Elderly´s Malnutrition, Processes/health Outcomes in Primary Health Care: A Scoping Review

Objectives - The aim of this study, as the rst review directed at Primary Health Care, is identifying screening/intervention tools/health outcomes that validate malnutrition in the elderly. Methods - Following PRISMA, searches were conducted in 4 electronic databases on observational, qualitative, quantitative, or mixed studies, written in Portuguese, Spanish or English language, with participants aged 65 years or older. Results - 483 studies were identied, 16 were considered eligible. The Mini Nutritional Assessment showed the highest criteria of choice, however, health systems do not demonstrate standardized practices in the screening´s use. Studies are more oriented towards the relationship´s analysis of mortality/morbidity and malnutrition than its effects on the person´s quality of life. Discussion - Malnutrition is one of the modiable factors and contributes to the frail elderly condition, with serious effects, especially when related to other comorbidities. Yet, several authors argue that Primary Health Care intervention can improve health outcomes.


Introduction
The 21st century is witnessing one of the most relevant social changes to which Portugal is no stranger.
According to National Statistical Institute (2017), the Portuguese demographic pyramid re ects a marked population aging (5th highest value and 3rd lowest value of the renewal index at European level). An aging population has a marked propensity for developing multimorbidity states, which project functional disabilities with effects on resource consumption (WHO, 2015). Santana (2000), although the health of the Portuguese population has improved in recent decades, this increase has not been accompanied by policies that re ect the need for elderly health, recognizing that the phenomenon may mirror an increase in the demand for care. Rodrigues et al. (2018) in their study, con rmed a high prevalence of multimorbidity (78.3%), increasing across age strata (72.8% for 65 -69 years to 83.4% for ≥ 80 years). The hospitalization was reported by 25.8% of the individuals, concluding that the high prevalence of multimorbidity, associated with unhealthy lifestyles, of which diet stands out, is a predictor of vulnerability in the elderly, requiring dedicated intervention. This fact represents an enormous challenge at the level of the health sector, speci cally for Primary Health Care (PHC) (a privileged and rst-line access route for the person to the National Health Systems), expecting (given their mission) the implementation and improvement of effective and rapid community intervention strategies that mobilize responses capable of satisfying the speci c needs of this population (DGS, 2004).
In Portugal, assumed the dynamics of aging, the Ministry of Health (2004) approved the National Programme for the Health of the Elderly, recommending special attention to the elderly, for the intervention of health professionals in the elderly with malnutrition.
Nutrition is an essential component of health in the elderly population, capable of determining the quality of aging. In this sense, the adequate nutritional status results from the re ection of the balance between food intake and the nutritional needs of the elderly body (Agarwal et al., 2013;Cederholm et al., 2017).
The concept of malnutrition refers to a state resulting from a lack of nutrient absorption or intake that leads to changes in body composition (decreased fat-free mass) and body cell mass, with a consequent decrease in physical and mental function, associated with a more reserved clinical prognosis (Rasmussen et al., 2010).
According to the National Programme for the Promotion of Healthy Eating (2020), the population's inadequate eating habits are the fourth modi able risk factor that most contributed to the loss of healthy life years (11.4% of the total number of deaths), especially malnutrition, particularly in the elderly.
It should be noted that malnutrition in the elderly is a current phenomenon often underdiagnosed and has not received the deserved attention. It is easily assumed as a natural and expected sign of aging, and therefore its early recognition becomes essential for appropriate and timely correction (Visvanathan, 2003). The common and cross-cutting thematic interest promoted by the different authors referenced for systematic reviews, oriented towards malnutrition in the hospitalized/institutionalized elderly is assumed  Silva et al., 2015). In this sense, it is important to recognize the importance of re-conducting a new research study capable of validating the terms of analysis for the context of the potential PHC intervention. The study will be based on a methodology that structures a scoping review and simultaneously substantiates the following objectives: 1. To identify the screening/intervention instruments that validate the phenomenon of malnutrition in the elderly; 2. To identify the health outcomes (morbidity, mortality, functional capacity, and quality of life) associated with under-diagnosis and under-intervention of Family Health Teams (Doctors and Nurses) regarding the phenomenon of malnutrition in the elderly;

Eligibility criteria
The selected studies complied with the following PICOS strategy. Only studies are written in English,

Study selection
Studies founded by database analysis were exported to the Rayyan Management Software. Reviewers (AT, AM) selected the eligible studies for this review. An inclusion/exclusion algorithm was created to facilitate the data screening phases (three in total). In the rst data screening phase, duplicates identi ed by the software were reviewed and removed by (AT, BS). In the second phase, two reviewers (AT, AM) independently identi ed assessed the titles and abstracts of the studies for inclusion. Each reviewer decided on the inclusion or exclusion of each paper based on the inclusion/exclusion criteria stated above. During the third phase, two reviewers (AT, AM) independently conducted a full review of the papers approved during the second phase data review for inclusion. Possible disagreements were resolved by consensus. The reason for exclusion was identi ed for all excluded studies and a PRISMA chart was plotted to summarise the study and selection process (Fig.1).

Data extraction
The selected data migrated to Excel document format. Values were placed on data from studies that identify (1) the screening/intervention tools most used by health professionals that validate the phenomenon of malnutrition in the elderly; (2) and/or data from studies that identify health outcomes associated with under-diagnosis and under-intervention by Family Health Teams.
In addition, when possible, data were extracted on: 1) study characteristics (study design, country of origin, year of publication, and sample size); 2) participant characteristics (socioeconomic and educational variables, clinical conditions, living arrangement, mean age, gender, and race); 3) screening instrument used in the diagnosis of malnutrition; 4) elderly´s health outcomes (morbidity, mortality, functional capacity and quality of life); 5) main conclusions. The descriptions of the studies are presented in Tables 1 and 2.

Data synthesis
The included articles were submitted to a qualitative synthesis. The main results were organized into different categories in a discrete and non-overlapping manner. In each category, the results were summarised, highlighting their meaning.

Results
Initially, 483 studies were identi ed through an electronic database search. After duplicates were removed (n = 54), the titles and abstracts were screened. Completed the entire screening process, 391 studies were excluded. The main reasons for the exclusion of studies were: i) did not consider the research scope (n=335); ii) study contexts were exclusively hospital/nursing homes /inpatient (n=32); iii) followed systematic review and meta-analysis methodology (n = 21); iv) include articles published in languages excluded (n=1); v) opinion´s articles (n=1); vi) book chapters (n=1). Of the 38 full-text articles assessed for eligibility, 13 met the inclusion criteria. References of these studies were manually analyzed, resulting in 3 additional studies. In total, 16 studies were identi ed for this scoping review (Fig.1).

Characteristics of included studies
The risk of malnutrition was positively related to social risk and the number of chronic diseases. 3.6% of participants who had social problems, were at risk of malnutrition and malnutrition (1.8%). People suffering from more than six pathologies, also had a higher nutritional risk The risk of undernutrition seems to be associated with a more disadvantaged social condition and comorbidities. The development of training programs in nutrition education and the use of simple tools to identify nutritional risk in primary health care could be effective to reduce the prevalence of malnutrition, avoid negative health consequences and improve the quality of care. If a situation of nutritional risk is not detected and treated early, it can lead to malnutrition, a serious pathological situation with very negative consequences for the elderly´s health, not to mention the social and health costs that this situation entails Geurden et al., Patients at risk of malnutrition were signi cantly sicker (P < 0.001), and reveals more eating problems such as di culties with chewing or swallowing and loss of appetite (P < 0.001) The mean age at death of participants with malnutrition and risk of malnutrition was ~ 3 and 1.5 years shorter (CI -95%, P<0.001) than that of participants with normal nutritional status, respectively, while malnutrition or risk of malnutrition together with abnormal biomarker levels (hemoglobin and albumin) was related to one year shorter survival Malnutrition and the risk of malnutrition are signi cantly associated with shorter survival. Poor nutritional status in combination with abnormalities in biomarkers is associated with even shorter survival Spirgienė et al.
The risk of/malnutrition was associated with chronic (P < 0.004) and intermittent pain (P < 0.001), chewing di culties (P < 0.001), swallowing disorders (P < 0.001), dental problems (P < 0.001), and medication use (P < 0.001). The risk of malnutrition and undernutrition was related to depression (P = 0.001) and Alzheimer's disease or other dementia (P < 0.001), but had no statistically signi cant relationship with cancer (P = 0.120) or diabetes mellitus (P = 0.065) Educating community elders about healthy nutrition and providing them with speci c updated guidelines to follow over the long term contributed to favorable changes. The ndings infer that community nurses' efforts to ensure better health outcomes for the elderly, using minimal nancial and human resources, appeared to be effective in improving elderly people's nutrition knowledge and practices on nutrition

Discussion
The absence of a scoping review on the health processes and outcomes in PHC associated with malnutrition in the elderly is a gap in the literature. In this context, according to Lima (2012), PHC represents a key vector for intervention in promoting healthy eating habits and the prevention of malnutrition. In this respect, a commitment to differentiated intervention assumes a guide by the synergy of efforts of multidisciplinary teams.
To ll this gap, this scoping review was conducted with the following objectives: i) to identify the screening/intervention tools that validate the phenomenon of malnutrition in the elderly; ii) to identify the health outcomes (morbidity, mortality, functional capacity, and quality of life) associated with underdiagnosis and under-intervention of Family Health Teams regarding the phenomenon of malnutrition in the elderly. Reading the articles allows us to state that the effects of malnutrition in the elderly, in terms of associated health outcomes, tend to be severe, especially when related to other comorbidities. Ahmed et al. (2018) concluded that mortality in an elderly person with diabetes and malnutrition increases by 69%, including ischaemic heart disease; chronic obstructive pulmonary disease; stroke, or transient ischaemic stroke; chronic renal failure, and acute myocardial infarction. In addition, the total annual expenditure on health care for the undernourished individual was signi cantly higher. However at this point, to Schilp et al. (2014), no statistically signi cant differences were found between the introduction of dietary treatment VS usual care in total costs. Shakersain et al. (2016), found that malnutrition and malnutrition risk was signi cantly associated with all-cause mortality and shortened survival by 3 and 1.5 years respectively. They also found that being elderly, living alone, and institutionalized directly correlated with poor nutritional status. However, the pure effect of malnutrition on mortality may not be perceived. In the present study, the relationship between poor nutritional status and mortality appears to be independent of chronic diseases suggesting that subclinical changes may play a role in the association between poor nutritional status and mortality. But then, Yang et al. (2011), supports the previous analyses by robustly stating by their study that malnutrition in the elderly is assumed to be a risk factor for increased health service utilization and mortality (Hegendörfer et al., 2020;Mastronuzzi et al., 2015;Pedersen et al., 2016). This corroborates Santana's (2000) opinion in recognizing that the phenomenon may re ect an increase in the demand for care.
The risk of malnutrition is identically related to lower physical and cognitive performance, greater functional disability (in terms of autonomy in ADL), and even entails an increased risk of depression and

Strengths And Limitations
To the best of our knowledge, this is the rst scoping review that synthesizes the range of knowledge available on PHC processes and health outcomes associated with malnutrition in older people. This reveals the greatest strength of the current study. The inclusion of peer-reviewed scienti c articles published in English, Portuguese and Spanish, with a timeframe that includes the last 10 years of research on the current and growing phenomenon of vulnerability in the elderly, is another possible strength of the scoping review. However, we are aware that it may have limited the analysis by excluding.
Given the interest of the current systematic reviews, it contrasts the need for scienti c investment in this area of intervention, the PHC. Efforts were made to capture all relevant articles, assumed by the decision and interest to consult the references of eligible studies; however, articles could be overlooked. The inclusion of studies with different sampling levels reveals another possible strength of scoping review (as it is advisable to present papers that support and reinforce the results, overcoming the limitation of those with a less representative number of participants). However, the same condition may represent a possible associated limitation. Studies with different sampling representativity are included and compared, which may limit the extrapolation of results.

Conclusion
In community settings, in terms of health outcomes analysis on the impact of malnutrition in the elderly, studies are mostly oriented towards its relationship with morbidity/mortality, then effectively to the effect on the cost or the person's quality of life. However, all studies reinforce the severity associated with malnutrition in the irreversible senescence process. The studies also add that, although health professionals evoke in their practice the impact of healthy eating in diagnosis and individual/community prognosis, they have di culties identifying the issue of risk/ malnutrition in the individual. Professionals need to adopt screening and early intervention practices regarding risk/ malnutrition in the elderly, considering that prompt and correct diagnosis/treatment can improve health outcomes for the person and the system. The current socio-economic situation, aggravated by a pandemic, has led countries, like Portugal, to an unprecedented economic crisis. Associated with this macro context, an increase in the phenomenon of malnutrition is foreseeable, given that people may lose income and see their purchasing power diminish, aspects that will in uence the acquisition of foodstuffs. Thus, the possible consequences arising from this new reality should be a call to researchers to invest time in analysis and intervention on the phenomenon of malnutrition in the elderly. Despite the relevant results found, and for futures researches, there are still understudied content areas. Namely, based on an experimental or mixed methodology in the PHC context, the study of the relationship between the effectiveness (cost/bene t) of good practices associated with malnutrition and their expression in results to produce health gains (elderly/system). The scienti c process is expected to be able to support the de nition of quality interventions/clinical governance that facilitate and promote decision-making in Family Health Teams.

Declarations
Ethical approval and consent to participate: As a scoping review, the study was not submitted to an Ethics Committee. However, the authors approved all included studies and informed consent was obtained.
Consent for publication: Not applicable.
Availability of data and materials: All of the data analysed in this study is included in this published article.
Con ict of interest declaration: The authors declare that there is no con ict of interest.
Funding: There is no nancing.
Authors' contributions: All authors were involved in this scoping review. AT, AM, and PC designed the study. AT and AM contributed to the development of selection criteria and data extraction. AT, AM and PC carried out the strategy. AT and AM evaluated the studies and data extraction. BS, AM, and PC provided a critical review of the article. AT drafted the manuscript. All authors have read and approved the nal version of the manuscript. Adaptation of PRISMA ow chart.