ESPEN practical guideline: Clinical nutrition and hydration in geriatrics

In the paper

“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).”

What the sources say

• Disputed

  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.

  cites [9] Hooper, 2015, Which frail older people are dehydrated? The UK DRIE study, J Gerontol- Series A Biol Sci Med Sci sourceExperimental — accuracy not yet measured

In the paper

“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).”

What the sources say

• Partly supported

  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)

  cites [1] Morley, 2017, Anorexia of ageing: a key component in the pathogenesis of both sarcopenia and cachexia, J Cachexia Sarcopenia Muscle sourceExperimental — accuracy not yet measured
• ?Not checked — no full text of the sourcecites [2] Agarwal, 2013, Malnutrition in the elderly: a narrative review, Maturitas source

In the paper

“Besides malnutrition, older persons are at increased risk of dehydration for various reasons, which is also related to serious health consequences (7,8).”

What the sources say

• Supported

  Section 6 explains several reasons older people are more susceptible to water-loss dehydration, including reduced fluid reserves, a less effective thirst response, and declining kidney function. Section 9 associates dehydration in older people with serious outcomes, including falls, delirium, renal failure, stroke, and death among those hospitalized with dehydration. (LLM, conf=0.94)

  cites [7] Hooper, 2014, Water-loss dehydration and aging, Mech Ageing Dev source
• ?Not checked — no full text of the sourcecites [8] Hodgkinson, 2003, Maintaining oral hydration in older adults: a systematic review, Int J Nurs Pract source

In the paper

“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).”

What the sources say

• ?Not checked — no full text of the sourcecites [10] Gallus, 2015, Overweight and obesity in 16 European countries, Eur J Nutr source
• Partly supported

  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)

  cites [11] Porter Starr, 2016, Challenges in the management of geriatric obesity in high risk populations, Nutrients sourceExperimental — accuracy not yet measured

In the paper

“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).”

What the sources say

• Partly supported

  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)

  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 sourceExperimental — accuracy not yet measured
• Partly supported

  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)

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

In the paper

“Daily amounts of 1.0 -1.2 g/kg BW have been suggested for healthy older persons by several expert groups (17)(18)(19).”

What the sources say

• Supported

  The “PROT-AGE recommendations for dietary protein intake in healthy older adults” section recommends an average daily intake of 1.0–1.2 g/kg body weight for older people. This position paper supports the cited recommendation as one of the expert-group sources; the supplied passage has no page number. (LLM, conf=0.94)

  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
• Supported

  The Dietary protein needs section supports increasing intake to 1.0–1.2 g/kg body weight/day for adults over 65. The Amount of protein section also describes recommendations from other expert groups, supporting the claim that several groups have suggested higher daily amounts. Page numbers were not available in our copy. (LLM, conf=0.93)

  cites [18] Deutz, 2014, Protein intake and exercise for optimal muscle function with aging: recommendations from the ESPEN Expert Group, Clin Nutr source
• ?Not checked — no full text of the sourcecites [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

In the paper

“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).”

What the sources say

• Supported

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

  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
• ?Not checked — no full text of the sourcecites [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
• Supported

  The Methods section identifies this paper as a systematic literature review. Its search strategy specifies interventions delivered to informal carers and non-clinical community care workers, matching the part of the citing sentence attributed to reference 65. The 'average quality' label is the citing authors' assessment of the review, not a finding attributed to it. (LLM, conf=0.92)

  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

In the paper

“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.”

What the sources say

• Supported

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

  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

In the paper

“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).”

What the sources say

• Supported

  The Results of intervention section compares participants who needed to increase energy intake by 20% or more across all four treatment groups. It reports no change in outcome variables among those who reached the target, but decreases in body weight and fat-free mass among those who did not. (LLM, conf=0.93)

  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

In the paper

“In older people weight loss occurs at the expense of muscle mass (78) and is associated with impaired physical function (79).”

What the sources say

• ?Not checked — no full text of the sourcecites [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
• Supported

  Citation (79) is attached to the physical-function clause, not the muscle-mass clause, which cites (78). The Abstract (page unavailable) reports that unintentional weight loss was associated with a faster rate of functional decline in older adults, regardless of baseline BMI; it does not establish causation. (LLM, conf=0.93)

  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

In the paper

“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).”

What the sources say

• Supported

  The Abstract (Results) explicitly calls for further high-quality studies because of the small number of participants and poor quality of some studies. The Discussion also identifies study heterogeneity as a reason for caution about the evidence on food-based fortification. (LLM, conf=0.94)

  cites [101] Morilla-Herrera, 2016, Effectiveness of food-based fortification in older people. A systematic review and meta-analysis, J Nutr Health Aging source

In the paper

“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).”

What the sources say

• ?Not checked — no full text of the sourcecites [136] Wirth, 2012, Complications and mortality after percutaneous endoscopic gastrostomy in geriatrics: a prospective multicenter observational trial, J Am Med Dir Assoc source
• Supported

  The Discussion (page not specified in our copy) says enteral nutrition delivered through nasoenteric tubes carries risks, including pneumothorax, aspiration pneumonia and death from tube malpositioning. This supports the potential harm from nasogastric tube feeding for which this source is cited; the sentence pairs the PEG-feeding point with a separate citation. (LLM, conf=0.90)

  cites [161] Sparks, 2011, Pulmonary complications of 9931 narrow-bore nasoenteric tubes during blind placement, J Parenter Enteral Nutr source

In the paper

“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.”

What the sources say

• Supported

  The Abstract’s Results state this claim directly. The Results sections on mortality and nutritional status also describe three studies favoring PEG for mortality and two of three studies reporting nutritional improvements, while explaining why neither outcome could be pooled. (LLM, conf=0.95)

  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

In the paper

“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).”

What the sources say

• Partly supported

  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)

  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 sourceExperimental — accuracy not yet measured

In the paper

“In patients with severe dementia, the risk-benefit ratio of EN is generally unfavorable and EN thus not recommended.”

What the sources say

• Supported

  Recommendation 17 in §3.4, “Artificial nutrition and hydration” (page not supplied), recommends against initiating tube feeding in patients with severe dementia. Its commentary reports no demonstrated survival benefit and says careful hand-feeding is the best alternative in the vast majority of cases, supporting the claim’s general risk-benefit characterization. (LLM, conf=0.93)

  cites [163] Volkert, 2015, ESPEN guidelines on nutrition in dementia, Clin Nutr source

In the paper

“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).”

What the sources say

• ?Not checked — no full text of the sourcecites [167] Anderson, 2004, The nasal loop provides an alternative to percutaneous endoscopic gastrostomy in high-risk dysphagic stroke patients, Clin Nutr source
• Partly supported

  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)

  cites [168] Beavan, 2007, Is looped nasogastric tube feeding more effective than conventional nasogastric tube feeding for dysphagia in acute stroke?, Trials sourceExperimental — accuracy not yet measured
• Partly supported

  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)

  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 sourceExperimental — accuracy not yet measured

In the paper

“Unfortunately, most trials assessed fluid intake hydration status and health outcomes poorly, so success in increasing fluid intake is unclear.”

What the sources say

• Partly supported

  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)

  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 sourceExperimental — accuracy not yet measured
• Partly supported

  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)

  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 sourceExperimental — accuracy not yet measured

In the paper

“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).”

What the sources say

• Supported

  The Main results report fewer participants with complications across 11 trials of oral multinutrient feeds (RR 0.71). The Increasing protein intake section finds no clear effect on complications from higher protein intake; complication data were unavailable from two of the four trials. The evidence is low quality, so “no such effect was found” should not be read as proof of no effect. Page numbers were not available in our copy. (LLM, conf=0.88)

  cites [182] Avenell, 2016, Nutritional supplementation for hip fracture aftercare in older people, Cochrane Database Syst Rev source

In the paper

“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”

What the sources say

• ?Not checked — no full text of the sourcecites [55] Olofsson, 2007, Malnutrition in hip fracture patients: an intervention study, J Clin Nurs source
• Partly supported

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

  cites [56] Stenvall, 2007, A multidisciplinary, multifactorial intervention program reduces postoperative falls and injuries after femoral neck fracture, Osteoporos Int sourceExperimental — accuracy not yet measured
• ?Not checked — no full text of the sourcecites [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
• ?Not checked — no full text of the sourcecites [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
• ?Not checked — no full text of the sourcecites [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

In the paper

“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).”

What the sources say

• Supported

  The Clinical course and outcome section reports a significantly longer hospital stay in the hypophosphataemia group. The In-hospital mortality section reports higher unadjusted mortality, but says the association was no longer significant after adjustment for all specified variables in a multivariate logistic regression. (LLM, conf=0.93)

  cites [176] Kagansky, 2005, Hypophosphataemia in old patients is associated with the refeeding syndrome and reduced survival, J Intern Med source

In the paper

“Memory problems may cause older adults to forget to drink and forget that they haven't drunk (7)(8)(9)252).”

What the sources say

• Supported

  The Problems section says that older people with dementia may forget drinks or believe they have recently had one. This supports the claim that memory problems may lead them to forget to drink or forget that they have not drunk. (LLM, conf=0.91)

  cites [7] Hooper, 2014, Water-loss dehydration and aging, Mech Ageing Dev source
• ?Not checked — no full text of the sourcecites [8] Hodgkinson, 2003, Maintaining oral hydration in older adults: a systematic review, Int J Nurs Pract source
• Partly supported

  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)

  cites [9] Hooper, 2015, Which frail older people are dehydrated? The UK DRIE study, J Gerontol- Series A Biol Sci Med Sci sourceExperimental — accuracy not yet measured
• Partly supported

  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)

  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 sourceExperimental — accuracy not yet measured

In the paper

“Among age-related physiological changes, reduced thirst and reduced urine concentration by the kidney increase dehydration risk (9,(243)(244)(245)(246).”

What the sources say

• Partly supported

  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)

  cites [9] Hooper, 2015, Which frail older people are dehydrated? The UK DRIE study, J Gerontol- Series A Biol Sci Med Sci sourceExperimental — accuracy not yet measured
• ?Not checked — no full text of the sourcecites [243] Davies, 1995, Age-associated alterations in thirst and arginine vasopressin in response to a water or sodium load, Age Ageing source
• ?Not checked — no full text of the sourcecites [244] de Castro, 1992, Age-related changes in natural spontaneous fluid ingestion and thirst in humans, J Gerontol: Psychol Sci source
• ?Not checked — no full text of the sourcecites [245] Lindeman, 1985, Longitudinal studies on the rate of decline in renal function with age, J Am Geriatr Soc source
• ?Not checked — no full text of the sourcecites [246] Rowe, 1976, The influence of age on the renal response to water deprivation in man, Nephron source

In the paper

“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).”

What the sources say

• Supported

  The Methods (p. 1) describe a small, short-term randomized crossover trial in older nursing-home residents with severe dementia and dysphagia. The Dysphagia limit discussion (p. 4) reports an increased dysphagia limit after gentle cervical spine mobilization. The Measurements section (p. 2) lists swallowing capacity, not hydration, as an outcome; the conclusion (p. 6) calls for future research on effects on drinking. (LLM, conf=0.90)

  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

In the paper

“Therefore, and to avoid a progression to obesity, maintaining stable BW is considered desirable for overweight older adults (11).”

What the sources say

• Supported

  In §1, “The Controversial Nature of Weight Management in Older Adults” (page unavailable), the review emphasizes the benefits of weight stability in later life and says there is no need to change body weight for older adults in the overweight BMI range. It distinguishes that range from obesity, supporting the cited recommendation to maintain a stable weight. (LLM, conf=0.92)

  cites [11] Porter Starr, 2016, Challenges in the management of geriatric obesity in high risk populations, Nutrients source

In the paper

“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.”

What the sources say

• Partly supported

  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)

  cites [110] Burgos, 2017, ESPEN guideline on clinical nutrition in Neurology, Clin Nutr sourceExperimental — accuracy not yet measured

In the paper

“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).”

What the sources say

• ?Not checked — no full text of the sourcecites [277] Visvanathan, 2012, Australian and New Zealand Society for Geriatric Medicine: position statement-obesity and the older person, Australas J Ageing source
• ?Not checked — no full text of the sourcecites [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
• Partly supported

  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)

  cites [285] Batsis, 2018, Addressing obesity in aging patients, Med Clin sourceExperimental — accuracy not yet measured
• ?Not checked — no full text of the sourcecites [283] Parr, 2013, ‘Sarcobesity’: a metabolic conundrum, Maturitas source

In the paper

“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).”

What the sources say

• Partly supported

  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)

  cites [11] Porter Starr, 2016, Challenges in the management of geriatric obesity in high risk populations, Nutrients sourceExperimental — accuracy not yet measured
• ?Not checked — no full text of the sourcecites [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
• Supported

  The guideline recommends weight loss for older people with obesity and weight-related comorbidities or functional limitations (Who Should Lose Weight and What Are the Concerns?; page not specified). It reports improvements in knee osteoarthritis pain and physical function with diet, especially with exercise, and describes benefits for cardiovascular and metabolic measures, insulin sensitivity, and inflammation (Life-Style Intervention: Is It Feasible in the Frail Elderly?; Why Add Exercise to a Diet?; pages not specified). (LLM, conf=0.92)

  cites [276] Mathus-Vliegen, 2012, Prevalence, pathophysiology, health consequences and treatment options of obesity in the elderly: a guideline, Obes Facts source
• ?Not checked — no full text of the sourcecites [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
• Partly supported

  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)

  cites [285] Batsis, 2018, Addressing obesity in aging patients, Med Clin sourceExperimental — accuracy not yet measured
• ?Not checked — no full text of the sourcecites [286] Gill, 2015, Weight management in older adults, Curr Obes Rep source

In the paper

“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).”

What the sources say

• Partly supported

  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)

  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 sourceExperimental — accuracy not yet measured

In the paper

“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).”

What the sources say

• Supported

  The Results (Body Weight and Composition; page not provided) report comparable reductions in body weight and fat mass with diet plus exercise and diet alone. Lean body mass decreased less with diet plus exercise (1.8 kg versus 3.2 kg). These findings are from obese adults aged 65 or older. (LLM, conf=0.91)

  cites [289] Villareal, 2011, Weight loss, exercise, or both and physical function in obese older adults, N Engl J Med source
• ?Not checked — no full text of the sourcecites [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
• Supported

  The Results section reports similar six-month losses of body weight and fat mass with diet plus exercise and diet alone. It also reports significantly smaller losses of fat-free mass with diet plus exercise (1.8 versus 3.5 kg), supporting the claim about better lean-mass preservation in this study of frail obese older adults. (LLM, conf=0.94)

  cites [291] Frimel, 2008, Exercise attenuates the weight-loss-induced reduction in muscle mass in frail obese older adults, Med Sci Sports Exerc source
• Supported

  The Results report similar reductions in body weight and whole-body fat mass for diet alone and diet plus exercise, while fat-free mass declined significantly only with diet alone. The Discussion likewise says the groups lost similar amounts of weight and body fat, but the diet-only group lost four times as much fat-free mass. The study concerns older adults with overweight or obesity. (LLM, conf=0.94)

  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
• Supported

  The Results (Body composition) report that body-mass and fat-mass changes did not differ between the diet-only and diet-plus-resistance-training groups, while fat-free mass was preserved in the training group and decreased in the diet-only group. The finding applies to the older women studied; this paper shows comparable, not greater, weight and fat loss with exercise. (LLM, conf=0.91)

  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
• Supported

  The Results (p. 1) report similar six-month reductions in body weight and fat mass with resistance training plus moderate weight loss versus weight loss alone. Lean body mass increased in the combined group but decreased in the weight-loss-only group. The finding is for older patients with type 2 diabetes. (LLM, conf=0.90)

  cites [297] Dunstan, 2002, High-intensity resistance training improves glycemic control in older patients with type 2 diabetes, Diabetes Care source
• Supported

  The Results (‘Changes in Physical Characteristics’; page not provided) report comparable weight and fat-mass reductions with combined exercise and diet versus diet-induced weight loss alone. The combined group lost less lean body mass (1.5% versus 4.3%), supporting the claim that it better preserved lean mass. (LLM, conf=0.94)

  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

In the paper

“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.”

What the sources say

• Partly supported

  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)

  cites [222] Cheuvront, 2013, Physiologic basis for understanding quantitative dehydration assessment, Am J Clin Nutr sourceExperimental — accuracy not yet measured
• Partly supported

  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)

  cites [223] Nadal, 1941, A comparison between dehydration from salt loss and from water deprivation, J Clin Invest sourceExperimental — accuracy not yet measured
• ?Not checked — no full text of the sourcecites [224] Thomas, 2008, Understanding clinical dehydration and its treatment, JAMDA source

In the paper

“but suggested that overall the studies were at high risk of bias.”

What the sources say

• Supported

  The Discussion states that risk of bias was considerable in most studies. The Conclusion likewise says that high risk of bias prevented the review from demonstrating the effectiveness of many strategies. This supports the citing sentence’s overall characterization. (LLM, conf=0.94)

  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

In the paper

“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).”

What the sources say

• Partly supported

  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)

  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 sourceExperimental — accuracy not yet measured
• Partly supported

  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)

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

In the paper

“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).”

What the sources say

• Partly supported

  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)

  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 sourceExperimental — accuracy not yet measured

In the paper

“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.”

What the sources say

• Supported

  The ‘Nasogastric tube feeding’ section reports four studies in which supplementation started within five days of surgery and usually continued until oral intake was sufficient or the patient was discharged. The review identifies study sizes of 18 participants (Sullivan 1998) and 140 participants (Hartgrink 1998). These details support the claim for the nasogastric-feeding studies, not for every intervention covered by the review; page numbers are unavailable in our copy. (LLM, conf=0.91)

  cites [182] Avenell, 2016, Nutritional supplementation for hip fracture aftercare in older people, Cochrane Database Syst Rev source

In the paper

“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.”

What the sources say

• Supported

  The Main results report that pooled data from three nasogastric-feeding trials showed no evidence of an effect on mortality, while one trial found no difference in complications. The same section reports no evidence of an effect on mortality or complications in a trial of tube feeding followed by oral supplementation. Complications in the EN-only group were assessed in one trial, not pooled. (LLM, conf=0.91)

  cites [182] Avenell, 2016, Nutritional supplementation for hip fracture aftercare in older people, Cochrane Database Syst Rev source

In the paper

“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.”

What the sources say

• Partly supported

  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)

  cites [182] Avenell, 2016, Nutritional supplementation for hip fracture aftercare in older people, Cochrane Database Syst Rev sourceExperimental — accuracy not yet measured

In the paper

“and consequently increases the risk of sarcopenia, frailty, functional decline, fractures, and malnutrition (276, 282, 283).”

What the sources say

• Partly supported

  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)

  cites [276] Mathus-Vliegen, 2012, Prevalence, pathophysiology, health consequences and treatment options of obesity in the elderly: a guideline, Obes Facts sourceExperimental — accuracy not yet measured
• Partly supported

  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)

  cites [282] Cetin, 2014, Obesity in the elderly: more complicated than you think, Cleve Clin J Med sourceExperimental — accuracy not yet measured
• ?Not checked — no full text of the sourcecites [283] Parr, 2013, ‘Sarcobesity’: a metabolic conundrum, Maturitas source

In the paper

“and following medical conditions resulting in excessive losses of fluid and electrolytes, such as excessive blood loss, vomiting, and diarrhea (221-224).”

What the sources say

• ?Not checked — no full text of the sourcecites [221] Cheuvront, 2010, Biological variation and diagnostic accuracy of dehydration assessment markers, Am J Clin Nutr source
• Partly supported

  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)

  cites [222] Cheuvront, 2013, Physiologic basis for understanding quantitative dehydration assessment, Am J Clin Nutr sourceExperimental — accuracy not yet measured
• Partly supported

  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)

  cites [223] Nadal, 1941, A comparison between dehydration from salt loss and from water deprivation, J Clin Invest sourceExperimental — accuracy not yet measured
• ?Not checked — no full text of the sourcecites [224] Thomas, 2008, Understanding clinical dehydration and its treatment, JAMDA source

In the paper

“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.”

What the sources say

• ?Not checked — no full text of the sourcecites [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

In the paper

“however, no intervention effects on energy or protein intake, BW, and functional measures.”

What the sources say

• ?Not checked — no full text of the sourcecites [47] Feldblum, 2011, Individualized nutritional intervention during and after hospitalization: the nutrition intervention study clinical trial, J Am Geriatr Soc source

In the paper

“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”

What the sources say

• ?Not checked — no full text of the sourcecites [47] Feldblum, 2011, Individualized nutritional intervention during and after hospitalization: the nutrition intervention study clinical trial, J Am Geriatr Soc source

In the paper

“Bodyweight, grip strength, complications, and length of hospital stay were however unaffected.”

What the sources say

• ?Not checked — no full text of the sourcecites [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

In the paper

“Multidisciplinary nutritional care concepts including regular team meetings increased dietary intake and improved quality of life in hip fracture patients (41)”

What the sources say

• ?Not checked — no full text of the sourcecites [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

In the paper

“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.”

What the sources say

• ?Not checked — no full text of the sourcecites [48] Beck, 2016, Multidisciplinary nutritional support for undernutrition in nursing home and home-care: a cluster randomized controlled trial, Nutrition source
• ?Not checked — no full text of the sourcecites [49] Beck, 2008, Multifaceted nutritional intervention among nursing-home residents has a positive influence on nutrition and function, Nutrition source
• ?Not checked — no full text of the sourcecites [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

In the paper

“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).”

What the sources say

• ?Not checked — no full text of the sourcecites [43] Rufenacht, 2010, Nutritional counseling improves quality of life and nutrient intake in hospitalized undernourished patients, Nutrition source
• ?Not checked — no full text of the sourcecites [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
• ?Not checked — no full text of the sourcecites [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

In the paper

“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).”

What the sources say

• Not checked yetcites [99] 2016, National Clinical Guideline for exercise and nutrition to old people with geriatric problems, DHMA

In the paper

“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.”

What the sources say

• ?Not checked — no full text of the sourcecites [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

In the paper

“Abbott et al. (64) included six feeding assistance studies.Two RCTs and three pre-post comparisons described positive effects on dietary intake.”

What the sources say

• ?Not checked — no full text of the sourcecites [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

In the paper

“Quality of life was examined in two studies which both found beneficial effects.”

What the sources say

• ?Not checked — no full text of the sourcecites [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

In the paper

“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.”

What the sources say

• ?Not checked — no full text of the sourcecites [77] Young, 2011, Nutritional education for community dwelling older people: a systematic review of randomised controlled trials, Int J Nurs Stud source

In the paper

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

In the paper

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

In the paper

“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).”

What the sources say

• ?Not checked — no full text of the sourcecites [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

In the paper

“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)”

What the sources say

• ?Not checked — no full text of the sourcecites [2] Agarwal, 2013, Malnutrition in the elderly: a narrative review, Maturitas source

In the paper

“Reported prevalence rates are generally below 10% in independently living older persons and increase up to two thirds in hospitalized older patients (5,6).”

What the sources say

• ?Not checked — no full text of the sourcecites [5] Kaiser, 2010, Frequency of malnutrition in older adults: a multinational perspective using the mini nutritional assessment, J Am Geriatr Soc source
• ?Not checked — no full text of the sourcecites [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

In the paper

“Given this variation, the use of the EFSA fluid recommendation seems appropriately cautious in older adults.”

In the paper

“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.”

What the sources say

• Not checked yetcites [23] European Food Safety Authority (EFSA), 2010, Scientific opinion on dietary reference values for carbohydrates and dietary fibre, EFSA J

In the paper

“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).”

In the paper

“Existing evidence was graded according to the SIGN (Scottish Intercollegiate Guidelines Network) grading system.”

In the paper

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

In the paper

“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.”

What the sources say

• ?Not checked — no full text of the sourcecites [59] Darmon, 2010, Restrictive diets in the elderly: never say never again?, Clin Nutr source

In the paper

“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.”

In the paper

“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.”

In the paper

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

In the paper

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

In the paper

“Eating is a social act, and eating in company is known to stimulate dietary intake, also in older persons (70,71).”

What the sources say

• ?Not checked — no full text of the sourcecites [70] Stroebele, 2004, Effect of ambience on food intake and food choice, Nutrition source
• ?Not checked — no full text of the sourcecites [71] De Castro, 1992, The amount eaten in meals by humans is a power function of the number of people present, Physiol Behav source

In the paper

“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).”

What the sources say

• ?Not checked — no full text of the sourcecites [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

In the paper

“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.”

In the paper

“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).”

What the sources say

• ?Not checked — no full text of the sourcecites [128] Loser, 1998, Enteral long-term nutrition via percutaneous endoscopic gastrostomy (PEG) in 210 patients a four-year prospective study, Dig Dis Sci source
• ?Not checked — no full text of the sourcecites [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
• ?Not checked — no full text of the sourcecites [130] Donini, 2009, Predicting the outcome of artificial nutrition by clinical and functional indices, Nutrition source

In the paper

“Rigorous prospective RCTs comparing EN with no feeding are not feasible for ethical reasons.”

In the paper

“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.”

What the sources say

• ?Not checked — no full text of the sourcecites [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

In the paper

“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).”

What the sources say

• ?Not checked — no full text of the sourcecites [126] Hébuterne, 1997, Effects of refeeding by cyclic enteral nutrition on body composition: comparative study of elderly and younger patients, Clin Nutr source

In the paper

“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.”

In the paper

“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).”

What the sources say

• ?Not checked — no full text of the sourcecites [127] Hubbard, 2012, A systematic review of compliance to oral nutritional supplements, Clin Nutr source

In the paper

“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.”

What the sources say

• ?Not checked — no full text of the sourcecites [102] Trabal, 2015, Effects of dietary enrichment with conventional foods on energy and protein intake in older adults: a systematic review, Nutr Rev source

In the paper

“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).”

What the sources say

• ?Not checked — no full text of the sourcecites [124] Persson, 2007, Nutritional supplementation and dietary advice in geriatric patients at risk of malnutrition, Clin Nutr source
• ?Not checked — no full text of the sourcecites [52] Neelemaat, 2012, Oral nutritional support in malnourished elderly decreases functional limitations with no extra costs, Clin Nutr source
• ?Not checked — no full text of the sourcecites [125] Neelemaat, 2011, Post-discharge nutritional support in malnourished elderly individuals improves functional limitations, J Am Med Dir Assoc source

In the paper

“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.”

What the sources say

• ?Not checked — no full text of the sourcecites [127] Hubbard, 2012, A systematic review of compliance to oral nutritional supplements, Clin Nutr source

In the paper

“EN is in principle a life-prolonging procedure.”

In the paper

“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.”

In the paper

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

In the paper

“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).”

What the sources say

• ?Not checked — no full text of the sourcecites [162] Druml, 2016, ESPEN guideline on ethical aspects of artificial nutrition and hydration, Clin Nutr source

In the paper

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

In the paper

“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.”

In the paper

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

In the paper

“In this situation, covering a patient's nutritional requirements is entirely irrelevant (162).”

What the sources say

• ?Not checked — no full text of the sourcecites [162] Druml, 2016, ESPEN guideline on ethical aspects of artificial nutrition and hydration, Clin Nutr source

In the paper

“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)”

What the sources say

• ?Not matched

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

  cites [172] 2006

In the paper

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

In the paper

“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.”

What the sources say

• Not checked yetcites [183] Liu, 2015, The role of perioperative oral nutritional supplementation in elderly patients after hip surgery, Clin Interv Aging

In the paper

“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).”

What the sources say

• ?Not checked — no full text of the sourcecites [130] Donini, 2009, Predicting the outcome of artificial nutrition by clinical and functional indices, Nutrition source
• ?Not checked — no full text of the sourcecites [178] Hearnshaw, 2007, Use of parenteral nutrition in hospitals in the North of England, J Hum Nutr Diet source
• ?Not checked — no full text of the sourcecites [179] Howard, 1997, Clinical outcome of geriatric patients in the United States receiving home parenteral and enteral nutrition, Am J Clin Nutr source
• Not checked yetcites [180] Thomas, 2005, A prospective, randomized clinical study of adjunctive peripheral parenteral nutrition in adult subacute care patients, J Nutr Health Aging
• ?Not checked — no full text of the sourcecites [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

In the paper

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

In the paper

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

In the paper

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

In the paper

“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).”

What the sources say

• ?Not checked — no full text of the sourcecites [185] Eneroth, 2006, Nutritional supplementation decreases hip fracture-related complications, Clin Orthop Relat Res source

In the paper

“Possible cardiac sudden death is described in up to 20%.”

In the paper

“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.”

In the paper

“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).”

What the sources say

• ?Not checked — no full text of the sourcecites [177] Lubart, 2009, Mortality after nasogastric tube feeding initiation in long-term care elderly with oropharyngeal dysphagia–the contribution of refeeding syndrome, Gerontology source

In the paper

“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.”

In the paper

“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.”

In the paper

“It is however only rarely indicated as oral and enteral interventions are generally the first choice for nutritional support (180).”

What the sources say

• Not checked yetcites [180] Thomas, 2005, A prospective, randomized clinical study of adjunctive peripheral parenteral nutrition in adult subacute care patients, J Nutr Health Aging

In the paper

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

In the paper

“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).”

What the sources say

• ?Not checked — no full text of the sourcecites [254] Philpin, 2011, Sociocultural context of nutrition in care homes, Nurs Older People source

In the paper

“This equation has also been found to be useful in younger adults (230).”

What the sources say

• ?Not checked — no full text of the sourcecites [230] Heavens, 2014, Validation of equations used to predict plasma osmolality in a healthy adult cohort, Am J Clin Nutr source

In the paper

“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).”

What the sources say

• ?Not matched

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

  cites Hooper unpublished

In the paper

“Physical access to drinks can also be an issue (8,255,256), as can swallowing problems and dysphagia.”

What the sources say

• ?Not checked — no full text of the sourcecites [8] Hodgkinson, 2003, Maintaining oral hydration in older adults: a systematic review, Int J Nurs Pract source
• ?Not checked — no full text of the sourcecites [255] Gaspar, 1988, What determines how much patients drink?, Geriatr Nurs source
• ?Not checked — no full text of the sourcecites [256] Leiper, 2005, A comparison of water turnover in older people in community and institutional settings, J Nutr Health Aging

In the paper

“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.”

What the sources say

• ?Not checked — no full text of the sourcecites [273] McGee, 1999, The rational clinical examination. Is this patient hypovolemic?, JAMA source

In the paper

“The authors report that postural hypotension has little additional predictive value.”

What the sources say

• ?Not checked — no full text of the sourcecites [273] McGee, 1999, The rational clinical examination. Is this patient hypovolemic?, JAMA source

In the paper

“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).”

What the sources say

• ?Not checked — no full text of the sourcecites [266] Pershad, 2010, A systematic data review of the cost of rehydration therapy, Appl Health Econ Health Pol source

In the paper

“However, these results were found in younger adults not taking beta-blockers, so sensitivity and specificity may vary in older persons.”

What the sources say

• ?Not checked — no full text of the sourcecites [273] McGee, 1999, The rational clinical examination. Is this patient hypovolemic?, JAMA source

In the paper

“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).”

What the sources say

• ?Not matched

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

  cites [360]

In the paper

“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).”

What the sources say

• ?Not checked — no full text of the sourcecites [284] Volpe, 2016, Obesity prevention in older adults, Curr Obes Rep source

In the paper

“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).”

What the sources say

• ?Not checked — no full text of the sourcecites [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

In the paper

“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.”

What the sources say

• ?Not checked — no full text of the sourcecites [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

In the paper

“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.”

What the sources say

• ?Not checked — no full text of the sourcecites [157] Chong, 2006, Percutaneous endoscopic gastrostomy outcomes: can patient profiles predict mortality and weaning?, Singap Med J

In the paper

“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.”

What the sources say

• ?Not checked — no full text of the sourcecites [115] Bally, 2016, Nutritional support and outcomes in malnourished medical inpatients: a systematic review and meta-analysis, JAMA Intern Med source
• ?Not checked — no full text of the sourcecites [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
• ?Not checked — no full text of the sourcecites [119] Milne, 2009, Protein and energy supplementation in elderly people at risk from malnutrition, Cochrane Database Syst Rev source
• ?Not checked — no full text of the sourcecites [121] Cawood, 2012, Systematic review and meta-analysis of the effects of high protein oral nutritional supplements, Ageing Res Rev source
• ?Not checked — no full text of the sourcecites [120] Stratton, 2013, A systematic review and meta-analysis of the impact of oral nutritional supplements on hospital readmissions, Ageing Res Rev source

In the paper

“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).”

What the sources say

• ?Not checked — no full text of the sourcecites [175] Friedli, 2017, Revisiting the refeeding syndrome: results of a systematic review, Nutrition source

In the paper

“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.”

In the paper

“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.”

What the sources say

• ?Not checked — no full text of the sourcecites [221] Cheuvront, 2010, Biological variation and diagnostic accuracy of dehydration assessment markers, Am J Clin Nutr source

In the paper

“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.”

What the sources say

• ?Not checked — no full text of the sourcecites [47] Feldblum, 2011, Individualized nutritional intervention during and after hospitalization: the nutrition intervention study clinical trial, J Am Geriatr Soc source

In the paper

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

What the sources say

• ?Not checked — no full text of the sourcecites [204] Gariballa, 2007, Effects of dietary supplements on depressive symptoms in older patients: a randomised double-blind placebo-controlled trial, Clin Nutr source

In the paper

“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).”

In the paper

“A standardized definition is unfortunately lacking, and current knowledge about the syndrome is altogether limited.”

In the paper

“Their suggested threshold is that serum or plasma osmolality >300 mOsm/kg is classified as dehydrated.”

What the sources say

• ?Not checked — no full text of the sourcecites [221] Cheuvront, 2010, Biological variation and diagnostic accuracy of dehydration assessment markers, Am J Clin Nutr source

In the paper

“Treatment for volume depletion aims to replace lost water and electrolytes and involves the administration of isotonic fluids (224, 271).”

What the sources say

• ?Not checked — no full text of the sourcecites [224] Thomas, 2008, Understanding clinical dehydration and its treatment, JAMDA source
• ?Not matched

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

  cites [271] 2013

In the paper

“However, the authors suggested that this form of diagnosis needs further assessment (273).”

What the sources say

• ?Not checked — no full text of the sourcecites [273] McGee, 1999, The rational clinical examination. Is this patient hypovolemic?, JAMA source

In the paper

“Isotonic or slightly hypotonic fluids are ideal (224).”

What the sources say

• ?Not checked — no full text of the sourcecites [224] Thomas, 2008, Understanding clinical dehydration and its treatment, JAMDA source