr source

  • May combine two claims.

    Premisecitation

    Known risk factors for the refeeding syndrome are a reduced BMI, significant unintended weight loss, no nutritional intake for several days, low plasma concentrations of magnesium, potassium or phosphate before feeding and a medical history of drug or alcohol abuse.

    “Known risk factors for the RFS are a reduced BMI, significant unintended weight loss, no nutritional intake for several days, low plasma concentrations of magnesium, potassium or phosphate before feeding and a medical history of drug or alcohol abuse (172)”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [172] 2006

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Premisenone given

    Refeeding syndrome is a condition of potential risk in malnourished patients with electrolyte disturbances leading to clinical deterioration.

    “Refeeding syndrome (RFS) is a condition of potential risk in malnourished patients with electrolyte disturbances leading to clinical deterioration.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    A second meta-analysis included a subset of ten RCTs with a total of 986 patients and came to the same conclusions regarding mortality and complications.

    “A second meta-analysis (183) included a subset of ten of these RCTs with a total of 986 patients and came to the same conclusions regarding mortality and complications.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [183] Liu, 2015, The role of perioperative oral nutritional supplementation in elderly patients after hip surgery, Clin Interv Aging

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Several studies have documented that parenteral nutrition is a feasible and successful method of nutritional support also in older people, not only in the hospital but also at home.

    “Several studies have documented that PN is a feasible and successful method of nutritional support also in older people (130,(178)(179)(180), not only in the hospital but also at home (181).”
    Quote in the paperSubstantial claim0 of 5 sources checked
    • cites [130] Donini, 2009, Predicting the outcome of artificial nutrition by clinical and functional indices, Nutrition source
    • cites [178] Hearnshaw, 2007, Use of parenteral nutrition in hospitals in the North of England, J Hum Nutr Diet source
    • cites [179] Howard, 1997, Clinical outcome of geriatric patients in the United States receiving home parenteral and enteral nutrition, Am J Clin Nutr source
    • cites [180] Thomas, 2005, A prospective, randomized clinical study of adjunctive peripheral parenteral nutrition in adult subacute care patients, J Nutr Health Aging

      Not checked in the free run.

    • cites [181] Violante, 2006, Adult home parenteral nutrition: a clinical evaluation after a 3-year experience in a Southern European centre, Eur J Clin Nutr source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisenone given

    Consequences of refeeding syndrome include volume overload, redistribution of phosphate, potassium, and magnesium, hypophosphatemia, muscle weakness, anemia and finally organ failure.

    “Consequences include volume overload, redistribution of phosphate, potassium, and magnesium, hypophosphatemia, muscle weakness, anemia and finally organ failure.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    As a consequence, rapid deterioration of nutritional status and impairment of recovery and rehabilitation are common.

    “As a consequence, rapid deterioration of nutritional status and impairment of recovery and rehabilitation are common.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Premisenone given

    Voluntary oral intake in the postoperative phase is often markedly below requirements.

    “Voluntary oral intake in the postoperative phase is often markedly below requirements.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    The risk of complications within four months was significantly reduced (RR 0.21 (99% CI 0.08-0.59)), while mortality risk, length of hospital stay and the proportion of participants who were discharged to their own homes were unaffected.

    “The risk of complications within four months was significantly reduced (RR 0.21 (99% CI 0.08-0.59),while mortality risk, length of hospital stay and the proportion of participants who were discharged to their own homes were unaffected (185).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [185] Eneroth, 2006, Nutritional supplementation decreases hip fracture-related complications, Clin Orthop Relat Res source

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Premisenone given

    Possible cardiac sudden death is described in up to 20% in refeeding syndrome.

    “Possible cardiac sudden death is described in up to 20%.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    In rare exceptions, such as hyperactive delirium, it may be advantageous for the patient to use drugs with sedative effects or even physical restraints for a very limited period of time to prevent the patient from self-injury.

    “It has to be mentioned, however, that in rare exceptions, such as hyperactive delirium, it may be advantageous for the patient to use drugs with sedative effects or even physical restraints for a very limited period of time to prevent the patient from self-injury.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    In 40 frail older patients with prolonged feeding problems before insertion of a nasogastric tube, a high mortality rate was observed mainly related to infectious complications, and the authors suggested the refeeding syndrome as a contributing factor to mortality.

    “Lubart et al. (177) evaluated 40 frail older patients with prolonged feeding problems before the insertion of a nasogastric tube.A high mortality rate was observed which was mainly related to infectious complications, but in the light of a considerable number of patients with hypophosphatemia, the authors suggested the RFS as a contributing factor to mortality (177).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [177] Lubart, 2009, Mortality after nasogastric tube feeding initiation in long-term care elderly with oropharyngeal dysphagia–the contribution of refeeding syndrome, Gerontology source

  • May combine two claims.

    Premisenone given

    Indication criteria for parenteral nutrition are the same as in middle-aged subjects: older patients facing a period of starvation of more than three days when oral nutrition or enteral nutrition is impossible, and when oral or enteral nutrition has been or is likely to be insufficient for more than 7-10 days.

    “Indication criteria for PN are the same as in middle-aged subject: older patients facing a period of starvation of more than three days when oral nutrition or EN is impossible, and when oral or EN has been or is likely to be insufficient for more than 7-10 days.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Premisenone given

    Cultural background, economical resources, social facilities as well as ethical and religious motivations may play a substantial role in determining the nutritional treatment and its outcome in very old, frail and chronically ill patients.

    “Cultural background, economical resources, social facilities as well as ethical and religious motivations may play a substantial role in determining the nutritional treatment and its outcome in very old, frail and chronically ill patients.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Parenteral nutrition is only rarely indicated as oral and enteral interventions are generally the first choice for nutritional support.

    “It is however only rarely indicated as oral and enteral interventions are generally the first choice for nutritional support (180).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [180] Thomas, 2005, A prospective, randomized clinical study of adjunctive peripheral parenteral nutrition in adult subacute care patients, J Nutr Health Aging

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    Loss of physical activity is a logical consequence of pharmacological sedation or physical restraints; consequently, it usually leads to muscle mass loss.

    “The loss of physical activity is a logical consequence of pharmacological sedation or physical restraints; consequently, it usually leads to muscle mass loss.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Social contact is a key trigger for drinking; as social isolation becomes more common, drinking routines are lost and drink intake is reduced.

    “Furthermore, social contact is a key trigger for drinking -but as social isolation becomes more common, drinking routines are lost and drink intake is reduced (254).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [254] Philpin, 2011, Sociocultural context of nutrition in care homes, Nurs Older People source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The equation has also been found to be useful in younger adults.

    “This equation has also been found to be useful in younger adults (230).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [230] Heavens, 2014, Validation of equations used to predict plasma osmolality in a healthy adult cohort, Am J Clin Nutr source

  • May combine two claims.

    Premisecitation

    In low-intake dehydration, despite raised serum osmolality, none of the major components (sodium, potassium, urea or glucose) is commonly raised out of the normal range; general fluid concentration leads to small rises within the normal range in all these components.

    “In low-intake dehydration, it is common that despite raised serum osmolality none of the major components (sodium, potassium, urea or glucose) is raised out of the normal range -but general fluid concentration leads to small rises within the normal range in all these components (Hooper unpublished).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Hooper unpublished

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Premisecitation

    Physical access to drinks, swallowing problems and dysphagia can be issues reducing fluid intake in older adults.

    “Physical access to drinks can also be an issue (8,255,256), as can swallowing problems and dysphagia.”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [8] Hodgkinson, 2003, Maintaining oral hydration in older adults: a systematic review, Int J Nurs Pract source
    • cites [255] Gaspar, 1988, What determines how much patients drink?, Geriatr Nurs source
    • cites [256] Leiper, 2005, A comparison of water turnover in older people in community and institutional settings, J Nutr Health Aging

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The clearest signs following excessive blood loss are a large postural pulse change (≥30 beats per minute) or severe postural dizziness leading to lack of ability to stand; these are 97% sensitive and 98% specific when blood loss is at least 630 mL, but much less sensitive at lower levels of blood loss.

    “The clearest signs following excessive blood loss are a large postural pulse change (≥30 beats per minute) or severe postural dizziness leading to lack of ability to stand (273), which are 97% sensitive and 98% specific when blood loss is at least 630 mL, but much less sensitive at lower levels of blood loss.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [273] McGee, 1999, The rational clinical examination. Is this patient hypovolemic?, JAMA source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Postural hypotension has little additional predictive value.

    “The authors report that postural hypotension has little additional predictive value.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [273] McGee, 1999, The rational clinical examination. Is this patient hypovolemic?, JAMA source

  • Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing).

    Premisecitation

    Financial costs of subcutaneous rehydration are probably lower than intravenous.

    “Another systematic review suggests that financial costs of subcutaneous rehydration are probably lower than intravenous, but the systematic review is methodologically poor and the evidence base it collates is of low quality -better-designed studies are needed (266).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [266] Pershad, 2010, A systematic data review of the cost of rehydration therapy, Appl Health Econ Health Pol source

  • May combine two claims.

    Interpretationcitation

    The results on signs following excessive blood loss were found in younger adults not taking beta-blockers, so sensitivity and specificity may vary in older persons.

    “However, these results were found in younger adults not taking beta-blockers, so sensitivity and specificity may vary in older persons.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [273] McGee, 1999, The rational clinical examination. Is this patient hypovolemic?, JAMA source

  • May combine two claims.

    Premisecitation

    Patients with dysphagia are at specific high risk of dehydration and fluid intake has been reported to be low, especially when thickened fluids are used to make swallowing safer.

    “Patients with dysphagia are at specific high risk of dehydration and fluid intake has been reported to be low, especially when thickened fluids are used to make swallowing safer (360).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [360]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Classified as probably not a substantial claim.

    Premisecitation

    A combination of a balanced, nutrient-rich diet providing adequate amounts of energy and protein, and physical activity, if possible even exercise, is a sound strategy to keep weight stable and to prevent obesity.

    “A combination of a balanced, nutrient-rich diet providing adequate amounts of energy and protein, and physical activity, if possible even exercise, is a sound strategy to keep weight stable and to prevent obesity (284).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [284] Volpe, 2016, Obesity prevention in older adults, Curr Obes Rep source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    A high-quality systematic review suggested that the use of chin down swallowing and thin fluids should be the first choice of therapy in chronic dysphagia.

    “A highquality systematic review, though not specific to older adults, has suggested that the use of chin down swallowing and thin fluids should be the first choice of therapy in chronic dysphagia (108).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [108] Andersen, 2013, Systematic review and evidence based recommendations on texture modified foods and thickened fluids for adults (18 years) with oropharyngeal dysphagia, e-SPEN source

  • May combine two claims.

    Premisecitation

    Only Rydwik et al. reported improved muscle strength in the combined intervention group compared to the nutrition group, while other functional and nutritional measures did not differ.

    “Only Rydwik et al. (81) reported improved muscle strength in the combined intervention group compared to the nutrition group, while other functional and nutritional measures did not differ.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [81] Rydwik, 2008, Effects of a physical and nutritional intervention program for frail elderly people over age 75. A randomized controlled pilot treatment trial, Aging Clin Exp Res source

  • May combine two claims.

    Premisecitation

    Weight loss and poor nutritional state are risk factors for mortality in general and particularly poor survival after PEG insertion.

    “As weight loss and poor nutritional state are risk factors for mortality in general and particularly J o u r n a l P r e -p r o o f poor survival after PEG insertion (157), weight loss before initiation of EN should be avoided as far as possible.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [157] Chong, 2006, Percutaneous endoscopic gastrostomy outcomes: can patient profiles predict mortality and weaning?, Singap Med J

  • May combine two claims.

    Premisecitation

    Positive effects of ONS on dietary intake and body weight, and reduced risk of complications and readmissions were reported, whereas length of hospital stay and mortality risk were not significantly reduced.

    “Altogether, positive effects of ONS on dietary intake (115, 116, 119, 121) and BW (115, 116, 119, 121), and reduced risk of complications (121) and readmissions (115, 120, 121) were reported, whereas the length of hospital stay (114, 115, 121) and mortality risk (114-116, 119, 121) were not significantly reduced.”
    Quote in the paperSubstantial claim0 of 5 sources checked
    • cites [115] Bally, 2016, Nutritional support and outcomes in malnourished medical inpatients: a systematic review and meta-analysis, JAMA Intern Med source
    • cites [116] Beck, 2013, Oral nutritional support of older (65 years+) medical and surgical patients after discharge from hospital: systematic review and meta-analysis of randomized controlled trials, Clin Rehabil source
    • cites [119] Milne, 2009, Protein and energy supplementation in elderly people at risk from malnutrition, Cochrane Database Syst Rev source
    • cites [121] Cawood, 2012, Systematic review and meta-analysis of the effects of high protein oral nutritional supplements, Ageing Res Rev source
    • cites [120] Stratton, 2013, A systematic review and meta-analysis of the impact of oral nutritional supplements on hospital readmissions, Ageing Res Rev source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Criteria to identify RFS vary from reduced phosphate or any electrolyte serum concentration, the coexistence of electrolyte disturbances and clinical symptoms.

    “Criteria to identify RFS vary from reduced phosphate or any electrolyte serum concentration, the coexistence of electrolyte disturbances and clinical symptoms (e.g.peripheral edema, acute circulatory fluid overload, disturbance to organ function) (175).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [175] Friedli, 2017, Revisiting the refeeding syndrome: results of a systematic review, Nutrition source

  • May combine two claims.

    Premisenone given

    All these trials used GDS as the main outcome measure, but the minimum clinically significant difference has not been defined for GDS.

    “All these trials used GDS (a validated depression screening instrument that measures depressive symptoms) as the main outcome measure, but the minimum clinically significant difference has not been defined for GDS.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Cheuvront et al. assessed the range of plasma osmolality in hydrated younger adults and then in the same persons when dehydrated, identifying the cut-off that best separated the two states.

    “They assessed the range of plasma osmolality in hydrated younger adults, then in the same persons who had been dehydrated, identifying the cut-off that best separated the two states.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [221] Cheuvront, 2010, Biological variation and diagnostic accuracy of dehydration assessment markers, Am J Clin Nutr source

  • May combine two claims.

    Premisecitation

    A second RCT explored an individualized nutritional intervention in 259 hospitalized older patients and found no changes in GDS scores at six months.

    “A second RCT explored an individualized nutritional intervention in 259 hospitalized older patients and found no changes in GDS scores at six months (47), the number of those with depression is not stated.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [47] Feldblum, 2011, Individualized nutritional intervention during and after hospitalization: the nutrition intervention study clinical trial, J Am Geriatr Soc source

  • May combine two claims.

    Premisecitation

    GDS was significantly better in the intervention compared to the control group at six months, but not at six weeks.

    “GDS was significantly better in the intervention compared to the control group at six months, but not at six weeks.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [204] Gariballa, 2007, Effects of dietary supplements on depressive symptoms in older patients: a randomised double-blind placebo-controlled trial, Clin Nutr source

  • May combine two claims.

    Interpretationnone given

    Nutrition and hydration interventions have only shown efficacy in the prevention of delirium when they are part of multidisciplinary interventions (10 of 19 trials on multidisciplinary interventions included at least one nutrition/hydration intervention).

    “In summary, nutrition and hydration interventions have only shown efficacy in the prevention of delirium when they are part of multidisciplinary interventions (10 of 19 trials on multidisciplinary interventions included at least one nutrition/hydration intervention).”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisenone given

    A standardized definition of RFS is lacking, and current knowledge about the syndrome is altogether limited.

    “A standardized definition is unfortunately lacking, and current knowledge about the syndrome is altogether limited.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    Cheuvront et al.'s suggested threshold is that serum or plasma osmolality >300 mOsm/kg is classified as dehydrated.

    “Their suggested threshold is that serum or plasma osmolality >300 mOsm/kg is classified as dehydrated.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [221] Cheuvront, 2010, Biological variation and diagnostic accuracy of dehydration assessment markers, Am J Clin Nutr source

  • May combine two claims.

    Premisecitation

    Treatment for volume depletion aims to replace lost water and electrolytes and involves the administration of isotonic fluids.

    “Treatment for volume depletion aims to replace lost water and electrolytes and involves the administration of isotonic fluids (224, 271).”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [224] Thomas, 2008, Understanding clinical dehydration and its treatment, JAMDA source
    • cites [271] 2013

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The authors suggested that this form of diagnosis needs further assessment.

    “However, the authors suggested that this form of diagnosis needs further assessment (273).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [273] McGee, 1999, The rational clinical examination. Is this patient hypovolemic?, JAMA source

  • Classified as probably not a substantial claim.

    Premisecitation

    Isotonic or slightly hypotonic fluids are ideal.

    “Isotonic or slightly hypotonic fluids are ideal (224).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [224] Thomas, 2008, Understanding clinical dehydration and its treatment, JAMDA source
125 of 125

  • The authors state this as an assumption.

    For older persons with underweight (BMI ≤21 kg/m²), energy requirements are between 32 and 38 kcal/kg.

    “For older persons with underweight (BMI ≤21 kg/m²) energy requirements between 32 and 38 kcal/kg are assumed (16).”

  • The authors state this as an assumption.

    One of the barriers to proper nutritional support in hospitals is a lack of sufficient education concerning nutrition among all staff groups.

    “One of the barriers to proper nutritional support in hospitals is assumed to be a lack of sufficient education concerning nutrition among all staff groups (62).”

  • The authors state this as an assumption.

    Eating-dependent older persons living in private households may also benefit from mealtime assistance.

    “Nevertheless, it is reasonable to assume that eating-dependent older persons living in private households may also benefit from mealtime assistance.”

  • The authors state this as an assumption.

    Persons who are otherwise unable to obtain regular meals may benefit from home-delivered meals.

    “but it seems reasonable to assume that persons who are otherwise unable to obtain regular meals may benefit from this support.”

  • The paper relies on this without support.

    Insufficient intake of energy increases protein requirements.

    “It is important to bear in mind that an insufficient intake of energy increases protein requirements.”

  • The paper relies on this without support.

    Exercise increases energy expenditure.

    “Exercise increases energy expenditure.”

  • The paper relies on this without support.

    To avoid weight loss and maintain muscle mass, a positive or at least zero energy balance is of particular importance during periods of exercise interventions.

    “To avoid (further) weight loss and to maintain muscle mass a positive or at least zero energy balance is of particular importance during periods of exercise interventions.”

  • The paper relies on this without support.

    Many older persons are restricted in their ability to eat and drink independently due to functional and cognitive limitations.

    “Many older persons are restricted in their ability to eat and drink independently due to functional and cognitive limitations.”

  • The paper relies on this without support.

    Dietary fiber may contribute to the normalization of bowel functions, and intake is usually low in geriatric patients.

    “Since dietary fiber may contribute to the normalization of bowel functions, and intake is usually low in geriatric patients, the importance of an adequate intake of dietary fiber is emphasized.”

  • The paper relies on this without support.

    Dietary recommendations for micronutrients for older persons do not differ from those for younger adults.

    “Dietary recommendations for micronutrients for older persons do not differ from those for younger adults, however, our knowledge about requirements in very old, frail or ill persons is poor.”

  • The paper relies on this without support.

    Older persons are at increased risk of micronutrient deficiencies due to an increasing prevalence of gastrointestinal diseases accompanied by reduced nutrient bioavailability.

    “Due to an increasing prevalence of gastrointestinal diseases, which are accompanied by reduced nutrient bioavailability (e.g.atrophic gastritis and impaired vitamin B12, calcium and iron absorption), older persons are at increased risk of micronutrient deficiencies, which should be corrected by supplementation.”

  • The paper relies on this without support.

    Individual fluid needs are related to energy consumption, water losses and kidney function.

    “Individual fluid needs are related to energy consumption, water losses and kidney function, so larger people may require more fluid.”

  • The paper relies on this without support.

    Fluid needs may be higher in extreme temperatures or at times of greater physical activity.

    “Needs may also be higher in extreme temperatures (e.g.summer heat) or at times of greater physical activity.”

  • The paper relies on this without support.

    Excessive losses due to fever, diarrhea, vomiting or severe hemorrhage must be balanced by additional intake.

    “Excessive losses due to, fever, diarrhea, vomiting or severe hemorrhage must also be balanced by additional intake.”

  • The paper relies on this without support.

    Specific clinical situations, namely heart and renal failure, may need a restriction of fluid intake.

    “On the other hand, specific clinical situations, namely heart, and renal failure may need a restriction of fluid intake.”

  • The authors state this as an assumption.

    Enrichment of texture-modified diets can have similar effects as enrichment of regular texture diets for patients with chewing and/or swallowing problems.

    “At present, also no studies about the effects of enrichment of texture-modified diets are available, but based on the positive effects of enrichment of regular texture diets (see recommendation 24) it is assumed that enrichment can have similar effects in texturemodified diets for patients with chewing and/or swallowing problems.”

  • The authors state this as an assumption.

    Enteral nutrition sometimes may be continued for longer than necessary once a PEG tube has been inserted.

    “It is also assumed that EN sometimes may be continued for longer than necessary once a PEG tube has been inserted.”

  • The paper relies on this without support.

    Additional snacks and/or finger food have little expense and no risk of harm.

    “Due to little expense and no risk of harm we recommend additional snacks and/or finger food despite presently very limited scientific evidence.”

  • The paper relies on this without support.

    Dietary counseling and food modifications may be better accepted for longer durations and are cheaper than ONS.

    “However, dietary counseling and food modifications J o u r n a l P r e -p r o o f may be better accepted for longer durations and are cheaper, so we suggest that in chronic clinical situations such as observed in the community or nursing homes, they may be proposed first and that ONS be offered when dietary counseling and food fortification are not sufficient to reach nutritional goals.”

  • The paper relies on this without support.

    Compliance is crucial to achieve beneficial effects of ONS.

    “To achieve beneficial effects, compliance is crucial.”

  • The paper relies on this without support.

    Oral intake is associated with sensory input and training of swallowing, increased quality of life and enhances cleaning of the oropharynx.

    “Oral intake of the safe texture should be encouraged as far as safely possible because oral intake is associated with sensory input and training of swallowing, increased quality of life and enhances the cleaning of the oropharynx.”

  • The paper relies on this without support.

    Even patients with dysphagia and nil-by-mouth have to swallow more than 500 ml of saliva per day which alone is a risk factor for aspiration pneumonia.

    “It has to be kept in mind that even patients with dysphagia and nil-by-mouth have to swallow more than 500 ml of saliva per day which alone is a risk factor for aspiration pneumonia.”

  • The paper relies on this without support.

    Sedation and physical restraints may lead to cognitive deterioration.

    “In addition, sedation and physical restraints may also lead to cognitive deterioration and should, therefore, be avoided.”

  • The paper relies on this without support.

    Short-term starvation in the acutely ill older person leads to loss of lean body mass which can be critical especially in older patients.

    “When indicated, PN should be initiated immediately due to the risk of loss of independence in older patients and because even short-term starvation in the acutely ill older person leads to loss of lean body mass which can be critical especially in older patients.”

  • The paper relies on this without support.

    Use of ONS or EN can result in a rise in glucose levels.

    “The use of ONS or EN can result in a rise in glucose levels.”

  • The paper relies on this without support.

    Prevention and treatment of malnutrition with its probable negative short-term outcomes are more important than possible long-term complications of hyperglycemia.

    “However, prevention and treatment of malnutrition with its probable negative short-term outcomes are regarded as more important than possible long-term complications of hyperglycemia.”

  • The paper relies on this without support.

    Raised osmolality is the key physiological trigger of protection mechanisms such as thirst and increased concentration of urine by the kidney.

    “The raised osmolality is the key physiological trigger of protection mechanisms (such as thirst and increased concentration of urine by the kidney).”

  • The paper relies on this without support.

    Extracellular water loss (volume depletion) due to diarrhea, vomiting or renal sodium loss is connected with normal or low plasma osmolality.

    “In contrast, extracellular water loss (volume depletion) due to diarrhea, vomiting or renal sodium loss is connected with normal or low plasma osmolality.”

  • The paper relies on this without support.

    Very old and frail persons are more vulnerable to any kind of stress.

    “As very old and frail persons are more vulnerable to any kind of stress, decisions for or against weight loss require particular care in this population subgroup (see commentary to Recommendation 55).”

  • The paper relies on this without support.

    PN is a safe and effective therapeutic procedure, which is used for the delivery of all macronutrients and micronutrients into the organism via a central or peripheral vein.

    “PN is a safe and effective therapeutic procedure, which is used for the delivery of all macronutrients and micronutrients into the organism via a central or peripheral vein.”

  • The paper relies on this without support.

    Older persons suffering from a hip fracture and undergoing orthopedic surgery are generally at risk of malnutrition due to the acute trauma and surgery-associated anorexia.

    “Older persons suffering from a hip fracture and undergoing orthopedic surgery are generally at risk of malnutrition due to the acute trauma and surgery-associated anorexia”
31 of 31

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Caregiver-education cross-reference points to an unrelated recommendation

    Minor

    The commentary directs readers to recommendation 12 when caregivers should receive nutritional information and education. Recommendation 12 addresses malnutrition screening; recommendation 11 addresses education for caregivers.

  • Parenteral-nutrition section assigns recommendation 43 to the preceding chapter

    Minor

    The text says recommendations 40-43 are in chapter 2.3.5.2, but it places recommendation 43 under chapter 2.3.6.1, the parenteral-nutrition indication section.

  • Food-enrichment cross-reference points to the snacks recommendation

    Minor

    The commentary cites recommendation 24 for enrichment of regular-texture diets, but recommendation 24 concerns snacks and finger food. Food fortification is addressed in recommendation 23.

3 of 3

Cites

Flagged first, then by citations

Research works printed but not linked: 5

  1. 2016, National Clinical Guideline for exercise and nutrition to old people with geriatric problems, DHMA
  2. Abdelhamid, 2016, Effectiveness of interventions to directly improve, maintain or facilitate food and drink intake in people with dementia: eating and Drinking Well IN dementiA (EDWINA) systematic review and meta-analysis, BMC Geriatr, 16, 26, 10.1186/s12877-016-0196-3 · DOI · Paper page
  3. Bunn, 2015, Clinical signs of water-loss dehydration are ineffective in older people living in residential care, RCN Ann Int Nurs Res Conf, 10
  4. Olde Rikkert, 2009, Heat waves and dehyration in the elderly: recognising the early warning signs can save lives, BMJ, 339, b2663
  5. Bunn, 2016, Effectiveness of interventions to indirectly improve, maintain or facilitate food and drink intake in people with dementia: eating and Drinking Well IN dementiA (EDWINA) systematic review and meta-analysis, BMC Geriatr, 16, 89, 10.1186/s12877-016-0256-8 · DOI · Paper page

Cited by

Sorted by citations

Related

Authors
Volkert, D., Beck, A. M., Cederholm, T., Cruz-Jentoft, A., Hooper, L., Kiesswetter, E., Maggio, M., Raynaud-Simon, A., Sieber, C., Sobotka, L., van Asselt, D., Wirth, R., & Bischoff, S. C.
Affiliations
  • Friedrich-Alexander-Universität Erlangen-Nürnberg (DE)
  • Herlev Hospital (DK)
  • Uppsala University (SE)
  • Instituto Ramón y Cajal de Investigación Sanitaria (ES)
  • University of East Anglia (GB)
  • University of Parma (IT)
  • Université Paris Cité (FR)
  • Charles University (CZ)
  • Universitätsklinik Marien Hospital Herne (DE)
  • University of Hohenheim (DE)
Corresponding author
Volkert, Dorothee
ORCID
Venue
Clinical Nutrition
Publisher
Elsevier BV
Published
2022-04
Volume
41
Issue
4
Pages
958-989
ISSN
0261-5614 (ISSN-L)
DOI
10.1016/j.clnu.2022.01.024
OpenAlex
W4221040785
Semantic Scholar
5ecf900bd2cd28a66bb93bef3809889ff63d01e3
Cited by
516
References
280
Citations by year
2026: 174 · 2025: 157 · 2024: 99 · 2023: 69 · 2022: 17
FWCI
43.76
Type
journal article
Language
en
Open access
Licence
Locations
  • Clinical Nutrition (publishedVersion)
  • PubMed (publishedVersion)
  • UEA Digital Repository (University of East Anglia) (submittedVersion)
  • Radboud Repository (Radboud University) (submittedVersion)
Funders
  • European Society for Clinical Nutrition and Metabolism
  • United European Gastroenterology
Topics
  • Health Sciences › Medicine › Physiology › Nutrition and Health in Aging
  • Health Sciences › Nursing › Nutrition and Dietetics › Clinical Nutrition and Gastroenterology
  • Health Sciences › Health Professions › Speech and Hearing › Dysphagia Assessment and Management
Keywords
malnutrition, dehydration, older adults, hydration, obesity, weight loss interventions, malnutrition screening, enteral nutrition, parenteral nutrition, oral nutritional supplements, nutrition counseling, dietary restriction, multidisciplinary care
MeSH terms
Aged, Aged, 80 and over, Geriatrics, Humans, Quality of Life, Nutritional Support, Malnutrition

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-23.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-23.

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Statistics and arithmetic are recomputed, not judged.

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