*2.5. Step 4: Data Charting*

The selected articles were summarized in Table 1 [23–31], including authors and year, aim, method, and main results.




#### **Table 1.** *Cont.*

*2.6. Step 5: Collating, Summarization, and Presenting the Findings*

Lastly, the results were collated and summarized according to Arksey and O'Malley's framework [18], respecting the proposed search strategy.

#### **3. Results**

The search strategy yielded 638 articles; 142 duplicates were excluded. A further 421 records were excluded after applying the title and abstract eligibility criteria. The full texts of 75 articles were reviewed. Of these, nine articles met the inclusion criteria and were included in this scoping review [23–31]. Figure 1 shows the search and selection process according to the PRISMA statement [21]. (Figure 1).

**Figure 1.** Flow diagram of the search and selection process, based on PRISMA flowchart.

The relationship between older people's nutritional status, hospitalization, and cognitive impairment as a result of the included studies is shown in Table 1 and in the Supplementary Material Table S1.

According to the scoping review framework, the main themes were divided into two results sections.

#### *3.1. Prevalence and Risk Factors of Malnutrition in Older Patients with Cognitive Impairment*

Orsitto et al. [23] described an extremely high prevalence of poor nutritional status in a sample of hospitalized older patients with different grades of cognitive impairment. Only 18% of the sample was well nourished, while 82% were at risk of malnutrition or malnourished. Findings showed a significantly greater malnutrition rate in hospitalized patients with severe cognitive impairment. This study showed the evidence of poor nutritional status even in patients with mild cognitive impairment who had not yet progressed to dementia [23]. Moreover, according to Salva et al. [28] patients with dementia showed a high risk of malnutrition with respect to other patients. According to Lin et al. [29], eating difficulty, no feeding assistance, moderate dependence, fewer family visits, and being female and older were six independent factors associated with low food intake after controlling for all other aspects [29].

Hospitalized frail patients develop a major risk of under-nutrition and weight loss [23,25]. However, according to the findings of another study [25] there are no differences in malnutrition among different groups of hospitalized patients concerning age, length of stay, gender, or baseline anthropometric scores.

## *3.2. Nursing Strategies Used to Enhance Clinical Outcomes*

Simple, inexpensive, and easy-to-implement strategies, such as early dietary assessment; dietary "grazing" and staggered mealtimes, can improve nutrition in hospitalized elderly patients [25]. Nursing strategies that provide information on the clinical, functional, and cognitive aspects of the disease should be used in hospitalized patients, especially those with cognitive impairment [25]. The immediate evaluation of eating abilities, nutritional needs, and dietary preferences is a simple and inexpensive strategy that can lead to positive changes in nutritional intake in this population [25,31]. Indeed, assessing the patient's nutritional needs early is critical to reducing hospitalization [24], as it improves the patient's weight, but this does not affect cognitive impairment [25]. A positive element emerges from the study of Avelino-Silva et al.: hospitalization, by allowing more time to assess each patient, provides the opportunity for a detailed and structured nutritional clinical assessment through a CGA tool that has proven useful in reducing mortality in these patients [24]. Other tools have been used in order to evaluate nutritional status, for instance, Salva et al. used the mini nutritional assessment scale [28].

Some studies have also shown other strategies to enhance the nutritional outcome in patients with cognitive impairment. For example, the main objective of Lauque et al. [26] was to evaluate the effects of OS. Overall, 46 patients (intervention group) received 3 month OS, while the other 45 patients (control group) received standard care in geriatric wards and daycare centers in the Toulouse region. Protein and energy consumption considerably increased in the intervention group between baseline and 3 months, leading to a considerable gain in weight as well as fat-free mass. Nevertheless, no substantial changes in biological markers, cognitive function, or dependence were observed. Therefore, the authors conclude that the regular OS assumption can aid in preserving the gain in fat-free mass and enhance these individuals' nutritional status. Additionally, a study conducted by Allen et al. [30] showed that supplement drinks may be beneficial in reducing the prevalence of malnutrition within the group, as more people meet their nutritional requirements. Moreover, another study by Allien et al. [27] showed that drinking nutritional beverages with a glass makes the patient more stimulated to drink rather than using a straw. Baumgartner et al. [31] found that individualized nutritional support improves functional outcomes and quality of life (QoL) over 30- and 180-day periods of nutritional support.

Finally, if nurses take the time to assess the nutritional status and needs, implement suitable care plans and provide food and drink in ways that ensure their safe consumption, this can positively affect both patients' nutritional status and their general health condition, reducing the risk of mortality too [28–31].

#### **4. Discussion**

#### *4.1. Nutritional Assessment and Screening*

Malnutrition has a high prevalence in hospitalized elderly patients [25,26]. This review confirms that the potential associated factors are different: medical history, medicines intakes, diet, oral health, swallowing ability, physical and cognitive function, gastrointestinal, psychiatric, and neurological conditions, and also social aspects of a person's life [24]. Therefore, every hospital should establish an interdisciplinary approach to nutrition care based on formal policies and procedures, ensuring the early identification of malnourished patients or malnutrition risk and implementing comprehensive nutrition care plans [24]. In fact, the review results suggest that patients should be screened for malnutrition within the first 24 h of admission and screened regularly during their hospital stay [23,24]. Moreover, it is critically important to establish individualized nutritional support to these patients, as this improves functional outcomes and QoL, as well as reducing mortality by 50% at 30 days in hospitalized elderly patients [31].

The MNA has become a tool allowed standardized, reproducible, and reliable determination of nutritional status [26,31]. However, some studies reported that the MNA-SF (mini nutritional assessment short-form) could overestimate malnutrition risk [28].

Avoiding and solving malnutrition in elderly individuals is a crucial element of geriatric care, since healthy people can also become malnourished during hospitalization. In this context, early dietary assessment and implementation of feeding strategies are crucial not only for vulnerable patients [25].
