Malnutrition in institutionalized seniors: the iatrogenic component

Food provision in Australian aged care homes does not meet protein needs of residents: A call for reform

AIM

Malnutrition is common in older adults in aged care homes, partly due to inadequate protein intake. Menu planning guidelines are available however, adherence to guidelines is unknown. This study aimed to determine; (i) what are the average serving sizes of menu items provided and do they meet recommended portion sizes? (ii) does consumption from a 'typical' menu provide sufficient protein? and (iii) can substituting a 'typical' menu with high-protein options enable residents to achieve protein adequacy?

METHODS

This study involved 572 residents (73% female; aged 86.4 ± 7.3 years) from 60 aged-care homes in Australia involved in a 2-year cluster-randomised trial. During the trial, food intake was recorded quarterly using visual estimation of plate-waste and 42 061 foods analysed. As part of a secondary analysis of these data, portion sizes of foods were compared to guidelines by calculating the mean (95% confidence interval). Items were deemed inadequate if the upper 95% confidence interval remained below recommended portion sizes.

RESULTS

On average 47% of breakfast and 80% of lunch/dinner items were below recommended portion sizes. Relative protein intakes, from a typical menu (most consumed foods), was 0.9 g and 0.8 g/kg body weight/day for females and males; both below recommendations. Substituting regular items with higher protein equivalents increased protein intake to 1.3 g and 1.2 g/kg body weight/day, for females and males, respectively.

CONCLUSION

Aged care homes in Australia are not meeting menu planning guidelines resulting in insufficient protein being provided. Reform to menu guidelines including provision of high-protein foods, will ensure protein adequacy in older adults in aged-care homes.

Canadian Nutrition Society Dialogue on disease-related malnutrition: a commentary from the 2022 Food For Health Workshop

This commentary represents a dialogue on key aspects of disease-related malnutrition (DRM) from leaders and experts from academia, health across disciplines, and several countries across the world. The dialogue illuminates the problem of DRM, what impact it has on outcomes, nutrition care as a human right, and practice, implementation, and policy approaches to address DRM. The dialogue allowed the germination of an idea to register a commitment through the Canadian Nutrition Society and the Canadian Malnutrition Task Force in the UN/WHO Decade of Action on Nutrition to advance policy-based approaches for DRM. This commitment was successfully registered in October 2022 and is entitled CAN DReaM (Creating Alliances Nationally for Policy in Disease-Related Malnutrition). This commitment details five goals that will be pursued in the Decade of Action on Nutrition. The intent of this commentary is to record the proceedings of the workshop as a stepping stone to establishing a policy-based approach to DRM that is relevant in Canada and abroad.

Characterizing Canadian long-term care home consumed foods and their inflammatory potential: a secondary analysis

BACKGROUND

Nutrient dense food that supports health is a goal of food service in long-term care (LTC). The objective of this work was to characterize the "healthfulness" of foods in Canadian LTC and inflammatory potential of the LTC diet and how this varied by key covariates. Here, we define foods to have higher "healthfulness" if the are in accordance with the evidence-based 2019 Canada's Food Guide, or with comparatively lower inflammatory potential.

METHODS

We conducted a secondary analysis of the Making the Most of Mealtimes dataset (32 LTC homes; four provinces). A novel computational algorithm categorized food items from 3-day weighed food records into 68 expert-informed categories and Canada's Food Guide (CFG) food groups. The dietary inflammatory potential of these food sources was assessed using the Dietary Inflammatory Index (DII). Comparisons were made by sex, diet texture, and nutritional status.

RESULTS

Consumption patterns using expert-informed categories indicated no single protein or vegetable source was among the top 5 most commonly consumed foods. In terms of CFG's groups, protein food sources (i.e., foods with a high protein content) represented the highest proportion of daily calorie intake (33.4%; animal-based: 31.6%, plant-based: 1.8%), followed by other foods (31.3%) including juice (9.8%), grains (25.0%; refined: 15.0%, whole: 10.0%), and vegetables/fruits (10.3%; plain: 4.9%, with additions: 5.4%). The overall DII score (mean, IQR) was positive (0.93, 0.23 to 1.75) indicating foods consumed tend towards a pro-inflammatory response. DII was significantly associated with sex (female higher; p<0.0001), and diet (minced higher; p=0.036).

CONCLUSIONS

"Healthfulness" of Canadian LTC menus may be enhanced by lowering inflammatory potential to support chronic disease management through further shifts from refined to whole grains, incorporating more plant-based proteins, and moving towards serving plain vegetables and fruits. However, there are multiple layers of complexities to consider when optimising foods aligned with the CFG, and shifting to foods with anti-inflammatory potential for enhanced health benefits, while balancing nutrition and ensuring sufficient food and fluid intake to prevent or treat malnutrition.

An investigation of recommended serve food portions and attaining energy and protein requirements in older adults living in residential care

BACKGROUND

Ageing populations show a propensity for reduced food intake, which impacts nutritional adequacy. Nutrition guidelines for residential care homes (RCHs) are currently based on serve size of core food groups and do not consider nutrient density. The present study aimed to investigate the weight of foods served/consumed compared to recommended serve sizes and to compare energy and protein intake with individual requirements.

METHODS

This was an observational study of older adults living in four RCHs. Dietary intake was estimated through the difference between weighed reference meals and a single, double-weighed 24-h food plate waste collected from each participant. FoodWorks9^® (Xyris^® Software, Brisbane, Australia) was used to calculate energy, protein and serves of core food groups from food intake and the menu provided to recommended serve sizes. Individual intake was compared with nutrition guidelines and estimated energy and protein requirements.

RESULTS

Across 420 participants, 9.8% completed a main meal (lunch or dinner). The servings provided [248 g; interquartile range (IQR) = 206-290 g] were less than the recommended servings for a main meal (306 g = protein/starch/two vegetables), with 157 g (IQR = 109-221 g) consumed. The menu provided for minimum serves of all core food groups except for dairy. Median energy intake (n = 389) (5272 kJ day^-1 , IQR = 4229-6720 kJ) and protein intake (47.3 g day^-1 , IQR = 35.9-60.8 g) were less than estimated requirements (8181 kJ day^-1 , IQR = 7300-9338 kJ day^-1 ; 76.7 g day^-1 , IQR = 66.7-90.8 g).

CONCLUSIONS

Nutritional needs were not met in this cohort. The findings of the present study highlight the need for smaller, nutrient-dense meals and revised menu standards to ensure nutritional adequacy in this vulnerable population.

Diet quality is associated with malnutrition and low calf circumference in Canadian long-term care residents

Background

Older adults living in long-term care (LTC) are nutritionally vulnerable. The purpose of this study was to determine diet quality of Canadian LTC residents and its association with malnutrition and low calf circumference.

Methods

A cross-sectional study was undertaken in 32 LTC homes across four Canadian provinces. Nutrient adequacy ratios (NARs) were calculated for seventeen nutrients; mean adequacy ratio (MAR) was calculated to describe overall diet quality. Malnutrition risk was assessed with the Mini Nutritional Assessment-Short Form (MNA-SF) and diagnosis of protein/energy malnutrition with the Patient-Generated Subjective Global Assessment (PG-SGA). Calf circumference (CC) was also assessed. Linear and logistic regressions for these outcomes with diet quality as the predictor were conducted adjusting for covariates.

Results

Average MNA-SF score was 10.7 ± 2.5. Residents (43.5%) had mild/moderate to severe malnutrition based on the PG-SGA and 32.6% had a CC of < 31 cm. Mean MAR score was 0.79 ± 0.09 with significant differences between those requiring eating assistance (0.77 ± 0.11) and those that did not require assistance (0.80 ± 0.07) (p < .05). MAR score was significantly associated with malnutrition in fully adjusted models: MNA-SF scores [β = 5.34, 95% Confidence interval (CI) (2.81, 7.85)] and PG-SGA [Odds ratio (OR) = 0.49, 95% CI (0.38, 0.64)]. Those who had better diet quality were more likely to be well nourished or not at risk. Although several individual nutrients were associated with low CC (< 31 cm), there was no association between overall diet quality (MAR) and low CC.

Conclusions

Diet quality is associated with malnutrition and individual nutrients (NARs) with a low CC. In addition to calories and protein, nutrient dense diets that promote adequate micronutrient intake are required in LTC.

Intake and Factors Associated with Consumption of Pureed Food in Long Term Care: An Analysis of Making the Most of Mealtimes (M3) Project

Residents living in long term care (LTC) who consume a pureed diet tend to have inadequate intake; understanding factors associated with poor intake in this group of residents is not well established. This study examined the adequacy of nutrient intake among LTC residents consuming a pureed diet and the factors associated with this intake (n = 67). Data was collected as part of a cross-sectional study conducted in 32 LTC homes. Weighed food intake was measured on three non-consecutive days and analyzed using Food Processor software. Intake of nutrients were adjusted for intra-individual variability and compared to the Estimated Average Requirement or Adequate Intake for women only. Consumers of a pureed diet had low micronutrient intakes. Multivariate analysis found that the average number of staff assisting with a meal was associated with energy and protein intake. Overcoming eating challenges, careful menu planning and nutrient-dense options for pureed diets in LTC are recommended.

Modified Texture Food Use is Associated with Malnutrition in Long Term Care: An Analysis of Making the Most of Mealtimes (M3) Project

OBJECTIVE

Modified texture food (MTF), especially pureed is associated with a high prevalence of under-nutrition and weight loss among older adults in long term care (LTC); however, this may be confounded by other factors such as dependence in eating. This study examined if the prescription of MTF as compared to regular texture food is associated with malnutrition risk in residents of LTC homes when diverse relevant resident and home-level covariates are considered.

DESIGN

Making the Most of Mealtimes (M3) is a cross-sectional multi-site study.

SETTING

32 LTC homes in four Canadian provinces.

PARTICIPANTS

Regular (n= 337) and modified texture food consumers (minced n= 139; pureed n= 68).

MEASUREMENTS

Malnutrition risk was determined using the Mini Nutritional Assessment short-form (MNA-SF) score. The use of MTFs, and resident and site characteristics were identified from health records, observations, and standardized assessments. Hierarchical linear regression analyses, accounting for clustering, were performed to determine if the prescription of MTFs is associated with malnutrition risk while controlling for important covariates, such as eating assistance.

RESULTS

Prescription of minced food [F(1, 382)=5.01, p=0.03], as well as pureed food [F(1, 279)=4.95, p=0.03], were both significantly associated with malnutrition risk among residents. After adjusting for age and sex, other significant covariates were: use of oral nutritional supplements, eating challenges (e.g., spitting food out of mouth), poor oral health, and cognitive impairment.

CONCLUSIONS

Prescription of minced or pureed foods was significantly associated with the risk of malnutrition among residents living in LTC facilities while adjusting for other covariates. Further work needs to consider improving the nutrient density and sensory appeal of MTFs and target modifiable covariates.

Nutritional quality of regular and pureed menus in Canadian long term care homes: an analysis of the Making the Most of Mealtimes (M3) project

Background

Long term care (LTC) menus need to contain sufficient nutrients for health and pureed menus may have lower nutritional quality than regular texture menus due to processes (e.g., recipe alterations) required to modify textures. The aims of this study were to: determine adequacy of planned menus when compared to the Dietary Reference Intake (DRI); compare the energy, macronutrients, micronutrients and fibre of pureed texture and regular texture menus across LTC homes to determine any texture, home or regional level differences; and identify home characteristics associated with energy and protein differences in pureed and regular menus.

Methods

Making the Most of Mealtimes (M3) is a cross-sectional multi-site study that collected data from 32 LTC homes in four Canadian provinces. This secondary analysis focused on nutrient analysis of pureed and regular texture menus for the first week of the menu cycle. A site survey captured characteristics and services of each facility, and key aspects of menu planning and food production. Bivariate analyses were used to compare menus, within a home and among and within provinces, as well as to determine if home characteristics were associated with energy and protein provision for both menus. Each menu was qualitatively compared to the DRI standards for individuals 70+ years to determine nutritional quality.

Results

There were significant provincial and menu texture interactions for energy, protein, carbohydrates, fibre, and 11 of 22 micronutrients analyzed (p < 0.01). Alberta and New Brunswick had lower nutrient contents for both menu textures as compared to Manitoba and Ontario. Within each province some homes had significantly lower nutrient content for pureed menus (p < 0.01), while others did not. Fibre and nine micronutrients were below DRI recommendations for both menu textures within all four provinces; variation in nutritional quality existed among homes within each province. Several home characteristics (e.g., for-profit status) were significantly associated with higher energy and protein content of menus (p < 0.01).

Conclusions

There was variability in nutritional quality of menus from LTC homes in the M3 sample. Pureed menus tended to contain lower amounts of nutrients than regular texture menus and both menus did not meet DRI recommendations for select nutrients. This study demonstrates the need for improved menu planning protocols to ensure planned diets meet nutrient requirements regardless of texture.

Trial registration

ClinicalTrials.gov ID: NCT02800291, retrospectively registered June 7, 2016.

Electronic supplementary material

The online version of this article (10.1186/s40795-017-0198-3) contains supplementary material, which is available to authorized users.

Making the Most of Mealtimes (M3): protocol of a multi-centre cross-sectional study of food intake and its determinants in older adults living in long term care homes

BACKGROUND

Older adults living in long term care (LTC) homes are nutritionally vulnerable, often consuming insufficient energy, macro- and micronutrients to sustain their health and function. Multiple factors are proposed to influence food intake, yet our understanding of these diverse factors and their interactions are limited. The purpose of this paper is to fully describe the protocol used to examine determinants of food and fluid intake among older adults participating in the Making the Most of Mealtimes (M3) study.

METHODS

A conceptual framework that considers multi-level influences on mealtime experience, meal quality and meal access was used to design this multi-site cross-sectional study. Data were collected from 639 participants residing in 32 LTC homes in four Canadian provinces by trained researchers. Food intake was assessed with three-days of weighed food intake (main plate items), as well as estimations of side dishes, beverages and snacks and compared to the Dietary Reference Intake. Resident-level measures included: nutritional status, nutritional risk; disease conditions, medication, and diet prescriptions; oral health exam, signs of swallowing difficulty and olfactory ability; observed eating behaviours, type and number of staff assisting with eating; and food and foodservice satisfaction. Function, cognition, depression and pain were assessed using interRAI LTCF with selected items completed by researchers with care staff. Care staff completed a standardized person-directed care questionnaire. Researchers assessed dining rooms for physical and psychosocial aspects that could influence food intake. Management from each site completed a questionnaire that described the home, menu development, food production, out-sourcing of food, staffing levels, and staff training. Hierarchical regression models, accounting for clustering within province, home and dining room will be used to determine factors independently associated with energy and protein intake, as proxies for intake. Proportions of residents at risk of inadequate diets will also be determined.

DISCUSSION

This rigorous and comprehensive data collection in a large and diverse sample will provide, for the first time, the opportunity to consider important modifiable factors associated with poor food intake of residents in LTC. Identification of factors that are independently associated with food intake will help to develop effective interventions that support food intake.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT02800291 , retrospectively registered June 7, 2016.

Malnutrition and Dysphagia in long-term care: a systematic review

Determining the co-occurrence of malnutrition and dysphagia is important to understand the extent to which swallowing impairment contributes to poor food intake in long-term care (LTC). This review investigated the impact of dysphagia on malnutrition in LTC by synthesizing the results of published literature. Seven electronic databases were used to search for English-language publications reporting malnutrition and dysphagia in LTC facilities from 1946 to 2013. Fourteen studies were eligible for inclusion. Overall, the literature on the co-occurrence of malnutrition and dysphagia in LTC shows a paucity of high-quality evidence. Articles reviewed lacked consistent definitions for both conditions. Methods used to confirm each diagnosis also differed and were of questionable validity. Based on a review of the literature, evidence of the existence of concurrent concerns with respect to malnutrition and dysphagia emerges. The reported frequency of participants in LTC with dysphagia ranges from 7% to 40%, while the percentage of those who were malnourished ranges from 12% to 54%. Due to discrepancies used to describe and measure these conditions, it is difficult to determine the exact prevalence of either condition separately, or in combination. Consequently, the impact of dysphagia on malnutrition must be considered and studied using valid definitions and measures.

The effect of tongue strength on meal consumption in long term care

PURPOSE

As many as 74% of residents in long-term care (LTC) are anticipated to have swallowing difficulties (dysphagia). Low food intake is commonly reported in persons with swallowing problems, but food intake may also be affected by fatigue in the swallowing muscles. As fatigue sets in during mealtimes, the strength of the tongue may decline. Tongue strength is also known to decline with age but it is unclear how this functional change may influence food intake. In this pilot study, we explored the relationship between tongue strength and meal consumption in persons not previously diagnosed with dysphagia.

METHODS

The Iowa Oral Performance Instrument was used to collect maximum anterior isometric tongue-palate pressures from 12 LTC residents (5 male; mean age: 85, range 65-99). Residents were also screened for dysphagia with applesauce and a water swallow test. Each resident was observed at three different meals to record the length of time taken to eat the meal, amount of food consumed, and any indication of overt signs of swallowing difficulty (e.g. coughing).

RESULTS

Residents who displayed observable swallowing difficulties at mealtimes had significantly lower tongue strength than those without swallowing difficulties (p < 0.01). Those with lower tongue strength took significantly longer to complete meals (p < 0.05) and consumed less food. Tongue strength was not predictive of performance on the water screen and the water swallow test was not a good predictor of which participants were observed to display mealtime difficulties.

CONCLUSION

Among seniors in long term care, reduced tongue strength is associated with longer meal times, reduced food consumption, and the presence of observable signs of swallowing difficulty. Further exploration of these relationships is warranted.

Interventions for improving mealtime experiences in long-term care

Poor food intake in residents living in long-term care (LTC) homes is a common problem. The mealtime experience is known to be important in the multifactorial causes of food intake. Diverse interventions have been developed, implemented, and/or evaluated to improve the mealtime experience in LTC; it is possible that multicomponent interventions will have a greater benefit than single activities. To identify the range of feasible and potentially useful interventions for including in a multicomponent intervention, this scoping review identified and summarized 58 studies that described and/or evaluated mealtime experience interventions. There were several randomized controlled trials, although most studies used less rigorous methods. Interventions that are multicomponent (e.g., food service, dining environment, staff education) and target multilevel factors (e.g., residents, staff) in LTC appear to be feasible, with a variety of outcomes measured. Further research is still needed with more rigorously designed studies, confirming effectiveness, feasible implementation, and scaling up of efficacious interventions.

A systematic review of malnutrition screening tools for the nursing home setting

RATIONALE

Malnutrition screening among nursing home residents is often performed with tools developed for use among older subjects, and sometimes with tools designed for an adult population. Only a few tools have been designed specifically for the nursing home setting. This systematic review assesses the criterion and predictive validity of malnutrition screening tools used in nursing homes.

METHODS

The databases MEDLINE, CINAHL, and EMBASE were searched on January 30, 2013, for manuscripts including search terms for malnutrition, screening or assessment tools, and setting. Articles were eligible for inclusion if they expressed criterion validity (how well can a tool assess nutritional status) or predictive validity (how well can a tool predict clinical outcome) of malnutrition screening tools in a nursing home population. Included were articles that had been published in the English, German, French, Dutch, Spanish, or Portuguese language.

RESULTS

The search yielded 8313 references. Of these, 24 met the inclusion criteria and were available; 2 extra manuscripts were retrieved by reference checking. Twenty tools were identified. Seventeen studies reported on criterion validity, and 9 on predictive validity. Four of the tools had been designed specifically for use in long term care. None of the tools, not even the ones specifically designed for the nursing home setting, performed (on average) better than "fair" in either assessing the residents' nutritional status or in predicting malnutrition-related outcomes.

CONCLUSION

The use of existing screening tools for the nursing home population carries limitations, as none performs better than "fair" in assessing nutritional status or in predicting outcome. Also, no superior tool can be pointed out. This systematic review implies that further considerations regarding malnutrition screening among nursing home residents are required.

Challenges in Planning Long-term Care Menus: That Meet Dietary Recommendations

Purpose: Long-term care (LTC) homes plan menus based on Eating Well with Canada’s Food Guide (CFG) recommendations for older adults. To determine whether recommended CFG servings and nutrients were being provided, we analyzed the menu of a large LTC facility in a metropolitan area and compared our analysis with a similar one conducted in 2000.

Methods: A full week’s menu from a large Saskatoon LTC facility was analyzed and compared with CFG and recent Dietary Recommended Intake nutrient recommendations. The menu was analyzed using The Food Processor SQL. The 2011 menu was compared with the similar 2000 menu analysis to permit an evaluation of changes over a decade.

Results: The 2011 menu demonstrated a significant improvement in servings of vegetables and fruit (4.6 to 7.2 servings). Servings of grain products had declined from 4.9 to 3.6 and servings of milk and alternatives had declined from 2.4 to 1.2 since 2000. Servings of meat and alternatives, total carbohydrate, and protein were not significantly different. Foods on the 2011 menu were lower in fat and higher in dietary fibre and offered more vitamins and minerals.

Conclusions: Greater attention to the planning of LTC menus may explain improvements in the 2011 LTC menu. The current menu, however, needs to overcome the challenges that prevent it from meeting CFG recommendations for older adults.

Plasma copper and zinc concentration in individuals with autism correlate with selected symptom severity

AIM

To assess plasma zinc and copper concentration in individuals with autism and correlate these levels with symptom severity.

SUBJECTS AND METHODS

Plasma from 102 autistic individuals, and 18 neurotypical controls, were tested for plasma zinc and copper using inductively-coupled plasma-mass spectrometry. Copper and zinc levels and Cu/Zn were analyzed for possible correlation with severity of 19 symptoms.

RESULTS

Autistic individuals had elevated plasma levels of copper and Cu/Zn and lower, but not significantly lower, plasma Zn compared to neurotypical controls. There was a correlation between Cu/Zn and expressive language, receptive language, focus attention, hyperactivity, fine motor skills, gross motor skills and Tip Toeing. There was a negative correlation between plasma zinc concentration and hyperactivity, and fine motor skills severity.

DISCUSSION

These results suggest an association between plasma Cu/Zn and severity of symptoms associated with autism.

Use of vitamin and mineral supplements in long-term care home residents

Vitamin–mineral supplementation may offer older adults health and cognition-related benefits but overuse may contribute to polypharmacy. We examined the prevalence of supplement usage in long-term care facility (LTC) residents (≥65 years of age). As cognition may be affected by nutrition, we also examined use in those with diagnosis of dementia and those with no dementia diagnosis. The prevalence of supplement usage and overall “pill count” from pharmaceutical use was assessed in 189 LTC residents and a subsample of 56 older adults with dementia diagnosis, respectively. Participants were residing in an LTC facility of a mid-size metropolitan area during 2009. The average use of supplements was 1.0 per day for all residents, with 35% taking vitamin D supplements, 20% multivitamins, and 26% calcium. Supplement use was similar (p ≥ 0.05) for those with dementia diagnosis (53%, average 2.0 per day) and for those without such diagnosis (45%, average 2.2 per day). Usage ranged between 1–6 supplements per day. In both of these groups, ∼73% of users were taking vitamin D. The number of prescribed medications ranged from 4 to 24 (average 10.2) in a subsample of residents whose supplement intake was 0 to 6 (average 2). These findings suggest an overall low rate of supplement use, with no significant differences (p ≥ 0.05) in use between residents with and without dementia diagnosis. However, some residents were at risk for supplement overuse.

Nutritional analysis of a long-term care menu before and after an increase in the raw food cost allowance

PURPOSE

Regular, nontherapeutic menus were compared before and after an increase in the Ontario long-term care (LTC) raw food cost allowance (RFCA). The purpose was to determine whether any significant nutritional differences existed between the old and new menus and whether they met target values for adequacy, according to the Dietary Reference Intake (DRI) nutrient recommendations or other target values relevant to Ministry of Health and Long-Term Care standards.

METHODS

A southeastern Ontario LTC facility fall/winter 2006/2007 menu and fall/winter 2007/2008 menu were used for nutrient analysis with ESHA Food Processor SQL 10.1.0. Each menu was compared with target values based on Canada's Food Guide (CFG) for 1992 and 2007, and with DRI nutrient recommendations.

RESULTS

The 2007/2008 menu provided significantly more servings of vegetables and fruit, meeting the 2007 CFG recommendations, and significantly greater amounts of some nutrients (e.g., vitamin C, protein, magnesium, potassium, fibre, and total water). It also came closer to meeting DRI target recommendations.

CONCLUSIONS

While some improvements have been made to the menu in this specific facility, further improvements, possibly through supplementation, must be made to ensure nutritional adequacy for all residents.

Analysis of Copper and Zinc Plasma Concentration and the Efficacy of Zinc Therapy in Individuals with Asperger's Syndrome, Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS) and Autism

AIM

To assess plasma zinc and copper concentration in individuals with Asperger's Syndrome, Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS) and autistic disorder, and to analyze the efficacy of zinc therapy on the normalization of zinc and copper levels and symptom severity in these disorders.

SUBJECTS AND METHODS

Plasma from 79 autistic individuals, 52 individuals with PDD-NOS, 21 individuals with Asperger's Syndrome (all meeting DSM-IV diagnostic criteria), and 18 age and gender similar neurotypical controls, were tested for plasma zinc and copper using inductively-coupled plasma-mass spectrometry.

RESULTS

Autistic and PDD-NOS individuals had significantly elevated plasma levels of copper. None of the groups (autism, Asperger's or PDD-NOS) had significantly lower plasma zinc concentrations. Post zinc and B-6 therapy, individuals with autism and PDD-NOS had significantly lower levels of copper, but individuals with Asperger's did not have significantly lower copper. Individuals with autism, PDD-NOS and Asperger's all had significantly higher zinc levels. Severity of symptoms decreased in autistic individuals following zinc and B-6 therapy with respect to awareness, receptive language, focus and attention, hyperactivity, tip toeing, eye contact, sound sensitivity, tactile sensitivity and seizures. None of the measured symptoms worsened after therapy. None of the symptoms in the Asperger's patients improved after therapy.

DISCUSSION

These results suggest an association between copper and zinc plasma levels and individuals with autism, PDD-NOS and Asperger's Syndrome. The data also indicates that copper levels normalize (decrease to levels of controls) in individuals with autism and PDD-NOS, but not in individuals with Asperger's. These same Asperger's patients do not improve with respect to symptoms after therapy, whereas many symptoms improved in the autism group. This may indicate an association between copper levels and symptom severity.

Increased Copper in Individuals with Autism Normalizes Post Zinc Therapy More Efficiently in Individuals with Concurrent GI Disease

AIM

To assess plasma zinc and copper concentration in individuals with autism.

SUBJECTS AND METHODS

Plasma from 79 autistic individuals, and 18 age and gender similar neurotypical controls, were tested for plasma zinc and copper using inductively-coupled plasma-mass spectrometry.

RESULTS

Autistic individuals had significantly elevated plasma levels of copper and Cu/Zn and lower, but not significantly lower, plasma Zn compared to neurotypical controls. Zn levels increased significantly in autistic individuals with and without GI disease after zinc therapy. Cu decreased significantly after zinc therapy in the GI disease group but not in the autistic group without GI disease. Autistic children significantly improved with respect to hyperactivity and stimming after zinc therapy in autistic children with GI disease. Autistic children without GI disease did not improve in these symptoms after the same therapy.

DISCUSSION

These results suggest an association between zinc and copper plasma levels and autism, and they suggest that zinc therapy may be most effective at lowering copper levels in autistic children with GI disease.

Nutritional status and eating habits of older Manitobans after relocating to a personal care home

We explored the effect of relocating to a personal care home (PCH) on older adults' nutritional status and eating habits. Fourteen Caucasian older adults (F=57%) with a mean age of 83 years (standard deviation = 9.79) consented to participate. Anthropometric information (height, weight, bioelectrical impedance analysis), biochemical and clinical information (diagnoses, data from scales measuring risk or function), and dietary information (three-day plate waste analysis) were collected at time points A (two to three months after relocation) and B (six to seven months after relocation) through face-to-face interviews and medical chart reviews, and from nursing staff. At time B, cognitive function declined (z = -2.185, p<0.05) and the number of medications prescribed increased (z = -2.00, p<0.05). Levels of 25-hydroxyvitamin D were insufficient among 83% of participants at both time points. Mean serum albumin was 34.4 ± 7.2 g/L at time B, and the prevalence of potential nutritional risk increased from 57% to 77%. Dietary intake was inadequate at both time points. Nutritional risk became more prevalent at time B. Protein-energy malnutrition and other nutritional inadequacies may result if dietary intakes do not improve. Strategies to improve dietary intakes should be implemented within PCHs to reduce potential malnutrition.

Mealtimes in nursing homes: striving for person-centered care

Malnutrition is a common and serious problem in nursing homes. Dietary strategies need to be augmented by person-centered mealtime care practices to address this complex issue. This review will focus on literature from the past two decades on mealtime experiences and feeding assistance in nursing homes. The purpose is to examine how mealtime care practices can be made more person-centered. It will first look at several issues that appear to underlie quality of care at mealtimes. Then four themes or elements related to person-centered care principles that emerge within the mealtime literature will be considered: providing choices and preferences, supporting independence, showing respect, and promoting social interactions. A few examples of multifaceted mealtime interventions that illustrate person-centered approaches will be described. Finally, ways to support nursing home staff to provide person-centered mealtime care will be discussed. Education and training interventions for direct care workers should be developed and evaluated to improve implementation of person-centered mealtime care practices. Appropriate staffing levels and supervision are also needed to support staff, and this may require creative solutions in the face of current constraints in health care.

Analysis of the food consumption of 87 elderly nursing home residents, depending on food texture

OBJECTIVES

Texture-modified food (chopped, mashed, or mixed) is often used for patients, and particularly for dependent elderly people facing swallowing disorders or dental problems. Food must be energy and protein enriched, because dilution is needed for preparation, and several meals like bread can be removed. The aim of the study was to assess the food consumption of residents in four French nursing homes depending on diet texture. DESIGN/PARTICIPANTS/MEASUREMENTS: The food consumption of 87 elderly people followed by a nutrition network, randomly taken and living in nursing homes in which texture-modified food enrichment was practiced was evaluated according to the type of texture used.

RESULTS

13.8% of residents had chopped texture and 29.9% mixed texture. There was no relationship between used food textures and nutritional status residents. Calorie consumption was below the recommended intakes for elderly nursing home residents in France, whatever the type of texture. The mixed texture had more protein than the normal one and was better balanced regarding fat intake. Protein consumption was at the lower limit of the recommended intakes. Residents in overweight were those whose food consumption relative to their weight was the lowest.

CONCLUSION

It seems important to check the mode of preparation of texture-modified food in nursing homes and to assess the real energy and protein consumptions of residents receiving this food.

The status of vitamins B6, B12, folate, and of homocysteine in geriatric home residents receiving laxatives or dietary fiber

BACKGROUND

Vitamin B12 deficiency as a digestive disorder and constipation as a gastro motility disorder are common in the elderly. Laxative treatment is often chosen without regard for gut health.

OBJECTIVE

To investigate whether the addition of oat-bran to the common oral diet for 12 weeks is able to reduce constipation and laxative use and improve gut health. It is assumed that this will lead to improved plasma levels of vitamins B6, B12, folate, and of homocysteine in nursing home residents.

METHODS

A controlled, parallel intervention trial. 30 frail patients with multiple chronic diseases, aged 57-98 years, receiving laxative therapy were included. Patients were randomized into a fiber (n=15) and a control group (n=15). The intervention group received 5.2g/d oat-bran for 84 days mixed into the daily common meals. The control group received the ward's habitual diet. Food intake and laxative use were documented and blood samples (on day 01, day 42 and day 84) were collected. Vitamin B12 and folate were analyzed by radioimmunoassay, B6 and homocysteine by RP-HPLC with fluorescence detection, in addition to the routine lab test of albumin and CRP.

RESULTS

In the fiber group, the intervention was well tolerated and laxative use decreased significantly (p < 0.001). In the control group, plasma B12 decreased faster (p < 0.05). In both groups, B6 and folate status remained unchanged. Plasma homocysteine decreased in both groups (p < 0.05). General mean energy intake was low (4861.4 kJ/d).

CONCLUSION

Oat-bran helps to improve constipation management and B12 bioavailability in elderly, with multiple chronic diseases who live in nursing homes.

How to improve nutritional support in geriatric institutions

Nutritional problems are frequent in nursing homes including undernutrition, obesity, and diabetes mellitus, mainly related to disability and behavior troubles. Adequate nutritional care relies both on the quality of menus for regular and modified diet (texture-modified and enriched food) and on the staff knowledge of nutritional problems, particularly undernutrition. Self-assessment of professional practices for all staff categories that are involved in this area can be used to increase training of staff and quality of nutritional care.

Undernutrition and anorexia in the older person

Minimizing frailty in older age is important to individuals and society, as the increasing prevalence of chronic disease is leading to greater disability and health care costs. Nutritional frailty can be defined as the disability that occurs in old age due to rapid, unintentional loss of body weight and sarcopenia (lack of lean mass). This article provides a brief overview of the prevalence and consequences of undernutrition, age-related changes to appetite, food intake, and body composition, the factors contributing to the development of anorexia and undernutrition, and recommended management strategies.

Nutritional assessment of residents in long-term care facilities (LTCFs): recommendations of the task force on nutrition and ageing of the IAGG European region and the IANA

Unintentional weight loss and Undernutrition are major problems among older people living in Long-Term Care Facilities (LTCF). Undernutrition manifests in LTCF particularly as weight loss and low Body Mass Index (BMI) and is associated with increased morbidity and mortality as well as with functional decline. There are many factors associated with poor nutritional status and affecting protein-energy intake and/or energy expenditure. These include age of 85 years or older, low nutrient intake, loss of ability to eat independently, swallowing and chewing difficulties, becoming bed-ridden, pressure ulcers, history of hip fracture, dementia, depressive symptoms and suffering from two or more chronic illnesses. Nutritional evaluation is an essential part of the Comprehensive Geriatric Assessment (CGA). This evaluation ranges from methods such as BMI to several validated tools such as Mini-Nutritional Assessment (MNA). After diagnosis, the management of undernutrition in LTCF requires a multidisciplinary approach which may involve dietary and environmental improvements and managing multiple co-morbidities, while avoiding polypharmacy as far as possible. Finally, the need for supplementation or artificial (tube) feeding may be considered taking into account the CGA and individual needs. This document presents a succinct review and recommendations of evaluation and treatment of undernutrition.

Hospital Diagnosis of Malnutrition: A Call for Action

The Canadian Institute for Health Information (CIHI) provides accurate health information needed to establish sound health care policies. The CIHI mandate is to develop and coordinate a uniform approach to health care information in Canada. The institute uses the International Classification of Diseases (ICD) system to record the most responsible diagnosis for each hospital admission. This investigation was conducted to determine if six ICD protein-calorie malnutrition (PCM) codes could be used for health care utilization analyses. Aggregate data (1996 to 2000) from the CIHI discharge abstract database were used. The data analyzed were the most responsible diagnoses data for the six PCM codes and a single summary statistic for all other “non-malnutrition” diagnoses for all long-term care facility residents aged 65 or older who were transferred to an acute care facility. In this population, fewer than five hospital admissions per year were assigned a PCM code. There were too few PCM cases to do trend analyses for morbidity or mortality. This study suggests a lack of recognition and documentation of PCM as a specific health condition in older adults. Lack of tracking of this diagnosis prevents documentation that could lead to policy changes to support older adults’ nutrition.

Use of fiber instead of laxative treatment in a geriatric hospital to improve the wellbeing of seniors

INTRODUCTION

Constipation is a common problem in the elderly population, especially in geriatric wards. Laxatives are the most preferred solution but current studies link constipation and laxative use to weight-loss and malnutrition in nursing homes. Dietary fibers also affect stool weight and transit time. So, oat-bran effectiveness in reducing the need for bowel medication and weight-loss for geriatric care patients was examined in a geriatric hospital.

AIM

To determine whether the addition of oat-bran to common oral diet can reduce the use of laxatives and improve the wellbeing and bodyweight of the inhabitants of a long-term-care facility.

METHODS

The study was designed as a controlled blind intervention trial among 30 frail inhabitants of a geriatric hospital aged 57-100 years with laxative use. Including criteria were: oral food intake and laxatives as therapy and excluding criteria were: parenteral and enteral feeding, surgeries in the gastro- intestinal tract, drugs that shorten or lengthen the passage through the gut, risk of aspiration, swallowing troubles. An intervention and a control group were formed. 15 of them received 7-8 g oat-bran/d for 12 weeks (fiber group) mixed up in the daily common diet of the ward and 15 served as control (control group).

DATA COLLECTION

Bodyweight was taken at baseline, after 6 weeks and at the end of the supplementation. Data on laxative use, stool frequency and the eating habits of the elderly were recorded.

RESULTS

Laxatives were successfully discontinued by 59% (p < 0.001) in the fiber-group; in the control-group there was an increase of 8% (p=0.218). Bodyweight remained constant in the fiber-group and decreased in the control-group (p=0.002). The oat-fiber supplementation in the introduced form was well tolerated.

CONCLUSIONS

Use of oat-fiber allowed discontinuation of laxatives by 59% while improving body-weight and wellbeing of the seniors. Fiber supplementation is a safe and convenient alternative to laxatives in a geriatric hospital.

A comparison of energy provision by diet order in a long-term care facility

Involuntary weight loss (IWL) is common in the North American elderly population and affects as many as 60 per cent of nursing home residents, representing a threat to health and function. Investigation into nutrient provision in a long-term care (LTC) centre showed that mean total energy exposure over the 5-week menu cycle differed significantly between regular and puréed diet orders, with lower mean levels of exposure to all three macronutrients on a puréed diet order. There is sufficient evidence that current LTC menus may provide fewer nutrients in those receiving puréed diets that further investigation in this area is warranted.

Nutrient Inadequacies Among Elderly Residents Of Long-term Care Facilities

Purpose: Regular, non-therapeutic diets were examined in long-term care (LTC) residents to determine whether these residents consumed adequate nutrients according to current recommendations.

Methods: Elderly (88 ± 8 years) residents (31 female, 17 male) in five Saskatoon LTC centres participated. All were receiving regular diets. Dietary intakes were collected for three days at breakfast, lunch, and dinner, by using simultaneous weighed and observation methods. Snacks provided and eaten were also recorded.

Results: Observed intakes provided more complete data on nutrient intake than did weighed intakes. Inadequacy was most prevalent (in 70% or more of participants) for folate (according to prefortification intake levels), magnesium, zinc, vitamin E, and vitamin B6; inadequacy prevalence was below 50% for protein, vitamin C, and thiamine. Mean intakes of calcium, vitamin D, and dietary fibre were well below their respective Adequate Intake (AI) values. Energy consumed at meals and with snacks was 16% less than that offered at meals alone; other nutrients ingested ranged from 0% to 32% below energy offered. To model nutrient planning, target usual intake distributions were calculated where possible.

Conclusions: These data suggest that nutrient-dense foods alone may not allow elderly LTC residents to meet intake requirements for many nutrients. Assessment of dietary adequacy in institutionalized elderly people allows for the development of realistic nutrition goals.

Nutritional status and delirium in long-term care elderly individuals

Delirium is physiologically plausible in elderly individuals with a poor nutritional status. We explored body composition, serum protein levels, and delirium in a multicenter long-term care study using bioelectrical impedance analysis (BIA). Estimates from the BIA procedure included the body cell mass and fat-free mass (FFM) of nursing home elderly residents (N = 312). Increased delirium was identified in men and women who were leaner and had lower FFM. Clinical surveillance for delirium in frail elderly individuals with low serum albumin levels and polypharmacy is recommended because of their increased likelihood of having drug toxicities for medications with protein-binding properties.

Should Long-term Care Residents Be Supplemented with Vitamin D?

The Health Canada recommendation of 600 IU of vitamin D daily for those over age 70 may be inadequate to prevent deficiencies. A literature search was conducted to examine whether older people living in long-term care (LTC) facilities are at high risk for vitamin D deficiency and therefore should receive a minimum daily supplement of 800 IU. The search included the major databases; the search terms “elderly” and “vitamin D” were used. Articles primarily related to calcium were excluded. The results show that North American seniors generally consume a diet low in vitamin D and have limited sun exposure. The majority, particularly those living in LTC facilities, may have a vitamin D deficiency. Also contributing to deficiencies is an age-related decline in cutaneous production of vitamin D and altered metabolic processes responsible for converting vitamin D to its active form. In summary, research conducted in both Canada and the United States provides sufficient evidence to indicate that older people living in LTC facilities are at high risk for vitamin D deficiency and should receive a minimum daily supplement of 800 IU.

Nutritional considerations in institutionalized elders

PURPOSE OF REVIEW

The aim of this article is to emphasize the importance of malnutrition in frail institutionalized elderly and discuss recent interventions that have been shown to decrease its prevalence.

RECENT FINDINGS

A Medline search was conducted from 1968 to 2007 under the search terms aging, nutrition, and nursing homes. The most current reviews relevant to the care of institutionalized elders were selected for inclusion in this report. Recent reports have shown that application of screening protocols in long-tem care institutions improved nutritional status. A complete physical assessment, with special attention to the oral cavity, should be conducted. Monitoring of weight and intake should be part of the institutional routine, recognizing that there may be differences between prescribed diet and actual intake. Nutritional interventions should be tried as early as possible, including enhancement of environment and increasing staff to assist with feeding, as malnutrition in this population is associated with falls (particularly with deficient vitamin D) and increased morbidity and mortality. To optimally facilitate nutritional care of nursing home patients reforms are needed to facilitate optimal staffing in the institutional setting.

SUMMARY

It is important to educate healthcare workers in the nursing home about simple interventions that could improve nutritional status.

Dietary Intake of Elderly Living in Toronto Long-Term Care Facilities: Comparison to the Dietary Reference Intake

OBJECTIVE

To compare the dietary intake of elderly living in 11 long-term care facilities (LTCFs) to the Estimated Average Requirement set as part of the Dietary Reference Intake for older adults.

DESIGN

A cross-sectional assessment of dietary intake using a 3 days food record among 407 elderly with mean age of 85.2 +/- 7.7 years and BMI of 23.8 +/- 5.7 kg/m(2). This population sample was similar to the one living in LTCFs in the province of Ontario.

RESULTS

The daily energy intake was 1513 +/- 363 kcal (6330.4 +/- 1518.8 kJ). Percentage of energy from fat, saturated fat, polyunsaturated fat, protein, and carbohydrate were 30%, 11%, 5.2%, 15%, and 56%, respectively. Although these values were close to the recommendations, 29.5% had protein intake below the recommended 0.8 g/kg; and 38.3% of subjects had cholesterol intake more than the recommended 300 mg/d. More than 50% of the subjects had suboptimal intake of calcium, magnesium, zinc and vitamins E, B(6), and folate. In addition, greater than 15% had suboptimal intakes of other micronutrients such as vitamins A, C, niacin, and copper.

CONCLUSIONS

Elderly subjects living in LTCFs in Toronto despite having a normal body mass index (BMI), do not meet the recommended levels of intake for protein and many of the micronutrients. LTCFs staff should monitor dietary intake. Menu modification and micronutrient supplementation may be required in order to meet the daily requirements of these elderly.

Protein Content of Puréed Diets: Implications for Planning

Purpose: Texture-modified diets offered in long-term care (LTC) facilities are often prepared from the regular menu, planned using Canada's Food Guide to Healthy Eating. The appropriateness of protein levels of puréed diets in LTC facilities was determined.

Methods: Protein content was measured in 29 duplicate diets, collected from 20 urban LTC facilities in Saskatchewan (SK) and Ontario (ON). Mealtime puréed food intakes of 20 LTC residents were assessed. The target protein levels were calculated as estimated average requirements plus one or two standard deviations of intake, thus allowing for moderate (16%) or low (2.5%) risk of inadequacy, respectively.

Results: The duplicate diets provided 57.9 ± 7.9 and 85.4 ± 31.1 g/day of protein in SK and ON, respectively. Protein intake of SK LTC residents consuming puréed food averaged 54 ± 19 g/day. Only 43% of the SK puréed diets provided more than 59 g/day of protein and none provided more than 78 g/day; in contrast, 87% and 40% of ON puréed diets provided more than 59 and 78 g/day of protein, respectively.

Conclusions: In-house prepared puréed diets do not consistently provide sufficient protein levels to ensure a low risk of inadequacy for the LTC residents consuming these diets.

Nutrient intake and plate waste from an Australian residential care facility

OBJECTIVE

To determine the plate waste, energy and selected-nutrient intake, from elderly residents living in a high-level care (HLC) and low-level care (LLC) facility.

DESIGN

Three, single, whole day assessments of plate waste, energy, and selected nutrients, using a visual rating plate waste scale.

SETTING

Long-term residential care establishment.

SUBJECTS

One hundred and sixty-nine (93 HLC and 76 LLC) individual daily intakes.

MAIN FINDINGS

The mean energy wasted throughout the whole day was 17%. The energy wasted from main meals (16%) was significantly less than the energy wasted at mid-meals (22%, P=0.049). The lowest mean energy wastage occurred at breakfast (8%) compared to lunch (22%) and dinner (25%, P<0.001). The mean (s.d.) daily energy served and consumed was 8.1 (2.0) and 6.6 (2.2) MJ, respectively. There was no difference in energy served or consumed between HLC and LLC residents. On the observation day, 60% of residents consumed less than their estimated energy requirement. The mean calcium intake was 796 (346) mg, and the median (inter-quartile range) vitamin D intake was 1.78 (2.05) microg.

CONCLUSION

On 1 day, more than half the residents surveyed were at risk of consuming an inadequate energy intake, which over-time, may result in body weight loss. Although wastage was not excessive and energy served was adequate, the amount of food eaten was insufficient to meet energy and calcium requirements for a significant number of residents and it is not possible to consume sufficient vitamin D through food sources.

A Novel Dysphagia Diet Improves the Nutrient Intake of Institutionalized Elders

OBJECTIVES

Dysphagia affects 35% to 60% of the institutionalized elderly population. This study aimed at evaluating the nutrient intake of frail institutionalized elderly persons with dysphagia and to assess the impact of Sainte-Anne's Hospital Advanced Nutritional Care program on dietary intake and weight.

DESIGN

A 12-week intervention study.

SUBJECTS/SETTING

Ninety-three individuals residing in a Montreal, Canada, long-term care facility who were aged at least 65 years were evaluated. Seventeen subjects with a body mass index (BMI; calculated as kg/m(2)) <24 or weight loss >7.5% within 3 months and with dysphagia were included.

INTERVENTION

The treated group (n=8; aged 82.5+/-4.41 years, weight 55.9+/-12.1 kg, BMI 22.4+/-3.93) received Sainte-Anne's Hospital reshaped minced- or pureed-texture foods with thickened beverages where required. The control group (n=9; aged 84.6+/-3.81 years, weight 54.3+/-7.49 kg, BMI 21.2+/-2.31) maintained traditional nourishment.

MAIN OUTCOME MEASURES

Macronutrient and micronutrient intake, weight, and BMI were measured at baseline, 6 weeks, and 12 weeks.

STATISTICS

Student t tests were performed to evaluate change within and between groups.

RESULTS

The treatment and control groups were similar at baseline, having a mean age of 82.5+/-4.41 years vs 84.6+/-3.81 years and BMI of 22.4+/-3.93 vs 21.2+/-2.31, respectively. The average weight in the treated group increased compared to the control group (3.90+/-2.30 vs -0.79+/-4.18 kg; P=0.02). Similarly, the treated group presented an increased intake of energy, proteins, fats, total saturated fats, monounsaturated fats, potassium, magnesium, calcium, phosphorus, zinc, vitamin B-2, and vitamin D compared to control subjects (P<0.05).

CONCLUSION

Institutionalized elderly patients with dysphagia can eat better and increase body weight via a diversified, modified in texture, and appealing oral diet that meets their nutrition needs.

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

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.