Original Communication

European Journal of Clinical Nutrition (2005) 59, 578–583. doi:10.1038/sj.ejcn.1602111 Published online 3 March 2005

Malnutrition and associated factors among aged residents in all nursing homes in Helsinki

Guarantor: KH Pitkala.

Contributors: MS, SM, PR, HS, IS-U, AP, HF-S and KP have all participated in planning and organizing the study and writing the article. KP analyzed the data.

M Suominen1, S Muurinen2, P Routasalo1,3, H Soini4, I Suur-Uski5, A Peiponen2, H Finne-Soveri6,7 and K H Pitkala1,7

  1. 1The Central Union for the Welfare of the Aged, Helsinki, Finland
  2. 2Social Services Department, Housing and Institutional Care Services for the Elderly, City of Helsinki, Helsinki, Finland
  3. 3University of Turku, Turku, Finland
  4. 4Department of Health Care, City of Helsinki, Helsinki, Finland
  5. 5Social Services Department, City of Helsinki, Helsinki, Finland
  6. 6The National Research and Development Centre for Welfare and Health, Helsinki, Finland
  7. 7Clinic of General Internal Medicine and Geriatrics, Helsinki University Hospital, Helsinki, Finland

Correspondence: KH Pitkala, The Central Union for the Welfare of the Aged, Malmin kauppatie 26, FIN-00700 Helsinki, Finland. E-mail: kaisu.pitkala@vanhustyonkeskusliitto.fi

Received 28 June 2004; Revised 29 October 2004; Accepted 19 November 2004; Published online 3 March 2005.

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Abstract

Objective:

 

To acquire information about nutritional problems and factors associated with them in all nursing homes in Helsinki, Finland.

Design:

 

Descriptive, cross-sectional study. The residents were assessed by the Mini Nutritional Assessment test (MNA) and information was gathered about residents' backgrounds, functional status, diseases and about daily routines in institutions providing nutritional care.

Setting:

 

All nursing homes in Helsinki community, the capital of Finland.

Subjects:

 

Of 2424 eligible subjects, 2114 (87%) aged residents, mean age 82 y, were examined.

Results:

 

One-third (29%) of the studied residents suffered from malnutrition (MNA<17), and 60% were at risk (MNA 17–23.5). Malnutrition was associated with the female gender, a longer stay in the nursing home, functional impairment, dementia, stroke, constipation and difficulties in swallowing. In addition, eating less than half of the offered food portion, not eating snacks and resident's weight control at long intervals were associated with malnutrition. In logistic regression analysis mainly patient-related factors predicted malnutrition: impaired functioning (OR 3.71, 95% CI 2.76–4.99), swallowing difficulties (OR 3.03, 95% CI 2.10–4.37), dementia (OR 2.06, 95% CI 1.45–2.93), constipation (OR 1.84, 95% CI 1.38–2.47), but also eating less than half of the offered food portion (OR 3.03, 95% CI 2.21–4.15).

Conclusions:

 

Although internal factors explain most about the poor nutritional status of aged residents in nursing homes, the factors related to nutritional care need further investigation to clarify their role in maintaining the nutritional status of aged residents.

Keywords:

malnutrition, nutritional status, Mini Nutritional Assessment test (MNA), nursing home, aged residents, nutritional care

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Introduction

Several studies have shown that aged residents living in institutions suffer from malnutrition (Abbasi & Rudman, 1994; Lamy et al, 1999; Lauque et al, 2000; Van Nes et al, 2001; Christensson et al, 2002; Gerber et al, 2003). In Sweden, one-third of aged residents living in old people's homes were malnourished (Saletti et al, 2000). Malnutrition, low body mass index (BMI) and unintentional weight loss are risk factors for mortality and have a negative influence on the functional status and psychosocial well-being of the aged population (Takala et al, 1994; Dey et al, 2001; Crogan & Pasvogel, 2003). Protein malnutrition is associated with falls, sarcopenia and hip fractures (Morley & Silver, 1995). Aging and malnutrition induces impairment in immune responses that exposes aged people to infections (Lesourd, 1997).

Malnutrition is particularly common among patients suffering from dementia and it decreases their functional capabilities further (Magri et al, 2003). Among demented subjects, impaired cognition impairs food intake early in the course of the disease (Barret-Connor, 1996; Cronin-Stubbs et al, 1997). With advanced dementia behavioral disturbances such as aversive eating behavior, restlessness and depression may cause weight loss (Blandford et al, 1998). Several other illnesses are known to be associated with malnutrition, such as stroke, Parkinson's disease and diseases of the mouth and throat (Hildebrandt et al, 1997; Lamy et al, 1999; Mojon et al, 1999; Wells et al, 2003). Alterations in smell and taste that come with aging may cause the feeling of early satiation. In addition, being served large portions of food at one meal may decrease the total amount of food eaten by the resident (Morley, 2001).

There is a wide variation in the prevalence of malnutrition in nursing homes. Residents' malnutrition is often unnoticeable by nurses and there is a lack of documentation of the nutritional deficiencies in nursing homes (Abbasi & Rudman, 1993). However, less is known about whether nutritional care has an impact on the nutritional status of aged residents.

The nutritional status of aged individuals may be reliably assessed by the widely used Mini Nutritional Assessment (MNA) test (Guigoz et al, 2002). The MNA is a simple and well-validated scale to estimate the nutritional status of aged individuals. It is also suitable for systematic and large studies (Compan et al, 1999). The MNA test has been used in several studies among aged residents living in various settings (Guigoz et al, 2002). According to the MNA, poor nutritional status has been associated with increased in-hospital mortality, a higher rate of discharge to nursing homes and a longer length of stay in hospitals (Van Nes et al, 2001).

The aim of this study was to assess the nutritional status of all aged residents living in nursing homes in Helsinki by using the MNA test and to study which patient-related factors and nutritional-care factors are associated with malnutrition. We hypothesized that both factors would have impact on the nutritional status of residents. In order to obtain a comprehensive picture, we wanted to assess all aged residents in all nursing homes in Helsinki, Finland.

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Subjects and methods

All nursing homes for long-term care in the Helsinki community (N=20) took part in the study. All available elderly residents living in 92 wards were included. Altogether 2114 (87%) of 2424 eligible residents participated. The dropouts were either refusals or patients who resided in the nursing home for a short time period.

Each resident was assessed by the MNA test. The MNA test gives a maximum of 30 points. Less than 17 points is regarded as indicating malnutrition, 17–23.5 a risk for malnutrition and 24 points or more indicate a good nutritional status (Vellas et al, 1997; Guigoz et al, 2002). In addition, the structured questionnaire included information on demographic characteristics, functional status, swallowing and diseases of the residents. Nurses gave information about daily routines related to nutritional care and meal management.

The use of nutritional supplements and snacks between meals were inquired with yes/no questions. The proportion of offered food eaten by residents was assessed with the question 'How much does the resident in average eat from the main meal' with four options of answers 'less than half, half, nearly all or all'. This was dichotomized to 'eating less than half or half' and to 'nearly all or all' categories. The nurses were instructed to compare the average portion of eaten meal with model portions of which they had photos available. The nurses were informed to make their estimations of the amount of eaten food and other factors related to the nutritional care from the period of last three months. Questions about how many times per year the nurses control the residents' bodyweight and the control of stomach functioning were also included in the questionnaire. The number of medications and the diagnoses of the residents were retrieved from pre-existing medical records.

The information regarding residents' ability to manage their activities of daily life (ADL) was retrieved from their medical records where the ADL score according to the last MDS-assessment had been recorded (Morris et al, 1999). This ADL score measures functional disability based on four factors: locomotion, toilet use, eating and personal hygiene. The score ranges from zero to six, where zero represents being totally independent and six totally dependent (Morris et al, 1999; Snowden et al, 1999). This variable was dichotomized (0–3=not totally dependent, 4–6=dependent).

The local ethics committee of Helsinki University Hospital approved the study. The study was performed during 2 weeks in February 2003 in all nursing homes in Helsinki. A responsible person was chosen from each ward. This person took part in educational sessions in which nurses were familiarized with the MNA, assessments and the questionnaire. During the training, the contact persons learned how to fill up the MNA with the help of the User's Guide and how to organize the study in the ward.

The data were analyzed by NCSS statistical program. The differences between men and women at the baseline were tested by an chi2 test for categorical variables and a two-sided T-test for continuous variables. Three groups of well-nourished, those at risk of malnutrition and those malnourished, were compared by chi2 test for categorical variables and with analysis of variance for continuous variables. For modeling purposes, categorical variables with many levels and continuous variables were dichotomized. Logistic regression analysis was used to determine which variables independently predicted malnutrition. Age, gender and all the variables showing significant differences in bivariate analyses between the malnourished and the others were entered in the model. The results were considered as statistically significant at level Pless than or equal to0.05.

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Results

The study population consisted of 19.3% men and 80.7% women. The male residents were younger (79.5plusminus8.5) than the female residents (84.2plusminus8.5), P=0.001. Over half of the females and less than one-third of the males (P<0.001) were widowed. Of the residents, 61% had a low level of education meaning primary school or less. The residents had lived in the present nursing home for a mean of 3 y and 3 months (Table 1).


Of the aged residents, 29% suffered from malnutrition (MNA<17) and 60% were at risk of malnutrition (MNA 17–23.5) (Table 2). The residents' mean BMI was 23.8. Malnutrition was associated with female gender (P<0.001), longer length of time residing in the nursing home (P=0.02) and impaired ADL (P<0.001). Those residents with dementia (P<0.001), pressure sores (P<0.001) or stroke (P=0.03) more often had an impaired nutritional status. Other diagnoses were not significantly associated with nutritional status.


When residents had difficulties in swallowing they suffered from malnutrition more often than the others (P<0.001). When residents ate all or nearly all from the offered food portion (P<0.001) or when they ate snacks between meals (P<0.001) their nutritional status was better than when they ate only a little from the offered portions or did not eat snacks. Malnutrition was also associated with constipation (P<0.001). When the nurses controlled bodyweight twice a year or more often the residents had better nutritional status (P<0.001) (Table 2). The use of nutritional supplements was very rare (4%) although a great proportion of the studied elderly individuals could have benefited from them.

In logistic regression analysis when age and sex were used as covariates, malnutrition was predicted by impaired functioning, dementia, swallowing difficulties, constipation and eating less than half of the offered food portion (Table 3). Other nursing-care-related factors lost their significance in this model.


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Discussion

Our study shows that malnutrition is a very common problem among elderly residents living in nursing homes in Helsinki. According to the MNA, nearly one-third (29%) of the studied residents suffered from malnutrition (<17 points) and 60% were at risk of malnutrition (17–23.5 points) while only 11% of them had a good nutritional status. In logistic regression analysis, patient-related factors such as dementia, impaired ADL, residents' swallowing difficulties and constipation mainly explained the malnutrition. However, eating half or less from the offered food portion had also predictive value on malnutrition.

The strength of our study is its high statistical power and representativeness of all residents in nursing homes in Helsinki. Since it aimed at including all nursing home residents (N=2424) in Helsinki, the study population was large. A high proportion, 87% (N=2114), of those eligible was examined. Thus, the studied, aged residents are representative of those old people who permanently live in nursing homes. It was already known from previous studies that malnutrition is a common problem among aged residents in institutional care facilities (Abbasi & Rudman, 1993; Lesourd, 1997; Saletti et al, 2000). However, large-scale studies performed with the validated MNA in nursing home populations are still scarce (Saletti et al, 2000; Van Nes et al, 2001). In addition, even though patient-related factors such as dementia and ADL impairment are known to be associated with malnutrition, much less is known about the impact of care-related factors on malnutrition.

Our study results concerning the prevalence of malnutrition and its patient-related associates are well in line with those of previous studies. In various institutional settings, the proportion of the resident population suffering from malnutrition has varied between 15 and 71% and the proportion at risk of malnutrition has been between 40 and 60% (Lauque et al, 2000; Van Nes et al, 2001; Christensson et al, 2002; Gerber et al, 2003). In a Swedish study, 33% of the aged residents living in old people's homes that correspond to our nursing homes suffered from malnutrition (Saletti et al, 2000). In the Swedish study those with the lowest MNA values ate less than the others just like our malnourished residents. Most institutionalized residents suffer from dementia and are highly dependent in their functioning, which explains their poor nutritional status. A significant proportion of our participants suffered from severe dementia and high dependency. In previous studies, low MNA values have been consistently shown to be associated with dementia and stroke (Morley, 2001), as well as with symptoms of mouth disease (Lamy et al, 1999). Constipation and dysphagia have been risk factors for poor appetite (Morley, 2001). Pressure sores are often a consequence of long-term malnutrition (Singer, 2002). There are several well-known patient-related causes for eating only a small part of the offered food portion such as difficulties in swallowing (Morley, 2001), aversive eating behavior, restlessness and anxiety related to dementia (Blandford et al, 1998). In addition, diseases and symptoms in the mouth can cause poor appetite and are common among institutionalized residents (Hildebrandt et al, 1997; Lamy et al, 1999; Mojon et al, 1999).

Our logistic regression analysis does not support that poor care or care-related factors would have a direct role in the residents' malnutrition. However, in the case of 'eating less than half of the offered food portion' it is not easy to distinguish whether poor appetite of the resident has induced malnutrition per se or whether intensified nutritional care could have prevented malnutrition. However, according to our results the nurses were aware that a large proportion of residents ate very little. This awareness should have warranted more intensive nutritional interventions. Yet, in our largest nursing home with over 500 residents only 1.7 % were on energy-dense meals and the use of nutritional supplements (4%) was rare in the studied nursing homes. The use of protein supplements has been shown to improve the nutritional status of aged patients (Potter et al, 1998; Lauque et al, 2000; Milne et al, 2002, Odlund et al, 2003) and to decrease the number of adverse events (Potter, 2001, Gil Gregorio et al, 2003). Our study shows that the possibilities of nutritional care consisting for instance energy-dense food and nutritional supplements were used only for a small proportion of those who might have benefit of them.

The results to this question about how much the residents ate from the offered meals in average can only approximately describe the amount of food the residents ate. However, it is known from previous studies that nurses often overestimate the actual food intake significantly among nursing home residents (Pokrywka et al, 1997; Simmons & Reuben, 2000; Suominen et al, 2004). Thus, our findings that nearly half of those suffering from malnutrition ate only half or less from the offered food portion is probably rather an underestimate than overestimate of the true situation. The study was conducted in February and it may be questioned whether the diet is different during the summer. In fact, the variations of diets in our nursing homes are quite small because of the central menu planning of the food service.

New guidelines for the special needs of elderly residents who have low food intake have been suggested (Wendland et al, 2003). The interventions of malnutrition of nursing home residents needs more research. More attention should also be paid to the education of nurses in nutritional issues. Nurses should be able to assess the nutritional status and food intake of aged residents. They should be able to respond to the needs of those malnutrition and with low-energy intake with energy-rich food and nutritional supplements (Odlund et al, 2003; Suominen et al, 2004). It is important to note that the detection and clear documentation of nutritional problems has been shown to be insufficient in institutional care (Abbasi & Rudman, 1993). For example, recognizing the importance of constipation and dysphagia should lead to prompt treatment, which could also delay and even prevent the development of malnutrition.

Our multivariate analysis showed that mainly patient-related factors explained the poor nutritional status of aged residents in nursing homes. However, some options in nutritional care are underused in caring for nursing home residents. Although on the basis of this study, it is not possible to comment on whether nutrition interventions may alter adverse outcomes, paying attention to nutritional problems, using more nutritional supplements, and providing energy and protein-dense food might delay malnutrition or even improve the nutritional status of these residents.

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Acknowledgements

This study is part of a larger study, which the City of Helsinki has organized in order to develop the nutritional care of the elderly nursing home residents. Great thanks to the personnel in the nursing homes for their cooperation during the study.

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