Predicting falls in elderly receiving home care: the role of malnutrition and impaired mobility

Associations between falls and general health, nutrition, dental health and medication use in Swedish home-dwelling people aged 75 years and over

The vast majority of elderly people in Sweden live in private homes in their communities for as long as possible. Poor health and a high risk of falls are very common among this group. This cross-sectional study investigates the association between falls and general health, appetite, dental health, and the use of multiple medications among home-dwelling men and women aged ≥ 75 years. Data were collected between October 2008 and March 2009 using a postal questionnaire. A total of 1243 people participated in the questionnaire survey (74% response rate), of which 1193 were included in the analysis. The majority of participants were women (n = 738, 62%). Falls in the previous 12-month period were reported by 434 (36%) participants. Most fallers (n = 276, 64%) were women. The majority of the fallers lived in a flat (n = 250, 58%). Poor health (aOR: 1.61; CI: 1.34-1.95), poor dental health (aOR: 1.22; CI: 1.07-1.39) and the use of four or more types of medication daily (aOR: 1.13; CI: 1.03-1.25) were significantly associated with falls in all participants. Poor dental health was found irrespectively of living in a flat (aOR: 1.23; CI: 1.04-1.46) or living in a house (aOR: 1.28; CI: 1.02-1.61), and both were significantly associated with falls. The use of more than four different types of medication daily (aOR: 1.25; CI: 1.11-1.41) was associated with falls for those living in a flat. The results highlight that falls are associated with poor general health, poor dental health and the use of four or more types of medication daily. Health professionals should provide health promotion education and investigate dental health and risk factors for oral disease. Likewise, medical and clinical practices of physicians and community care nurses should include assessing the risk of falling, and treatment that predisposes falls.

Poor nutritional status is associated with a higher risk of falling and fracture in elderly people living at home in France: the Three-City cohort study

Falling and fractures are a public health problem in elderly people. The aim of our study was to investigate whether nutritional status is associated with the risk of falling or fracture in community-dwelling elderly. Poor nutritional status was significantly associated with a higher risk of both falling and fractures.

INTRODUCTION

Nutrition could play a role to prevent falls and fractures. The purpose of this study is to investigate whether a poor nutritional status is associated with the risk of falling and of fracture in community dwelling elderly.

METHODS

Baseline nutritional status of participants was assessed using the Mini Nutritional Assessment (MNA). After a follow-up of 12 years, 6040 individuals with available data for falls and 6839 for fracture were included. People who presented the outcomes at baseline were excluded. Cox models were used to evaluate the associations between nutritional status and the risks of fall or fracture.

RESULTS

The frequency of poor nutritional status (MNA ≤ 23.5), at baseline, was respectively 12.0% in the "fall study sample" and 12.8% in the "fracture study sample." Incident fall and fracture over 12 years were reported in 55.8 and 18.5% of the respective samples, respectively. In multivariate models controlled for sociodemographic data and several baseline health indicators, poor nutritional status was significantly associated with a higher risk of falling (hazard ratio (HR) = 1.66, 95% confidence interval (95% CI) 1.35-2.04 in men and HR = 1.20, 95% CI 1.07-1.34 in women) and with a higher risk of fracture (HR = 1.28, 95% CI 1.09-1.49).

CONCLUSION

Poor nutritional status was associated with a higher risk of both falling and fractures in French elderly community-dwellers. Early screening and management of the nutritional status may be useful to reduce the frequency of these events in older people.

Macronutrient Intake and Inadequacies of Community-Dwelling Older Adults, a Systematic Review

BACKGROUND

Anorexia of ageing may predispose older adults to under-nutrition and protein energy malnutrition. Studies, however, report a large variation in nutrient inadequacies among community-dwelling older adults.

SUMMARY

This systematic review provides a comprehensive overview of the energy and macronutrient intakes and possible inadequacies in community-dwelling older adults. PubMed and EMBASE were screened up to December 2013; data from national nutrition surveys were added. Forty-six studies were included, following the PRISMA guideline.

KEY MESSAGES

Mean daily energy intake was 8.9 MJ in men and 7.3 MJ in women. Mean daily carbohydrate and protein intakes were 46 and 15 En% in men and 47 and 16 En% in women, respectively. Mean daily total fat, saturated fatty acid (SFA), mono-unsaturated fatty acid (MUFA) and poly-unsaturated fatty acid intakes were respectively 34, 13, 13 and 5-6 En%. The carbohydrates and MUFA intakes are below the acceptable macronutrient distribution ranges (AMDR). Fat intake is relatively high, and SFA intake exceeds the upper-AMDR. Based on the estimated average requirement (EAR) cut-point method, 10-12% of older adults do not meet the EAR for protein. To interpret a possible energy imbalance additional information is needed on physical activity, energy expenditure and body weight changes. This systematic review indicates a suboptimal dietary macronutrient distribution and a large variation in nutrient intakes among community-dwelling older adults.

Malnutrition and risk of falling among elderly without home-help service--a cross sectional study

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.

Mobility is the key! Trends and associations of common care problems in German long-term care facilities from 2008 to 2012

BACKGROUND

Although enormous efforts have been made in auditing the quality of care, there are only few epidemiological studies available about the actual occurrence of immobility, malnutrition, urinary incontinence, cognitive impairment, falls and pressure ulcers in long-term care facilities.

OBJECTIVE

The objective of this study was to provide prevalence estimates of common nursing care problems in long-term care facilities and to investigate any associations between them.

DESIGN

Secondary data analysis of five consecutive annual cross-sectional multicenter studies from 2008 to 2012.

SETTING

262 different long-term care facilities throughout Germany.

PARTICIPANTS

14,798 residents older than 18 years who gave informed consent.

METHODS

Health conditions were rated based on direct resident examinations according to the current international definitions. Demographic characteristics were compared with available national population statistics. Apart from descriptive statistics, Chi(2) tests were carried out for bivariate and log-regression models were performed for multivariate associations.

RESULTS

Prevalence rates were stable over the years with the highest prevalence of 73.5% (95% CI 72.8-74.2) being found for urinary incontinence, for cognitive impairment it was 54.1% (95% CI 53.3-54.9) and for immobility it was 36.5% (95% CI 35.7-37.3). The lowest prevalence rates were established for the risk of malnutrition with 13.0 (95% CI 12.4-13.5), for pressure ulcers with 4.8% (95% CI 4.5-5.1) and for falls (4.4% 95% CI 4.1-4.8). In the multivariate model, immobility was most strongly associated with all of the other conditions. No statistically significant associations were found between pressure ulcers and falls, pressure ulcers and urinary incontinence, pressure ulcers and cognitive impairment and between malnutrition and urinary incontinence.

CONCLUSION

Decision-makers and clinical practitioners may primarily focus on the maintenance and enhancement of mobility, because this seems to be the key predictor for many other health conditions in the context of care dependency in the nursing home setting.

Nutritional status and falls in community-dwelling older people: a longitudinal study of a population-based random sample

BACKGROUND

Falls are common in older people and may lead to functional decline, disability, and death. Many risk factors have been identified, but studies evaluating effects of nutritional status are limited. To determine whether nutritional status is a predictor of falls in older people living in the community, we analyzed data collected through the Survey of Health and Living Status of the Elderly in Taiwan (SHLSET).

METHODS

SHLSET include a series of interview surveys conducted by the government on a random sample of people living in community dwellings in the nation. We included participants who received nutritional status assessment using the Mini Nutritional Assessment Taiwan Version 2 (MNA-T2) in the 1999 survey when they were 53 years or older and followed up on the cumulative incidence of falls in the one-year period before the interview in the 2003 survey.

RESULTS

At the beginning of follow-up, the 4440 participants had a mean age of 69.5 (standard deviation= 9.1) years, and 467 participants were "not well-nourished," which was defined as having an MNA-T2 score of 23 or less. In the one-year study period, 659 participants reported having at least one fall. After adjusting for other risk factors, we found the associated odds ratio for falls was 1.73 (95% confidence interval, 1.23, 2.42) for "not well-nourished," 1.57 (1.30, 1.90) for female gender, 1.03 (1.02, 1.04) for one-year older, 1.55 (1.22, 1.98) for history of falls, 1.34 (1.05, 1.72) for hospital stay during the past 12 months, 1.66 (1.07, 2.58) for difficulties in activities of daily living, and 1.53 (1.23, 1.91) for difficulties in instrumental activities of daily living.

CONCLUSION

Nutritional status is an independent predictor of falls in older people living in the community. Further studies are warranted to identify nutritional interventions that can help prevent falls in the elderly.

Charlson co-morbidity index and albumin significantly associated with fracture risk in peritoneal dialysis patients

Published literature on fracture in dialysis patients seldom addressed the effect of co-morbidity and malnutrition. In this study, we reported the incidence and risk factors for fracture in peritoneal dialysis patients. Peritoneal dialysis patients who had fractures between 2006 and 2011 were recruited. Demographic data, details of fracture, Charlson Co-morbidity Index (CCI) and biochemical parameters were also collected. Non-fracture controls, matched for age, gender and duration of dialysis, were also recruited at ratio 1:1 for fracture risk analysis. The incidence of fracture was 1 in 37 patient-years. The commonest site of fracture was neck of femur (n = 16, 55.2%). Twenty-four patients (82.8%) developed fracture after slip and fall injury. Eight out of 17 self-ambulatory patients (47.1%) became non-ambulatory after fracture. Infection was the commonest complication during hospitalization. Univariant analysis demonstrated high CCI (P = 0.001), hypoalbuminaemia (P < 0.001), loss of self autonomy (P = 0.006) and non-ambulatory state (P = 0.011) significantly associated with increased fracture risk. However, only CCI (odds ratio (OR) 1.373, P = 0.028) and albumin (OR 0.893, P = 0.025) increased fracture risk significantly on multivariant analysis. Bone profile and parathyroid hormone were not significant risk factors. To conclude, fracture associated with adverse outcome in peritoneal dialysis patients. High CCI score and hypoalbuminaemia significantly increase risk of fracture.

Geriatric syndromes increased the nutritional risk in elderly cancer patients independently from tumour site and metastatic status. The ELCAPA-05 cohort study

BACKGROUND & AIMS

We assessed the prevalence and risk factors of malnutrition in elderly cancer patients.

METHODS

We studied a prospective cohort of solid cancer patients aged ≥70 years at referral to two geriatric oncology clinics between 2007 and 2010. Nutrition was evaluated using the Mini-Nutritional Assessment (MNA) using validated cut-offs (<17: malnutrition, 17-23.5: at-risk for malnutrition). Patients with non-digestive tumours (breast, prostate, urinary tract) and with digestive (colorectal, upper digestive tract and liver) were analysed separately using multinomial logistic regression.

RESULTS

Of 643 consecutive patients, 519 had available data (median age, 80; men, 48.2%; metastases, 46.3%; digestive cancer 47.8%). In non-digestive group, 13.3% had malnutrition versus 28.6% in digestive group. The link between metastasis and malnutrition was significantly higher in non-digestive group (adjusted odds ratio [ORa ], 25.25; 95%CI: 5.97-106.8) than in digestive group (ORa, 2.59; 1.08-6.24; p for heterogeneity = 0.04). Other factors independently associated with malnutrition were cognitive impairment (ORa MMMSE ≤ 24 versus > 24 in non-digestive group: 16.68; 4.89-56.90 and in digestive group: 3.93; 1.34-11.50), and depressed mood (ORa MiniGDS ≥1 versus <1 in non-digestive group: 11.11; 3.32-37.17 and in digestive group: 3.25; 1.29-8.15) and fall risk (ORa fall risk versus no fall risk in non-digestive group: 4.68; 1.77-12.37; in digestive group: 100% of malnourished patients were faller's).

CONCLUSION

We highlighted, in elderly cancer patients, the high prevalence of malnutrition and that geriatrics syndromes (i.e. cognitive impairment, depressed mood and fall risk) were independent risk factors for malnutrition. Moreover, metastatic status was significantly much more strongly associated with malnutrition in non-digestive than digestive tumours.