Showing papers in "Journal of Nutrition Health & Aging in 2013"
TL;DR: The present report provides the first definition of a “Cognitive Frailty” condition in older adults and proposes the use of multidomain interventions focused on the physical, nutritional, cognitive and psychological domains for improving the well-being and quality of life in the elderly.
Abstract: The frailty syndrome has recently attracted attention of the scientific community and public health organizations as precursor and contributor of age-related conditions (particularly disability) in older persons. In parallel, dementia and cognitive disorders also represent major healthcare and social priorities. Although physical frailty and cognitive impairment have shown to be related in epidemiological studies, their pathophysiological mechanisms have been usually studied separately. An International Consensus Group on "Cognitive Frailty" was organized by the International Academy on Nutrition and Aging (I.A.N.A) and the International Association of Gerontology and Geriatrics (I.A.G.G) on April 16th, 2013 in Toulouse (France). The present report describes the results of the Consensus Group and provides the first definition of a "Cognitive Frailty" condition in older adults. Specific aim of this approach was to facilitate the design of future personalized preventive interventions in older persons. Finally, the Group discussed the use of multidomain interventions focused on the physical, nutritional, cognitive and psychological domains for improving the well-being and quality of life in the elderly. The consensus panel proposed the identification of the so-called "cognitive frailty" as an heterogeneous clinical manifestation characterized by the simultaneous presence of both physical frailty and cognitive impairment. In particular, the key factors defining such a condition include: 1) presence of physical frailty and cognitive impairment (CDR=0.5); and 2) exclusion of concurrent AD dementia or other dementias. Under different circumstances, cognitive frailty may represent a precursor of neurodegenerative processes. A potential for reversibility may also characterize this entity. A psychological component of the condition is evident and concurs at increasing the vulnerability of the individual to stressors.
596 citations
TL;DR: A long-term intervention with an EVOO-rich MedDiet resulted in a better cognitive function in comparison with a control diet, however, non-significant differences were found for most cognitive domains.
Abstract: XXXto assess the effect on cognition of a controlled intervention testing Mediterranean diets (MedDiet). XXXrandomized trial after 6.5 years of nutritional intervention. Eight primary care centers affiliated to the University of Navarra. A random subsample of 285 participants (95 randomly allocated to each of 3 groups) of the PREDIMED-NAVARRA trial. All of them were at high vascular risk (44.8% men, 74.1± 5.7 years at cognitive evaluation). Nutritional intervention comparing two MedDiets (supplemented with extra-virgin olive oil [EVOO] or mixed nuts) versus a low-fat control diet. Participants received intensive education to increase adherence to the intended intervention. Participants allocated to the MedDiet groups received EVOO (1 l/week) or 30 g/day of mixed nuts. Dietary habits were evaluated using a validated 137-item food frequency questionnaire (FFQ). Additionally, adherence to MedDiet was appraised using a 14-item questionnaire both at baseline and yearly thereafter. XXXcognitive performance as a main outcome and cognitive status (normal, mild cognitive impairment [MCI] or dementia) as a secondary outcome were evaluated by two neurologists blinded to group assignment after 6.5 years of nutritional intervention. Better post-trial cognitive performance versus control in all cognitive domains and significantly better performance across fluency and memory tasks were observed for participants allocated to the MedDiet+EVOO group. After adjustment for sex, age, education, apolipoprotein E genotype, family history of cognitive impairment/dementia, smoking, physical activity, body mass index, hypertension, dyslipidaemia, diabetes, alcohol and total energy intake, this group also showed lower MCI (OR=0.34 95% CI: 0.12–0.97) compared with control group. Participants assigned to MedDiet+Nuts group did not differ from controls. A long-term intervention with an EVOO-rich MedDiet resulted in a better cognitive function in comparison with a control diet. However, non-significant differences were found for most cognitive domains. Participants allocated to an EVOO-rich MedDiet had less MCI than controls.
222 citations
TL;DR: The MK-0773-induced increase in LBM did not translate to improvement in strength or function vs. placebo, and the improvement of strength and physical function in the placebo group could be at least partly attributed to protein and vitamin D supplementation.
Abstract: Background
Sarcopenia, the age-related loss of muscle mass [defined as appendicular LBM/Height2 (aLBM/ht2) below peak value by>1SD], strength and function, is a major contributing factor to frailty in the elderly. MK-0773 is a selective androgen receptor modulator designed to improve muscle function while minimizing effects on other tissues.
218 citations
TL;DR: Age, cognition, ADL, IADL, health self-perception, ischemic heart disease and sarcopenia were associated in the bivariate analysis with survival and negative predictive value for sarc Openia regarding mortality was of 90%.
Abstract: Sarcopenia has an important impact in elderly. Recently the European Working Group on Sarcopenia in Older People (EWGSOP) defined sarcopenia as the loss of muscle mass plus low muscle strength or low physical performance. Lack of clinical sounding outcomes (ie external validity), is one of the flaws of this algorithm. The aim of our study was to determine the association of sarcopenia and mortality in a group of Mexican elderly. A total of 345 elderly were recruited in Mexico City, and followed up for three years. The EWGSOP algorithm was integrated by: gait speed, grip strength and calf circumference. Other covariates were assessed in order to test the independent association of sarcopenia with mortality. Of the 345 subjects, 53.3% were women; with a mean age of 78.5 (SD 7) years. During the three year follow-up a total of 43 (12.4%) subjects died. Age, cognition, ADL, IADL, health self-perception, ischemic heart disease and sarcopenia were associated in the bivariate analysis with survival. Negative predictive value for sarcopenia regarding mortality was of 90%. Kaplan-Meier curves along with their respective log-rank test were significant for sarcopenia. The components of the final Cox-regression multivariate model were age, ischemic heart disease, ADL and sarcopenia. Adjusted HR for age was 3.24 (CI 95% 1.55–6.78 p 0.002), IHD 5.07 (CI 95% 1.89–13.59 p 0.001), health self-perception 5.07 (CI 95% 1.9–13.6 p 0.001), ADL 0.75 (CI 95% 0.56–0.99 p 0.048) and sarcopenia 2.39 (CI 95% 1.05–5.43 p 0.037).
206 citations
TL;DR: The use of the Gérontopôle Frailty Screening Tool may help at raising awareness about the importance of identifying frailty, training healthcare professionals at the detection of the syndrome, and developing preventive interventions against disabling conditions.
Abstract: The frailty syndrome is a pre-disability condition suitable to be targeted by preventive interventions against disability. In order to identify frail older persons at risk of negative outcomes, general practitioners must be provided with an easy and quick screening tool for detecting frailty without special effort. In the present paper, we present the screening tool for frailty that the Gerontopole of Toulouse (France) has developed and implemented in primary care in the region with the collaboration of the Department of Family Medicine of the University of Toulouse. The Gerontopole Frailty Screening Tool (GFST) is designed to be administered to persons aged ≥65 years with no physical disability and acute clinical disease. It is composed by an initial questionnaire aimed at attracting the general practitioner’s attention to very general signs and/or symptoms suggesting the presence of an underlying frailty status. Then, in a second section, the general practitioner expresses his/her own view about the frailty status of the individual. The clinical judgment of the general practitioner is finally retained for determining the eventual presence of frailty. Preliminary data document that almost everyone (95.2%) of the 442 patients referred to the Gerontopole frailty clinic by general practitioners using the GFST indeed presents a condition of (pre-)frailty according to the criteria proposed by Fried and colleagues in the Cardiovascular Health Study. The use of the GFST may help at raising awareness about the importance of identifying frailty, training healthcare professionals at the detection of the syndrome, and developing preventive interventions against disabling conditions.
181 citations
TL;DR: It is confirmed the necessity to routinely perform nutritional status evaluation in elderly subjects, to carry out training courses for health workers and caregivers, to implement nutritional education of the geriatric population, and to identify and reduce clinical, functional, social or economic risk factors for malnutrition.
Abstract: Malnutrition occurs frequently in the frailest groups of the population, especially in people who are on a low income and elderly subjects, overall if they are institutionalized. The aim of this study was to assess the prevalence of malnutrition in a sample of elderly people living in different settings and to identify the determinants of malnutrition. Methods:A total of 718 subjects, 472 females (F) and 246 males (M), were recruited from nursing homes or were free living in three different regions in Italy. Nutritional status, depression, social, functional and cognitive status, were evaluated. Results:According to the Mini Nutritional Assessment (MNA), a high prevalence of malnutrition was found out in both genders: 26% of F and 16.3% of M were classified as being malnourished (MNA<17); 40.9% of F and 35% of M were at risk of malnutrition (MNA 17- 23,5). The prevalence of malnutrition was significantly higher in NH subjects in both sexes. Moreover, a relationship was shown between malnutrition and inability to shop, prepare and cook meals because of a low income, distance from markets or supermarkets as well as impossibility to drive the car or to use public transportation. This study confirms the necessity to routinely perform nutritional status evaluation in elderly subjects, to carry out training courses for health workers (doctors, nurses, psychologists, dietitians), to implement nutritional education of the geriatric population, to develop tools and guidelines for health workers and caregivers, to identify and reduce clinical, functional, social or economic risk factors for malnutrition.
172 citations
TL;DR: A profound understanding of the interdependency of these two geriatric concepts will represent the basis for successful treatment strategies and underline the close association between frailty syndrome and nutritional status in older persons.
Abstract: Objective
This study investigates the association between MNA results and frailty status in community-dwelling older adults. In addition the relevance of singular MNA items and subscores in this regard was tested.
148 citations
TL;DR: The present data supports previous findings, that sympatho-vagal balance is related to BMI in non-obese, healthy individuals, providing evidence for a prominent role of the vagus nerve in the modulation of the energy expenditure of the human organism.
Abstract: Objectives
The present analysis is a replication of previous findings presenting first evidence of an association between body mass index (BMI) and autonomic nervous system (ANS) activity as measured by heart rate variability (HRV), in healthy non-obese adults.
132 citations
TL;DR: The hypothesis that adherence to a diet comprised of vegetables, fruits, whole grains, fish, and legumes may protect against the development of depressive symptoms in older age is supported.
Abstract: Objective
To examine whether adherence to a Mediterranean-based dietary pattern is predictive of depressive symptoms among older adults.
118 citations
TL;DR: High STV at fast-pace walking speed was a specific gait disturbance ofMCI patients in the sample of studied participants, and thus could be used in the future as a specific biomarker of MCI patients.
Abstract: Background
The interpretation of the increase in stride-to-stride variability of stride time (STV) regarding the evolution of cognitive deficits across the dementia spectrum is matter of debate.
109 citations
TL;DR: The results will allow a better understanding of the clinical stage previous to malnutrition and an adequate diagnosis and treatment of identified modifiable factors like functional impairment, eating behaviours and depression could delay or avoid malnutrition.
Abstract: Objectives
The objective of this study is to assess the nutritional status, measured by the MNA, in community-dwelling elderly individuals with dementia and to identify clinical risk factors for nutritional risk or malnutrition.
TL;DR: An overview of multidomain intervention trials that investigated effects of combined lifestyle-related factors on cognitive decline and the progression of dementia up to October 2011 is given.
Abstract: Objective
The risk for cognitive decline and for developing Alzheimer’s disease increases with age The aetiology is assumed to be of multi-factorial origin, and treatment opportunities are lacking Despite the multi-factorial origin, many intervention studies focused on single factors to influence cognitive health with inconsistent findings In this view, more and more intervention studies aim to intervene on multiple factors simultaneously to affect or slow down cognitive decline The purpose of this paper is to give an overview of these multidomain intervention trials
TL;DR: It is demonstrated that one-month consumption of a probiotics-containing biscuit was effective in redressing some of the age-related dysbioses of the intestinal microbiota.
Abstract: Objectives
Evaluation of the impact of a biscuit containing the probiotics Bifidobacterium longum Bar33 and Lactobacillus helveticus Barl3 on the intestinal microbiota in the elderly.
TL;DR: More than one half of the seniors receiving home care were at nutritional risk and poor functional level, respectively, and Malnutrition according to MNA was significantly associated to both questionnaire- and performance-based functional measures even after exclusion of functional MNA items.
Abstract: Objectives
The aims of this work were (a) to provide a detailed description of the association between nutritional (Mini Nutritional Assessment; MNA®) and functional status in a sample of older adults receiving home care, using both questionnaire- and performance-based functional methods, and (b) to investigate the impact of different MNA subscales on this association
TL;DR: The dietary patterns identified may provide a useful basis on which to base dietary interventions targeted at older adults and suggest that older adults are not meeting nutrient recommendations and should continue to be encouraged to choose high quality diets.
Abstract: Objectives
To characterize dietary patterns among a diverse sample of older adults (≥ 65 years).
TL;DR: For all tools a significant association between nutritional status and mortality was demonstrated during follow-up as classification in ‘malnourished’ or ‘nutritional risk’, was significantly associated with increased hazard ratios, however, the MNA showed the best predictive value for survival among well-nourishing residents.
Abstract: Background
The European Society for Clinical Nutrition and Metabolism (ESPEN) has recommended the Mini Nutritional Assessment (MNA®), the Nutritional Risk Screening 2002 (NRS), and the Malnutrition Universal Screening Tool (MUST) for nutritional screening in various settings and age groups. While in recent years all three tools have been applied to nursing home residents, there is still no consensus on the most appropriate screening tool in this specific setting.
TL;DR: The high prevalence of nutritional risk highlights the importance of regular screening of nursing home residents and requires increased awareness for nutritional problems especially in functionally impaired residents to early initiate nutritional measures and thus, prevent further nutritional and functional deterioration.
Abstract: Objectives
To identify nursing home residents with malnutrition or at risk of malnutrition by using different markers, determine if the Mini Nutritional Assessment (MNA®) is able to identify all residents at risk according to single risk markers and explore the relation between risk markers and functional impairment.
TL;DR: Higher “vegetables-fruits” and “snacks-drinks-milk products” pattern scores were associated with reduced risk of cognitive impairment in Chinese older women in Hong Kong.
Abstract: Background
Dietary patterns can be identified using a priori and a posterior approaches. Few studies have related dietary patterns with cognitive impairment in Chinese population. This study examined the risk of cognitive impairment associated with dietary patterns identified by both approaches.
TL;DR: The findings show that a FCR dietary regime is effective in improving mood states and nutritional status among ageing men.
Abstract: Objective
An intervention study on the FCR (Fasting and Calorie Restriction) dietary regime was carried out to determine its efficacy in improving mood states and depression status among ageing men.
TL;DR: An international consensus group comprised of investigators from the International Academy of Nutrition and Aging and the International Association of Gerontology and Geriatrics recently convened in Toulouse, France to establish a definition for cognitive frailty in older adults, and an initial working definition was developed.
Abstract: An international consensus group comprised of investigators from the International Academy of Nutrition and Aging (IANA) and the International Association of Gerontology and Geriatrics (IAGG) recently convened in Toulouse, France to establish a definition for cognitive frailty in older adults. This effort was motivated by growing awareness that many people with physical frailty are also prone to cognitive problems. In “Cognitive Frailty: Rationale and Definition” [1], an initial working definition was developed, and a framework proposed for future studies of cognitive frailty.
TL;DR: A practical overview and rating of the level and type of available evidence that n-3 LC-PUFA supplements are safe and protective against cognitive aging and Alzheimer’s disease is provided, with additional discussion of the evidence for effects on quality of life, vascular aging, and the rate of aging.
Abstract: An NIH State of the Science Conference panel concluded in 2010 that insufficient evidence is available to recommend the use of any primary prevention therapy for Alzheimer’s disease or cognitive decline with age. Despite the insufficient evidence, candidate therapies with varying levels of evidence for safety and efficacy are taken by the public and discussed in the media. One example is the long-chain n-3 (omega-3) polyunsaturated fatty acids (n-3 LC-PUFA), DHA and EPA, found in some fish and dietary supplements. With this report, we seek to provide a practical overview and rating of the level and type of available evidence that n-3 LC-PUFA supplements are safe and protective against cognitive aging and Alzheimer’s disease, with additional discussion of the evidence for effects on quality of life, vascular aging, and the rate of aging. We discuss available sources, dose, bioavailability, and variables that may impact the response to n-3 LC-PUFA treatment such as baseline n-3 LC-PUFA status, APOE ɛ4 genotype, depression, and background diet. Lastly, we list ongoing clinical trials and propose next research steps to validate these fatty acids for primary prevention of cognitive aging and dementia. Of particular relevance, epidemiology indicates a higher risk of cognitive decline in people in the lower quartile of n-3 LC-PUFA intake or blood levels but these populations have not been specifically targeted by RCTs.
TL;DR: An international panel representing 6 international groups has recently suggested that all persons over the age of 70 years should be screened for physical frailty by simple, validated screening tests such as the FRAIL.
Abstract: that geriatricians should recognize a new syndrome of Cognitive Frailty (1). Physical frailty has now been recognized as an important syndrome in older persons (2-7). An international panel representing 6 international groups has recently suggested that all persons over the age of 70 years should be screened for physical frailty by simple, validated screening tests such as the FRAIL (8-13) (Table 1).
TL;DR: One in seven community-dwelling elderly with newly diagnosed AD is at risk of malnutrition and assessment of the nutritional status should be included in the comprehensive assessment of AD patients, which warrants further investigation.
Abstract: Objetives
To determine the prevalence of malnutrition and its relation to various factors in community-dwelling elderly with newly diagnosed Alzheimer’s disease (AD)
TL;DR: These results point to several key factors influencing global DQ in older adults and also show gender-based differences, which need to be understood to ensure good diet quality as people age.
Abstract: Judicious food choices are of prime importance during aging. This study was conducted to identify individual and collective attributes determining global diet quality (DQ). Participants were 1,793 adults (52% women) from the NuAge study on nutrition and successful aging. Subjects aged 67 to 84 years in relatively good health were recruited from the Quebec Medicare Database. Sociodemographic, affective, and cognitive data, health conditions, perceived physical health and functional status, dietary habits and dietary attributes and community resources were obtained using questionnaires. Body weight and height were measured and body mass index (BMI) was calculated. Three non-consecutive 24-hour diet recalls were collected at recruitment. DQ, assessed using the Canadian Healthy Eating Index (C-HEI, /100), was computed on the mean intakes from the diet recalls. Analyses were stratified by gender. Variables significantly related to DQ in bivariate analyses (p<.05) were entered into backward stepwise multiple regression analyses. Among men, the final model showed higher education (β=0.23, p=.01), diet knowledge (β=0.96, p<.0001), number of daily meals (β=1.91, p=.02) and perceived physical health (β=0.06, p=.01) to be positive determinants of DQ, whereas alcohol consumption (β=−2.25, p=.05), wearing dentures (β=−2.31, p=.01) and eating regularly in restaurants (β=− 1.65, p=.03) were negative determinants of DQ (adjusted R2 = 13.7%). Among women, higher education (β=0.29, p=.002), diet knowledge (β=0.54, p=.002), number of daily meals (β=3.61, p<.0001), and hunger (β=0.61, p<.0001) were positive determinants of global DQ; greater BMI (β=−0.16, p=.03) and chewing problems (β=−0.48, p=.03) were negative determinants of DQ (adjusted R2 = 7.8%). These results point to several key factors influencing global DQ in older adults and also show gender-based differences. More research must be done to better understand how these factors change with aging and exert their impact on diet, particularly since variance in DQ was largely unexplained. As diet knowledge was an independent predictor for both genders, targeted, sustainable interventions are needed to ensure good diet quality as people age.
TL;DR: High levels of thigh IMAT appear to blunt the adaptive MQ response to training in older adults, and may be a potential reason why some older adults do not change their MQ following training.
Abstract: Objective
To examine the influence of intramuscular adipose tissue (IMAT) on muscle quality (MQ) changes in older adults after 12 weeks of exercise training.
Centre Hospitalier Universitaire de Toulouse1, French Institute of Health and Medical Research2, World Health Organization3, McGill University4, University of KwaZulu-Natal5, European Medicines Agency6, Hallym University7, Taipei Veterans General Hospital8, University of Perugia9, International Longevity Center10, Centre Hospitalier Universitaire de Nice11, RMIT University12, Ghent University Hospital13, Dalhousie University14, Charles University in Prague15
TL;DR: Experts' positions on the main aspects of the frailty syndrome in the older persons are presented and an agreement with an international common definition is necessary to develop screening and to reduce the morbidity in older persons.
Abstract: Frailty tends to be considered as a major risk for adverse outcomes in older persons, but some important aspects remain matter of debate.
TL;DR: Age and higher baseline BMI, independent of gender, and other confounding factors, are risk factors for cognitive decline and reading habit plays a protective role seven years later among northern Italian adults aged 70 years or older.
Abstract: Objectives
The relative contributions of risk factors, as body mass index (BMI), depression, chronic diseases, smoking, and lifestyles (as physical and performance activity, social contacts and reading habit) to cognitive decline in the elderly are unclear We explored these variables in relation to 7-year cognitive decline in long-lived Italian elderly
TL;DR: Malnutrition was significantly more frequent in elderly subjects aged more than 85 years, in females, widowed and illiterate people and those who had worse oral health status and depressive disorders and cognitive dysfunction were significantly related to malnutrition.
Abstract: Objectives: This study aimed to assess the nutritional status, measured by MNA, and its association with socio-demographic indicators and health related characteristics of a representative sample of community dwelling elderly subjects. Design:Cross-sectional study. Setting:Community dwelling elderly individuals living in rural communities in Lebanon. Participants: 1200 elderly individuals aged 65 years or more. Measurements: Socio-demographic indicators and health related characteristics were recorded during a standardized interview. Nutritional status was assessed through Mini Nutritional Assessment (MNA). The 5-item GDS score and the WHO-5-A score were used to assess mood, whereas Mini Mental Status (MMS) was applied to evaluate cognitive status. Results: The prevalence of malnutrition and risk of malnutrition was 8.0% respective 29.1% of the study sample. Malnutrition was significantly more frequent in elderly subjects aged more than 85 years, in females, widowed and illiterate people. Moreover, participants who reported lower financial status were more often malnourished or at risk of malnutrition. Regarding health status, poor nutritional status was more common among those reporting more than three chronic diseases, taking more than three drugs daily, suffering from chronic pain and those who had worse oral health status. Also, depressive disorders and cognitive dysfunction were significantly related to malnutrition. After multivariate analysis following variables remained independently associated to malnutrition: living in the governorate of Nabatieh (ORa 2.30, 95% CI 1.35 -3.93), reporting higher income (ORa 0.77, 95% CI 0.61-0.97), higher number of comorbidities (ORa 1.22, 95% CI 1.12-1.32), chronic pain (ORa 1.72, 95% CI 1.24-2.39), and depressive disorders (ORa 1.66, 95% CI 1.47-1.88). On the other hand, better cognitive functioning was strongly associated with decreased nutritional risk (ORa 0.27, 95%CI 0.17- 0.43). Conclusion: Our results highlighted the close relationship between health status and malnutrition. The identification of potential predictive factors may allow better prevention and management of malnutrition in elderly people.
TL;DR: One in six patients attending their general practitioner for an annual health assessment were identified as being at nutritional risk which is an additional risk factor for a severe health issue, highlighting that older people can be atritional risk although they may be overweight or obese.
Abstract: Background: Objective
The study aimed to determine the prevalence of malnutrition risk in a population of older people (aged 75 years and over) attending a community general practice and identify characteristics of those classified as malnourished or at risk of malnutrition.
TL;DR: Baseline data showed high levels of dependence, comorbidities, psychological disturbances and medication’s consumption among NH residents, which may constitute the basis for the development of new work modalities within the French health system, and serve as a model of a feasible research approach in NHs.
Abstract: Whilst the number of people living in nursing homes (NH) is expected to rise, research on NH quality is scarce. The purpose of this article is to describe the research protocol of the IQUARE study and to present its baseline data. Methods and design: IQUARE is a 18-month multicentric individually-tailored controlled trial of education and professional support to NH staff. The main purposes of IQUARE are to improve the quality of the health care provided in NHs and to reduce the risk of functional decline among residents. Data on internal organisation and residents' health for the 175 participating NHs were recorded by NH staff at baseline. NHs were allocated to either a light intervention group (LIG, n = 90 NHs, totalising 3 258 participants) or a strong intervention group (SIG, n = 85 NHs, totalising 3 017 participants). Intervention for LIG consisted at delivering to NH staff descriptive statistics on indicators of quality regarding their NH and the NHs from their sub-region of health and region; whereas for SIG, NH staff received the same information that LIG, but quality indicators were discussed by a cooperative work (two half-day meetings) between a hospital geriatrician and NH staff. Strategies for overcoming NH's weaknesses were then traced; the efficacy of strategies is evaluated at a 6-month period. Results: Baseline data showed high levels of dependence, comorbidities, psychological disturbances and medication's consumption among NH residents. Large discrepancies among NHs were observed. Conclusions: IQUARE is one of the largest controlled trials in NHs developed in France. Results from IQUARE may constitute the basis for the development of new work modalities within the French health system, and serve as a model of a feasible research approach in NHs.