J Nutr Health Aging
THE JOURNAL OF NUTRITION, HEALTH & AGING©
MALNUTRITION AND RISK OF FALLING AMONG ELDERLY WITHOUT HOME-HELP SERVICE – A CROSS SECTIONAL STUDY A. WESTERGREN1, P. HAGELL1, C. SJODAHL HAMMARLUND1,2 1. The PRO-CARE group, School of Health and Society, Kristianstad University, Sweden; 2. Department of Health Sciences, Medical Faculty, Lund University, Sweden. Corresponding author: Albert Westergren, School of Health and Society, Kristianstad University, SE-291 88 Kristianstad, Sweden, E-mail: [email protected], Phone: +46 44 208550. Mobile: +46 705-329131
Abstract: Objectives: The aim of this study was to explore the frequency of malnutrition risk and associated risk of falling, social and mental factors among elderly without home-help service. The aim was also to explore factors associated with risk of falling. Design: A cross-sectional design was used. Setting: Elderly persons own homes. Participants: Data were collected during preventive home visits to 565 elderly (age range 73-90 years) without home-help service. Those with complete SCREEN II forms were included in the study (n=465). Measurements: Measurements included rating scales regarding malnutrition risk (SCREEN II) and risk of falling (Downton). In addition, single-items: general health, satisfaction with life, tiredness, low-spiritedness, worries/anxiety and sleeping were used. Results: According to the SCREEN II, 35% of the sample had no malnutrition risk, 35% had moderate risk and 30% had high malnutrition risk. In an ordinal regression analysis, increased malnutrition risk was associated with being a woman living alone (OR 4.63), male living alone (OR 6.23), lower age (OR 0.86), poorer general health (OR 2.03-5.01), often/always feeling tired (OR 2.38), and an increased risk of falling (OR 1.21). In a linear regression analysis, risk of falling was associated with higher age (B 0.020), not shopping independently (B 0.162), and low meat consumption (B 0.138). Conclusion: There are complex associations between malnutrition risk and the gender-cohabitation interaction, age, general health, tiredness, and risk of falling. In clinical practice comprehensive assessments to identify those at risk of malnutrition including associated factors are needed. These have to be followed by individual nutritional interventions using a holistic perspective which may also contribute to reducing the risk of falling. Key words: Malnutrition, home-dwelling, fall risk, SCREEN II, preventive home visits.
nutritional status. In a longitudinal study of home-living elderly people (75 and 80 years), predictors for developing undernutrition were higher age, poorer perceived health and more symptoms of depression (6). Whether a person eats alone or together with others has an impact on caloric intake (22), as intake may increase due to an extended duration of the meal related to social facilitation (23). Previous research has shown that living with others or receiving help from informal providers can be beneficial for dietary intake among older adults (24, 25). Qualitative research has shown that sudden and stressful life events such as being widowed or falling ill can negatively affect meals (1) in different ways among men (26) and women (27), i.e. depending on earlier roles. However, the potential interaction between cohabitation and gender on malnutrition risk has not been studied quantitatively. Furthermore, undernutrition has been shown to be associated with an increased risk of falling in residential long-term care (28) but not among elderly living at home, with or without home help service (29, 30). However, in a large (n=2971) study among elderly (>65 years), receiving home care, fallers could be predicted by immobility, high care dependency, and undernutrition (31). Further on, a relationship between low vitamin D intake (fish, dairy products, eggs etc.) and falls (3234), as well as between low protein intake (meet, fish, eggs, poultry etc.) and risk of falling (35) has been suggested. However, the relationship between risk of falling and
Background There is an increasing focus on nutrition among homedwelling elderly people (1, 2). However, such work has focused on those having home-help service such as meals-on-wheels (35) or included both persons with and without home-help service (6, 7). Thus, there is a need for studies exploring malnutrition risk and associated factors among home-dwelling elderly people without home-help service. Malnutrition does not only include undernutrition, but also overweight/obesity and nutrient deficiencies. For example, the prevalence of undernutrition in the elderly home-dwelling population has been estimated to be 14.5% according to the Mini Nutritional Assessment (MNA) [6], while another study, using the Seniors in the Community: Risk Evaluation for Eating and Nutrition Questionnaire (SCREEN), found that more than half of home-dwelling seniors had moderate (24%) or high (33%) malnutrition risk (8). This illustrates the need to address malnutrition and not only undernutrition among the elderly. The sequelae of undernutrition in elderly include functional decline or frailty (9-11), decreased quality of life (12), increased health care utilisations and costs (13, 14), higher rates of adverse complications from other health conditions (15), and increased mortality (10, 11, 16). Risk factors for undernutrition have been identified as low functional status, diseases, multipharmacy, and symptoms of depression (17-21). Low functional status by means of needing help with shopping and cooking can negatively affect food intake (1) and possibly Received December 13, 2013 Accepted for publication January 20, 2014
1
J Nutr Health Aging
MALNUTRITION AND RISK OF FALLING malnutrition risk has not been studied among elderly living at home without home help service. Aging is associated with a decrease in total energy expenditure, for instance due to a more sedentary life style. If this coincided with a maintained or increased energy intake overweight/obesity might develop (36). For instance, among 70-years-old Swedes, the overweight (BMI > 25)/obesity (BMI > 30) prevalence in percent was 67/20 among men and 64/24 among women, respectively (37). The sequelae of obesity in the elderly include decreased survival rates, metabolic syndromes, arthritis, pulmonary abnormalities, urinary incontinence, cataracts and cancer and has a negative impact on physical function and quality of life (36). Thus, there are several possible contributing factors for developing malnutrition, or for malnutrition to cause problems, but relatively little is known regarding this among home-dwelling elderly without home-help services. Considering the negative effects of malnutrition, it seems of utmost importance to identify persons at risk of developing malnutrition, or who have already developed it, in order to provide treatment or take suitable preventive actions among elderly without home-help service. Thus, the aim of this study was to explore the frequency of malnutrition risk and associated risk of falling as well as associated social and mental factors among elderly without home-help service. Methods Design A cross-sectional design was used. Context Preventive home visits (PHVs) often involve elderly in early stages of poor health or disability (38), and aim at maintaining health and independence and preventing disability and hospitalization (39, 40). This study was conducted within an established structure for PHVs among elderly people without home-help service in a south Swedish municipality. The municipality has approximately 12.500 inhabitants and two smaller towns (1). Data collection process Data for this study were collected by two experienced nurses during 2010-2011. Previous to this study they had conducted over 1500 PHVs. Interobserver agreement was neither assessed nor secured by co-training. However, in addition to their excessive experience with the protocol the two nurses worked in close collaboration and had frequent opportunities to discuss any uncertainties regarding data collection. The PHV took the form of a single home visit by one or both nurses. During the visits the nurse(s) used an interview protocol including questions about health, risk for falling, and nutrition. Each PHV lasted for about one hour. In addition to data collection, unmet needs that could be met by the municipality, voluntary 2
associations or by own efforts were discussed during the visits. Sample Inclusion criteria were 70 years or older, and without homehelp service. Exclusion criteria were cognitive deficits, enteral and parenteral nutrition. Out of 565 cognitively intact people (according to the clinical judgement of experienced nurses), 465 persons had complete forms regarding malnutrition and were included in this study. Instruments Malnutrition Version 2 of the Seniors in the Community: Risk Evaluation for Eating and Nutrition Questionnaire (SCREEN II) is a 17item rating scale regarding the risk of malnutrition in ordinary housing based on self-reports (7). Items cover, e.g. weight change, dietary habits, appetite, food intake, eating difficulties, use of meal replacements/supplements, eating alone/together, shopping and meal preparation. Summation of item scores (with different ranges, typically 0-4) yields a total score that can range from 0 to 64 (higher scores = better). Scores ≥54 have been suggested to indicate no risk of malnutrition, scores
THE JOURNAL OF NUTRITION, HEALTH & AGING©
MALNUTRITION AND RISK OF FALLING AMONG ELDERLY WITHOUT HOME-HELP SERVICE – A CROSS SECTIONAL STUDY A. WESTERGREN1, P. HAGELL1, C. SJODAHL HAMMARLUND1,2 1. The PRO-CARE group, School of Health and Society, Kristianstad University, Sweden; 2. Department of Health Sciences, Medical Faculty, Lund University, Sweden. Corresponding author: Albert Westergren, School of Health and Society, Kristianstad University, SE-291 88 Kristianstad, Sweden, E-mail: [email protected], Phone: +46 44 208550. Mobile: +46 705-329131
Abstract: Objectives: The aim of this study was to explore the frequency of malnutrition risk and associated risk of falling, social and mental factors among elderly without home-help service. The aim was also to explore factors associated with risk of falling. Design: A cross-sectional design was used. Setting: Elderly persons own homes. Participants: Data were collected during preventive home visits to 565 elderly (age range 73-90 years) without home-help service. Those with complete SCREEN II forms were included in the study (n=465). Measurements: Measurements included rating scales regarding malnutrition risk (SCREEN II) and risk of falling (Downton). In addition, single-items: general health, satisfaction with life, tiredness, low-spiritedness, worries/anxiety and sleeping were used. Results: According to the SCREEN II, 35% of the sample had no malnutrition risk, 35% had moderate risk and 30% had high malnutrition risk. In an ordinal regression analysis, increased malnutrition risk was associated with being a woman living alone (OR 4.63), male living alone (OR 6.23), lower age (OR 0.86), poorer general health (OR 2.03-5.01), often/always feeling tired (OR 2.38), and an increased risk of falling (OR 1.21). In a linear regression analysis, risk of falling was associated with higher age (B 0.020), not shopping independently (B 0.162), and low meat consumption (B 0.138). Conclusion: There are complex associations between malnutrition risk and the gender-cohabitation interaction, age, general health, tiredness, and risk of falling. In clinical practice comprehensive assessments to identify those at risk of malnutrition including associated factors are needed. These have to be followed by individual nutritional interventions using a holistic perspective which may also contribute to reducing the risk of falling. Key words: Malnutrition, home-dwelling, fall risk, SCREEN II, preventive home visits.
nutritional status. In a longitudinal study of home-living elderly people (75 and 80 years), predictors for developing undernutrition were higher age, poorer perceived health and more symptoms of depression (6). Whether a person eats alone or together with others has an impact on caloric intake (22), as intake may increase due to an extended duration of the meal related to social facilitation (23). Previous research has shown that living with others or receiving help from informal providers can be beneficial for dietary intake among older adults (24, 25). Qualitative research has shown that sudden and stressful life events such as being widowed or falling ill can negatively affect meals (1) in different ways among men (26) and women (27), i.e. depending on earlier roles. However, the potential interaction between cohabitation and gender on malnutrition risk has not been studied quantitatively. Furthermore, undernutrition has been shown to be associated with an increased risk of falling in residential long-term care (28) but not among elderly living at home, with or without home help service (29, 30). However, in a large (n=2971) study among elderly (>65 years), receiving home care, fallers could be predicted by immobility, high care dependency, and undernutrition (31). Further on, a relationship between low vitamin D intake (fish, dairy products, eggs etc.) and falls (3234), as well as between low protein intake (meet, fish, eggs, poultry etc.) and risk of falling (35) has been suggested. However, the relationship between risk of falling and
Background There is an increasing focus on nutrition among homedwelling elderly people (1, 2). However, such work has focused on those having home-help service such as meals-on-wheels (35) or included both persons with and without home-help service (6, 7). Thus, there is a need for studies exploring malnutrition risk and associated factors among home-dwelling elderly people without home-help service. Malnutrition does not only include undernutrition, but also overweight/obesity and nutrient deficiencies. For example, the prevalence of undernutrition in the elderly home-dwelling population has been estimated to be 14.5% according to the Mini Nutritional Assessment (MNA) [6], while another study, using the Seniors in the Community: Risk Evaluation for Eating and Nutrition Questionnaire (SCREEN), found that more than half of home-dwelling seniors had moderate (24%) or high (33%) malnutrition risk (8). This illustrates the need to address malnutrition and not only undernutrition among the elderly. The sequelae of undernutrition in elderly include functional decline or frailty (9-11), decreased quality of life (12), increased health care utilisations and costs (13, 14), higher rates of adverse complications from other health conditions (15), and increased mortality (10, 11, 16). Risk factors for undernutrition have been identified as low functional status, diseases, multipharmacy, and symptoms of depression (17-21). Low functional status by means of needing help with shopping and cooking can negatively affect food intake (1) and possibly Received December 13, 2013 Accepted for publication January 20, 2014
1
J Nutr Health Aging
MALNUTRITION AND RISK OF FALLING malnutrition risk has not been studied among elderly living at home without home help service. Aging is associated with a decrease in total energy expenditure, for instance due to a more sedentary life style. If this coincided with a maintained or increased energy intake overweight/obesity might develop (36). For instance, among 70-years-old Swedes, the overweight (BMI > 25)/obesity (BMI > 30) prevalence in percent was 67/20 among men and 64/24 among women, respectively (37). The sequelae of obesity in the elderly include decreased survival rates, metabolic syndromes, arthritis, pulmonary abnormalities, urinary incontinence, cataracts and cancer and has a negative impact on physical function and quality of life (36). Thus, there are several possible contributing factors for developing malnutrition, or for malnutrition to cause problems, but relatively little is known regarding this among home-dwelling elderly without home-help services. Considering the negative effects of malnutrition, it seems of utmost importance to identify persons at risk of developing malnutrition, or who have already developed it, in order to provide treatment or take suitable preventive actions among elderly without home-help service. Thus, the aim of this study was to explore the frequency of malnutrition risk and associated risk of falling as well as associated social and mental factors among elderly without home-help service. Methods Design A cross-sectional design was used. Context Preventive home visits (PHVs) often involve elderly in early stages of poor health or disability (38), and aim at maintaining health and independence and preventing disability and hospitalization (39, 40). This study was conducted within an established structure for PHVs among elderly people without home-help service in a south Swedish municipality. The municipality has approximately 12.500 inhabitants and two smaller towns (1). Data collection process Data for this study were collected by two experienced nurses during 2010-2011. Previous to this study they had conducted over 1500 PHVs. Interobserver agreement was neither assessed nor secured by co-training. However, in addition to their excessive experience with the protocol the two nurses worked in close collaboration and had frequent opportunities to discuss any uncertainties regarding data collection. The PHV took the form of a single home visit by one or both nurses. During the visits the nurse(s) used an interview protocol including questions about health, risk for falling, and nutrition. Each PHV lasted for about one hour. In addition to data collection, unmet needs that could be met by the municipality, voluntary 2
associations or by own efforts were discussed during the visits. Sample Inclusion criteria were 70 years or older, and without homehelp service. Exclusion criteria were cognitive deficits, enteral and parenteral nutrition. Out of 565 cognitively intact people (according to the clinical judgement of experienced nurses), 465 persons had complete forms regarding malnutrition and were included in this study. Instruments Malnutrition Version 2 of the Seniors in the Community: Risk Evaluation for Eating and Nutrition Questionnaire (SCREEN II) is a 17item rating scale regarding the risk of malnutrition in ordinary housing based on self-reports (7). Items cover, e.g. weight change, dietary habits, appetite, food intake, eating difficulties, use of meal replacements/supplements, eating alone/together, shopping and meal preparation. Summation of item scores (with different ranges, typically 0-4) yields a total score that can range from 0 to 64 (higher scores = better). Scores ≥54 have been suggested to indicate no risk of malnutrition, scores
