Changes in relative weight among institutionalized elderly adults

Active aging promotion: results from the vital aging program

Active aging is one of the terms in the semantic network of aging well, together with others such as successful, productive, competent aging. All allude to the new paradigm in gerontology, whereby aging is considered from a positive perspective. Most authors in the field agree active aging is a multidimensional concept, embracing health, physical and cognitive fitness, positive affect and control, social relationships and engagement. This paper describes Vital Aging, an individual active aging promotion program implemented through three modalities: Life, Multimedia, and e-Learning. The program was developed on the basis of extensive evidence about individual determinants of active aging. The different versions of Vital Aging are described, and four evaluation studies (both formative and summative) are reported. Formative evaluation reflected participants' satisfaction and expected changes; summative evaluations yielded some quite encouraging results using quasi-experimental designs: those who took part in the programs increased their physical exercise, significantly improved their diet, reported better memory, had better emotional balance, and enjoyed more cultural, intellectual, affective, and social activities than they did before the course, thus increasing their social relationships. These results are discussed in the context of the common literature within the field and, also, taking into account the limitations of the evaluations accomplished.

Weight loss in elderly women in low-level care and its association with transfer to high-level care and mortality

Background

The purpose of this study was to determine whether unintentional weight loss in older women predicts an imminent transition out of low-level care (either to higher-level care or by mortality).

Methods

Fifty-three Australian women, ambulatory while living in low-level care and requiring minimal assistance, were studied. At baseline, when the women were aged (mean ± standard deviation) 86.2 ± 5.3 years, body composition was assessed by dual energy X-ray absorptiometry, dietary intake was determined by a three-day weighed food record, a venous blood sample was taken, and both muscle strength and physical functioning were measured. The women were then followed up for 143 weeks to record the composite outcome of transfer to high-level care or mortality.

Results

During follow-up, unintended loss of body weight occurred in 60% of the women, with a mean weight loss of −4.6 ± 3.6 kg. Seven women (13.2%) died, and seven needed transfer to high-level care. At baseline, those who subsequently lost weight had a higher body mass index (P < 0.01) because they were shorter (P < 0.05) but not heavier than the other women. Analysis of their dietary pattern revealed a lower dietary energy (P < 0.05) and protein intake (P < 0.01). The women who lost weight also had lower hip abductor strength (P < 0.01), took longer to stand and walk (P < 0.05), and showed a slower walking speed (P < 0.01). Their plasma C-reactive protein was higher (P < 0.05) and their serum albumin was lower (P < 0.01) than women who did not lose weight. Nonintentional weight loss was a significant predictor of death or transfer to high care (hazards ratio 0.095, P = 0.02).

Conclusion

Weight loss in older women predicts adverse outcomes, so should be closely monitored.

The accuracy of monthly weight assessments in nursing homes: implications for the identification of weight loss

BACKGROUND

The prevalence of weight loss is a quality indicator for nursing homes (NH), and monthly weight assessments are conducted by NH staff to determine weight loss.

METHODS

A longitudinal study was conducted with 90 long-stay residents in four NHs for 12 study months. Monthly weight values documented in the medical record by NH staff were compared to independent weight values collected by research staff using a standardized protocol. Weight loss was defined according to the Minimum Data Set (MDS) criterion: >or= 5% in 30 days or >or= 10% in 180 days.

RESULTS

The total frequency of weight loss episodes per person was comparable between NH and research staff weight assessments across the 12 study months. However, monthly weight values recorded by NH staff were consistently higher than values recorded by research staff, which resulted in a higher prevalence of weight loss and earlier identification of weight loss according to research staff weight values using a standardized weighing protocol.

CONCLUSIONS

A standardized weighing protocol improved the detection of weight loss among NH residents and should allow for earlier nutrition intervention.

Prevention of unintentional weight loss in nursing home residents: a controlled trial of feeding assistance

OBJECTIVES

To determine the effects of a feeding assistance intervention on food and fluid intake and body weight.

DESIGN

Crossover controlled trial.

SETTING

Four skilled nursing homes (NHs).

PARTICIPANTS

Seventy-six long-stay NH residents at risk for unintentional weight loss.

INTERVENTION

Research staff provided feeding assistance twice per day during or between meals, 5 days per week for 24 weeks.

MEASUREMENTS

Research staff independently weighed residents at baseline and monthly during a 24-week intervention and 24-week control period. Residents' food and fluid intake and the amount of staff time spent providing assistance to eat was assessed for 2 days at baseline and 3 and 6 months during each 24-week period.

RESULTS

The intervention group showed a significant increase in estimated total daily caloric intake and maintained or gained weight, whereas the control group showed no change in estimated total daily caloric intake and lost weight over 24 weeks. The average amount of staff time required to provide the interventions was 42 minutes per person per meal and 13 minutes per person per between-meal snack, versus usual care, during which residents received, on average, 5 minutes of assistance per person per meal and less than 1 minute per person per snack.

CONCLUSION

Two feeding assistance interventions are efficacious in promoting food and fluid intake and weight gain in residents at risk for weight loss. Both interventions require more staff time than usual NH care. The delivery of snacks between meals requires less time than mealtime assistance and thus may be more practical to implement in daily NH care practice.

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.

Nursing Home Staff Delivery of Oral Liquid Nutritional Supplements to Residents at Risk for Unintentional Weight Loss

OBJECTIVES

To describe nursing home (NH) staff delivery of oral liquid nutritional supplements to residents with an order to receive supplementation.

DESIGN

Descriptive.

SETTING

Six skilled NHs.

PARTICIPANTS

One hundred thirty-two long-stay residents.

MEASUREMENTS

Research staff conducted direct observations for 2 days during and between meals and documented NH staff delivery of supplements, amount consumed (fluid ounces), and amount of assistance (minutes) provided by staff to encourage consumption.

RESULTS

Eighty-eight percent had an order to receive a supplement one to three times daily (mode = 3); 12% had an order to receive a supplement four to six times daily. Fewer than 10% received the supplement consistent with their orders during the 2 observation days. On average, NH staff provided a supplement less than once per participant per day during or between meals. When a supplement was provided, residents consumed an average+/-standard deviation of 4.91+/-2.19 fluid ounces during meals with 6.16+/-7.46 minutes of staff assistance and 3.98+/-2.60 fluid ounces between meals with less than 1 minute of staff assistance. Participants with orders that specified time of delivery received the supplement at a significantly higher frequency between meals.

CONCLUSION

Oral liquid nutritional supplements are not provided consistent with orders in NH practice. Staff spends little time promoting supplement consumption during or between meals. The specificity of the order related to time of delivery may influence when and how often supplements are provided to residents.

Salivary sIgA and cortisol: markers for functional dependence in older adults

Elderly persons with health problems and physical limitations have reduced independence. Since poor functional ability is a known risk factor for disease among older populations, including oral disease, this study was undertaken to assess whether salivary defense factors and the stress hormone cortisol are significant markers for functional dependence. Oral examinations; salivary and microbial analyses; and interviews using the Activities of Daily Living (ADD index, the Mini Nutritional Assessment (MNA) and the Perceived Life Stress Questionnaire (PLSQ) were conducted for 123 dentate subjects. Of the subjects, 80 lived independently in the community or in apartments at the Baycrest Centre for Geriatric Care in Toronto, Canada, and 43 resided in the Baycrest nursing home or the Baycrest Hospital. Whole saliva samples were assayed for total secretory immunoglobulin A (sIgA), sIgA1, sIgA2, total protein and cortisol using ELISA. Dependent residents in the nursing home/hospital scored significantly lower in the nutritional assessment, had higher mean PLSQ scores, increased total protein and cortisol concentrations, and reduced salivary flow rates in comparison to ambulatory residents in the community/apartments. In multivariable logistic regression, factors associated with functional dependence were: being male, perceiving income as inadequate, having low salivary flow rate and drinking less than 5 cups of water per day. These results indicate that salivary flow and cortisol may be useful markers of functional dependence; however, the ability of these markers to predict functional decline cannot be confirmed until longitudinal studies are conducted.

Estimating deaths attributable to obesity in the United States

Estimates of deaths attributable to obesity in the United States rely on estimates from epidemiological cohorts of the relative risk of mortality associated with obesity. However, these relative risk estimates are not necessarily appropriate for the total US population, in part because of exclusions to control for baseline health status and exclusion or underrepresentation of older adults. Most deaths occur among older adults; estimates of deaths attributable to obesity can vary widely depending on the assumptions about the relative risks of mortality associated with obesity among the elderly. Thus, it may be difficult to estimate deaths attributable to obesity with adequate accuracy and precision. We urge efforts to improve the data and methods for estimating this statistic.

What do certified nurse assistants actually know about dysphagia and feeding nursing home residents?

The purpose of this study was to examine certified nurse assistants' (CNAs') knowledge of dysphagia and how to feed nursing home residents using nonparticipatory structured feeding observation, critique of staged feeding behaviors on film, and semistructured interview in a triangulation methods design. Content analysis of the data confirmed previous studies that suggested CNAs lack knowledge about dysphagia and how to feed residents. A surprising result was the lack of accurate, comprehensive information in CNA texts and classrooms about dysphagia and how to manage challenging feeding behaviors. Speech-language pathologists are uniquely trained to improve CNA communication skills and provide accurate information to nursing colleagues. Specific recommendations of how to improve CNA feeding training programs are provided.

The Minimum Data Set Weight-Loss Quality Indicator: Does It Reflect Differences in Care Processes Related to Weight Loss?

OBJECTIVES

To determine whether nursing homes (NHs) that score differently on prevalence of weight loss, according to a Minimum Data Set (MDS) quality indicator, also provide different processes of care related to weight loss.

DESIGN

Cross-sectional.

SETTING

Sixteen skilled nursing facilities: 11 NHs in the lower (25th percentile-low prevalence) quartile and five NHs in the upper (75th percentile-high prevalence) quartile on the MDS weight-loss quality indicator.

PARTICIPANTS

Four hundred long-term residents.

MEASUREMENTS

Sixteen care processes related to weight loss were defined and operationalized into clinical indicators. Trained research staff conducted measurement of NH staff implementation of each care process during assessments on three consecutive 12-hour days (7 a.m. to 7 p.m.), which included direct observations during meals, resident interviews, and medical record abstraction using standardized protocols.

RESULTS

The prevalence of weight loss was significantly higher in the participants in the upper quartile NHs than in participants in the lower quartile NHs based on MDS and monthly weight data documented in the medical record. NHs with a higher prevalence of weight loss had a significantly larger proportion of residents with risk factors for weight loss, namely low oral food and fluid intake. There were few significant differences on care process measures between low- and high-weight-loss NHs. Staff in low-weight-loss NHs consistently provided verbal prompting and social interaction during meals to a greater proportion of residents, including those most at risk for weight loss.

CONCLUSION

The MDS weight-loss quality indicator reflects differences in the prevalence of weight loss between NHs. NHs with a lower prevalence of weight loss have fewer residents at risk for weight loss and staff who provide verbal prompting and social interaction to more residents during meals, but the adequacy and quality of feeding assistance care needs improvement in all NHs.

Nutritional assessment of demented patients: a descriptive study

BACKGROUND AND AIMS

It is well-known that subclinical and overt malnutrition are strong predictive indices of morbidity and mortality in old subjects, particularly in demented ones, and may deeply affect the quality of life. The aim of this study was evaluation of nutritional status in demented patients, as a whole and according to type of dementia, at the moment of hospital admission and before discharge.

METHODS

The study concerns 174 old demented patients, aged 80.2 +/- 8 SD, diagnosed as having Alzheimer's disease, vascular dementia, degenerative and vascular dementia, reversible dementia, and other types of dementia. In each subject, anthropometric measures, body composition analysis by the bioelectric impedance technique, Mini Nutritional Assessment (MNA) and cognitive, functional and affective assessment by conventional geriatric instruments were performed. A blood sample allowed assay of the main biochemical nutritional markers. At the end of the hospitalization period, the same cognitive, functional and nutritional assessment was repeated, in order to evaluate the effects of vitamin and protein supplements and of care during meals.

RESULTS

In all subgroups of demented patients, obtained according to type of dementia, the mean MNA score was indicative of risk for malnutrition. Furthermore, the MNA score was significantly related to severe cognitive impairment, functional status, comorbidity, BMI values, and transferrin and total protein serum levels. Malnourished patients and demented elderly at risk for malnutrition (according to the MNA score) were given oral nutritional supplements during hospitalization, lasting a mean of 45 days. Before discharge, these two subtypes of demented patients showed substantial maintenance of their cognitive, functional and nutritional status, whereas the subgroup of well-nourished demented patients exhibited significant worsening of the nutritional pattern.

CONCLUSIONS

Demented patients show a high percentage of malnutrition, particularly evident in subjects with deeper cognitive impairment. Nutritional status seems to be linked more to functional abilities than to duration of disease. However, nutritional intervention or special care during meals may act in synergy with specific pharmacologic therapy of dementia.

Nutrition in the elderly

Malnutrition is more common in elderly persons than in younger adults. Ageing itself, however, neither leads to malabsorption nor to malnutrition with the exception of a higher frequency of atrophic gastritis in older persons. Malnutrition in elderly people is therefore a consequence of somatic, psychic or social problems. Typical causes are chewing or swallowing disorders, cardiac insufficiency, depression, social deprivation and loneliness. Undernutrition is associated with a worse prognosis and is an independent risk factor for morbidity and mortality. Awareness of this problem is therefore important. For the evaluation of nutritional status, it must be remembered that most normal values are derived from younger adults and may not necessarily be suitable for elderly persons. Suitable tools for evaluating the nutritional status of elderly persons are e.g. the body mass index, weight loss within the last 6 months, the Mini Nutritional Assessment (MNA) or the Subjective Global Assessment (SGA). An improvement in the nutritional status can be achieved by simple methods such as the preparation of an adequate diet, hand feeding, additional sip feeding or enteral nutrition.

Improving food intake in nursing home residents with feeding assistance: a staffing analysis

BACKGROUND

Recommendations have been made to increase the number of nursing home (NH) staff available to provide feeding assistance during mealtime. There are, however, no specific data related to two critical variables necessary to estimate mealtime staffing needs: (1) How many residents are responsive to feeding assistance? (2) How much staff time is required to provide feeding assistance to these residents? The purpose of this study was to collect preliminary data relevant to these two issues.

METHODS

Seventy-four residents in three NHs received a 2-day, or six-meal, trial of one-on-one feeding assistance. Total percentage (0% to 100%) of food and fluid consumed during mealtime was estimated across 3 days during usual NH care and 2 days during the intervention. The amount of time that staff spent providing assistance and type of assistance (i.e., frequency of verbal and physical prompts) was measured under each condition.

RESULTS

One half (50%) of the participants significantly increased their oral food and fluid intake during mealtime. The intervention required significantly more staff time to implement (average of 38 minutes per resident/meal vs 9 minutes rendered by NH staff).

CONCLUSIONS

The time required to implement the feeding assistance intervention greatly exceeded the time the nursing staff spent assisting residents in usual mealtime care conditions. These data suggest that it will almost certainly be necessary to both increase staffing levels and to organize staff better to produce higher quality feeding assistance during mealtimes.

Nutrition Knowledge of Nurses in Long-Term Care Facilities

BACKGROUND

The purpose of this study was to determine knowledge-based nutrition competencies of nurses and describe needed nutrition education relative to reducing protein-calorie malnutrition (PCM) in nursing home residents.

METHOD

A sample of 44 nurses (35 RNs, 9 LPNs) from five eastern Washington nursing homes completed a 50-item questionnaire that measured nutrition knowledge based on Benner's Novice to Expert Model.

RESULTS

Nurses scored an average 65% +/- 11% on the nutrition examination.

CONCLUSION

An educational program addressing the identified deficient areas could improve the ability of nursing staff to assess and monitor resident food intake, thereby reducing the prevalence of PCM of residents in nursing homes.

Nutritional management in long-term care: development of a clinical guideline. Council for Nutritional Strategies in Long-Term Care

BACKGROUND

Involuntary weight loss resulting from malnutrition is a major problem among residents in long-term care facilities. Although body weight is easily measured, the evaluation of unintended weight loss in long-term care facilities is difficult.

METHODS

The Council for Nutritional Clinical Strategies in Long-Term Care, an expert panel of interdisciplinary thought leaders representing academia and the medical community, derived a structured approach aimed at improving management of malnutrition in long-term care settings, using literature review and consensus development. The Clinical Guide to Prevent and Manage Malnutrition in Long-Term Care is based on a best-evidence approach to the management of nutritional problems in long-term care.

RESULTS

The Clinical Guide is divided into two parts, one designed for nursing staff, dietary staff, and dietitians, and a second directed to physicians, pharmacists, and dietitians.

CONCLUSIONS

A structured approach to the management of unintended weight loss or malnutrition in long-term care is intended to ensure a comprehensive resident evaluation. While the Clinical Guide is presented in a linear fashion, many of the considerations can be done simultaneously and the order varied dependent on the individual resident's needs. Further research to validate the effectiveness of using the algorithm in long-term care settings will be required.

Nutritional intake monitoring for nursing home residents: a comparison of staff documentation, direct observation, and photography methods

BACKGROUND

The current approach to assessing nutritional intake requires nursing home (NH) staff to document total percentage of food and fluid consumed at each meal. Because NH staff tend to significantly overestimate total food intake, methods need to be developed to improve the accuracy of food intake measurement.

OBJECTIVE

To compare three methods of assessing the nutritional intake of NH residents.

RESEARCH DESIGN

Validation Study.

SUBJECTS

Fifty-six NH residents in one facility.

MEASURES

Total percentage of food and fluid intake of each resident for each of nine meals, or all three meals for 3 consecutive days, was assessed by: (1) Nursing home staff chart documentation, (2) Research staff documentation according to direct observations, and (3) Research staff documentation according to photographs of residents' trays before and after each meal.

RESULTS

Research staff documentation of total intake and intake of all individual food and fluid items was similar for the direct observation and photography methods. In comparison with these two methods, NH staff documentation reflected a significant overestimate (22%) of residents' total intake levels. In addition, NH staff failed to identify the more than half (53%) of those residents whose intake levels were equal to or below 75% for most meals.

CONCLUSIONS

The photography method of nutritional assessment yielded the same information as direct observations by research staff, and both of these methods showed the intake levels of NH residents to be significantly lower than the intake levels documented by NH staff. The photography method also has several advantages over a documentation system that relies on an observer to be present to record food and fluid intake levels.

Assessment of protein energy malnutrition in older persons, part I: History, examination, body composition, and screening tools

Protein-energy malnutrition is a prevalent problem in older persons. Its relation to increased morbidity and mortality has been well documented. Early recognition of malnutrition allows for a timely intervention. A large proportion of chronic diseases affecting older persons can be either prevented or significantly improved by improving nutrition, which underscores the importance of developing a screening system that can trigger a more comprehensive evaluation when indicated. Screening for malnutrition in older persons can be difficult because of the normal age-related changes in many of the commonly used parameters. A comprehensive nutritional evaluation includes a complete history and physical examination in addition to a more specific nutrition-oriented assessment. Specific nutritional assessment includes estimating food intake, anthropometric measurements, and evaluation of several biochemical parameters commonly affected by changes in nutritional status. In this article, we review the commonly used tools for nutritional assessment in older persons. The goal is to promote disease-free, active, and successful aging.

Body mass index and mortality among older people living in the community

OBJECTIVES

To determine if body mass index (BMI = weight/height2), predictive of mortality in seriously ill hospitalized and institutionalized patients, is also predictive of mortality in a longitudinal epidemiologic study.

DESIGN

A prospective cohort study.

SETTING

Rovereto, a town in northern Italy.

PARTICIPANTS

A consecutive sample of 214 patients aged 81.2 +/- 7.3 years receiving community care services.

MAIN OUTCOME MEASURES

Malnutrition and mortality.

RESULTS

According to logistic regression analysis, malnutrition status, expressed by a BMI < 22 Kg/m2, was correlated with dependency in Activity of Daily Living (odds ratio 1.21; 95% confidence interval (CI) 1.01-1.45). Only a low BMI was associated with 1-year survival in Cox regression analysis, after adjusting for potential confounders (relative risk 0.85; 95%CI, 0.74-0.97). A high BMI (>27 Kg/m2) was not significantly related to risk of mortality.

CONCLUSIONS

Nutrition variables are a cardinal component of comprehensive geriatric assessment. Our results suggest that BMI, a simple anthropometric measure of nutritional status, is an important predictor of mortality among older people living in the community. Even when controlling for clinical and functional variables, a low BMI remained a significant and independent predictor of shortened survival.

Longitudinal weight changes, length of survival, and energy requirements of long-term care residents with dementia

OBJECTIVE

We hypothesized that institutionalized patients with dementia, who frequently have feeding problems and require supervised and assisted feeding, would lose more weight during their residency than nondemented, independently functioning residents and have compromised survival. To test this hypothesis, we examined the survival and longitudinal changes in weight of two cohorts of institutionalized residents with dementia and compared these cohorts with a cohort of nondemented residents. We also measured the resting energy expenditures of a subset of the subjects with dementia as an indicator of their energy needs.

DESIGN

A longitudinal cohort study with retrospective baseline chart review and subsequent follow-up of monthly weights and mortality over 4 years.

SETTING

A 725-bed long-term care institution with specified levels of care.

SUBJECTS

Two cohorts of residents with dementia, one consisting of subjects who required total care throughout their institutional stay (n = 31) and another group who did not initially require total care (n = 48); these were compared with a cohort with normal mentation who were functionally independent in their daily activities (n = 26). The total number of subjects was 105.

MEASUREMENTS

Demographics, medical problems, and medications by chart review; functional and mental status evaluations; longitudinal monthly weights and mortality for the 48-month study period; and resting energy expenditures by indirect calorimetry.

MAIN RESULTS

Residents with dementia had lower weights on admission and throughout their stay than nondemented, independently functioning residents, and they were more likely to have a weight loss of 10 lbs or more at some point during the 4-year study period. However, their mean weights did not change during the study period. The mean survival from admission of those demented residents who died was more than 3 years. Resting energy expenditures of women residents with advanced dementia were 12% lower than predicted from the Harris Benedict equations.

CONCLUSION

Dementia is not necessarily associated with unremitting weight loss during institutionalization despite the frequent occurrence of feeding difficulties and temporary weight loss. This may be caused partly by the lower than expected resting energy expenditures and, hence, energy needs of affected residents as their dementia progresses. Demented residents weighed significantly less than nondemented, independently functioning residents throughout their institutional stay. Nevertheless, nursing staff are able to maintain weight and survival for extended periods even in very impaired residents.

Markers of failure to thrive among older hip fracture patients

OBJECTIVES

To determine whether there is a group of recent hip fracture patients who exhibit the signs of failure to thrive and to identify potential precursors to their decline in physical functioning.

DESIGN

Prospective (nonintervention) study of hip fracture recovery; patients were assessed in the hospital and at 2, 6, 12, 18, and 24 months post-fracture.

SETTING

Hip fracture patients admitted to one of eight Baltimore area hospitals from the community with a new fracture of the proximal femur between January 1, 1990, and June 15, 1991.

PARTICIPANTS

Patients were 65 years of age and older and lived in the community before the fracture. A total of 804 patients were eligible for the study; the present study analyses were restricted to the 252 patients who survived 1 year and had a self-report assessment at 6 and 12 months post-fracture.

MEASUREMENTS

A questionnaire administered during hospitalization assessed pre-fracture functional and health status and current affective and cognitive status. In-home interviews post-fracture ascertained dependence and difficulty with physical and instrumental activities of daily living. Abstraction of the medical records provided information about comorbidities, surgical procedure, and hospital length of stay.

RESULTS

Patients who declined in ability to walk from 6 to 12 months post-fracture had greater use of health resources (more hospitalizations) and poorer physical functioning up to 2 years post-fracture. Impaired function in physical activities of daily living at 6 months, high glucose, calcium, and CO2 at admission, and low BUN and creatinine at admission were more prevalent among decliners than among non-decliners.

CONCLUSIONS

Findings indicate that certain older hip fracture patients begin to exhibit signs and symptoms of failure to thrive. About 10% of patients who survived at least 1 year after fracture could not retain their recovery level of functioning after 6 months and began to decline further. High glucose and CO2 and low BUN and creatinine on hospital admission were associated with later functional decline among hip fracture patients, but their clinical significance is uncertain.

Weight change and physical function in older women: findings from the Nun Study

OBJECTIVE

To investigate the association between change in weight and decline in physical function in older women.

DESIGN

Longitudinal study of a defined population of Catholic sisters (nuns) whose weight and function were assessed twice, an average of 584 days apart.

SETTING

Unique life communities (convents) located throughout the United States.

PARTICIPANTS

475 Catholic sisters who were 75 to 99 years of age (M = 82.1, SD = 4.8) and were independent in at least one Activity of Daily Living (ADL) at the first assessment of weight and function.

INTERVENTIONS

None.

MEASUREMENTS

At each assessment, weight, ADLs, and cognitive function were evaluated as part of the Nun Study--a longitudinal study of aging and Alzheimer's disease. Annual percent weight change was calculated using weights from the two assessments, as well as the number of days that elapsed between assessments.

RESULTS

Mean weight at first assessment was 140 pounds (range 78 to 232, SD = 27). The mean annual percent weight change was 0.1% (range 22% loss to 16% gain, SD = 3.8). Age- and initial weight-adjusted findings indicated that those participants with an annual percent weight loss of 3% or greater had 2.7 to 3.9 times the risk of becoming dependent in each ADL, compared to the sisters with no weight change. The elevated risk persisted in those who were mentally intact or were independent in their eating habits.

CONCLUSION

Monitoring of weight may be an easy and inexpensive method of identifying older individuals at increased risk of disability.

Observations on the nutrient intakes of eating-dependent nursing home residents: underutilization of micronutrient supplements

OBJECTIVE

To estimate the intakes of essential nutrients by eating-dependent nursing home residents (EDR).

METHODS

This study was done in a 190 bed VA nursing home. Thirty-four EDR were selected for the study. Clinical data base which included age, sex, primary diagnosis, body mass index, albumin, hematocrit, activities of daily living status, decubitus ulcer medications and use of multivitamin/trace mineral supplement were recorded from the medical records. Caloric and essential nutrient intakes were determined over a 3-day period by a registered dietitian.

RESULTS

Seventy percent (24/34) residents in the study group were underweight (body mass index < 23 kg/m2), 26% were hypoalbuminemic (serum level < 3.5 g/dl), 50% were anemic (hematocrit < 37%); and 38% had pressure ulcers. In 88% EDR, the dietary intakes of three or more essential nutrients were below 50% of the RDA. Most frequent and severely deficient were zinc, copper, and vitamin B6. Despite the inadequate essential micronutrient intakes in the majority of EDR, only 35% received a multivitamin supplement and only 3% received a trace mineral supplement. A survey of 30 other VA nursing homes indicated generally similar findings to those in the Milwaukee facility with regard to the high frequency for eating-dependence, and the low frequency for administration of multivitamin and trace mineral supplements.

CONCLUSIONS

Despite eating supervision and assistance, the majority of EDR have inadequate intakes of numerous essential macro- and micronutrients. The deficient micronutrient intakes could be normalized by administration of a multivitamin/trace mineral supplement daily. Nevertheless, only a minority of EDR in VA nursing homes currently receive such a supplement.

Predictors of dietary intake in a functionally dependent elderly population in the community

OBJECTIVES

The aim of this study was to describe dietary intake and identify predictors of energy and protein intake in a group of high-risk elderly people.

METHODS

All elderly persons receiving publicly financed home care services in the area of Sherbrooke, Quebec, Canada, were eligible. Subjects (n = 145) 60 to 94 years of age from three home care programs were interviewed to measure sociodemographic, health, and food-related behavior variables. Three nonconsecutive 24-hour recalls were used to describe usual dietary intake. Independent predictors of energy and protein intake were derived from multiple regression analyses.

RESULTS

Very low mean energy intakes were observed in this functionally dependent population. More than 50% of the study subjects did not meet the recommended levels of daily protein intake (0.8 g/kg body weight). Significant independent determinants of intake were burden of disease, stress, poor appetite, and vision.

CONCLUSIONS

Results suggest that community-living elderly people with loss of autonomy may have more nutritional problems than healthy elderly individuals. Surveillance of predictors of dietary intake may enable early detection and prevention of nutritional deficits.

Involuntary weight loss in older outpatients: incidence and clinical significance

OBJECTIVES

To describe the incidence, anthropometric parameters, and clinical significance of weight loss in older outpatients.

DESIGN

Four-year prospective cohort study.

SETTING

University-affiliated Veterans Affairs Medical Center.

PATIENTS

Two hundred forty-seven community-dwelling male veterans 65 years of age or older.

MEASUREMENTS

Anthropometrics (weight, height, skin-folds, and circumferences), health status measures (Sickness Impact Profile scores, health care utilization, self-reported ratings of health), and bloodwork (cholesterol, albumin, others) were obtained at baseline and followed annually for 2 years. Outcome measures (hospitalization, nursing home placement, and mortality rates) were followed for a minimum of 2 years after any identified weight change.

MAIN RESULTS

The mean annual percentage weight change for the study population was -0.5% (SD: +/- 4.0%; range: -17% to +25%). Four percent annual weight loss was determined to be the optimal cutpoint for defining clinically important involuntary weight loss using ROC curve analysis. The annual incidence of this degree of involuntary weight loss was 13.1%. At baseline, involuntary weight losers were similar to nonweight losers in age (73.9 +/- 7.9 vs 73.3 +/- 6.7 years), body mass index (26.8 +/- 3.9 vs 26.9 +/- 4.1 kg/m2), and all other anthropometric, health status, and laboratory measures. Relative to nonweight losers, involuntary weight losers had significantly (P < or = .05) greater decrements in central skinfold and circumference measures (subscapular skinfolds, -2.9 vs -0.4 mm; suprailiac skinfolds, -4.2 vs -0.2 mm; and waist to hip ratio, -.01 vs + .00). Both groups had significant decreases in their triceps skinfolds (an estimate of peripheral subcutaneous fat), whereas arm muscle area and albumin levels did not decline significantly in either group. Over a 2-year follow-up period, mortality rates were substantially higher (RR = 2.43; 95% CI = 1.34-4.41) among involuntary weight losers (28%) than among nonweight losers (11%). Of interest, a similar increase in 2-year mortality (36%) was also observed among subjects with voluntary weight loss (by dieting). Survival analyses adjusting for differences between weight losers and nonweight losers in baseline age, BMI, tobacco use, and other health status and laboratory measures yielded similar results.

CONCLUSIONS

These results indicate that involuntary weight loss occurred frequently (13.1% annual incidence) in this population of older veteran outpatients. When involuntary weight loss occurred, the predominant anthropometric changes were decrements in measures of centrally distributed fat (trunkal skinfolds and circumferences). Finally, involuntary weight loss greater than 4% of body weight appears to be clinically important as an independent predictor of increased mortality.

Involuntary weight loss

Involuntary weight loss is a common finding and one associated with increased morbidity and mortality, especially in the elderly patient. The precise mechanisms by which weight loss occurs are currently being elucidated and probably involve the actions of classic hormones as well as cytokines, such as TNF (cachectin), adipsin, and interleukin-1 and interleukin-6. The differential diagnosis of involuntary weight loss is extensive, but case studies indicate that cancer, depression, and disorders of the gastrointestinal tract may be the most common causes. In approximately 25% of cases, no cause of weight loss is found despite extensive evaluation and prolonged follow-up. In the majority of cases, history, physical examination, and limited laboratory and radiologic studies reveal the cause of weight loss, when a cause is to be found. If an initial evaluation does not identify a cause, careful follow-up rather than undirected diagnostic testing is recommended. In the treatment of patients with involuntary weight loss, the underlying medical or psychiatric cause of the weight loss should be treated first if possible. Several medications are currently being investigated for treatment of patients with weight loss.

A critical review of research on cognitive function/impairment in older adults

Research on aspects of cognitive function and impairment in older adults is critically reviewed with the aim of evaluation and synthesis. The body of research on cognitive aging, mostly atheoretical, has not been placed within the larger context of cognitive sciences. Methodological concerns and lack of a unifying framework inhibit integration of previous studies and the development of a cohesive body of knowledge. Therefore, one paradigm of adult cognition, information processing, is recommended to further advance nursing theory and research.

Recent weight loss is related to short-term mortality in nursing homes

A two-year review of weight changes and mortality in nursing home residents was completed. Factors examined included age, gender, principal diagnosis, cause of death, and amount and duration of weight loss before death. A 10% loss of body weight over a six-month interval strongly predicted mortality in the ensuing six months, with sensitivity 0.60, specificity 0.91, positive predictive value 0.62 and negative predictive value 0.90. Diagnosis and cause of death did not appear to influence this relationship. Routine weight measurements may be useful as predictors of six-month survival in certain nursing home residents.

Causes of weight loss in a community nursing home

OBJECTIVE

To determine the causes of weight loss in nursing home residents.

DESIGN

Retrospective chart review of all weights over the previous 6 months and an in-depth examination of all residents who lost 5 or more pounds over that period.

SETTING

A for-profit community nursing home in an urban area.

SUBJECTS

All residents who had been in the nursing home for 3 or more months. Their mean age was 80.1 years, and 89% were female.

RESULTS

Weight loss of 5 pounds or more occurred in 19% of subjects. Only 15% of subjects had lost 5% of body weight, and 4% had lost more than 10% of their body weight. Depression accounted for 36% of the weight loss. Other causes of anorexia included medications, psychotropic drug reduction, swallowing disorders, paranoia, dementia with apraxia, gallstones, and obsessive-compulsive disorder. Increased energy utilization as a cause of weight loss was seen in two residents who wandered incessantly, one with tardive dyskinesia and one with chronic obstructive pulmonary disease. Dehydration was the cause of weight loss in two residents, and one resident had international weight loss for obesity. Cancer was the cause of weight loss in two residents. Four of 30 residents had more than one cause of weight loss. One of 25 tube-fed residents displayed weight loss.

CONCLUSIONS

A single cause of weight loss can be identified in most nursing home residents. Depression is the most common cause of weight loss. Psychotropic drug reduction may cause weight loss. The majority of causes of weight loss in a community nursing home are potentially treatable.

Impact of nutritional status on morbidity in a population of geriatric rehabilitation patients

OBJECTIVE

The primary objective was to confirm the results of a prior study that demonstrated a strong independent correlation between the severity of protein-energy undernutrition and the risk of subsequent morbidity in a population of elderly rehabilitation patients. A second objective was to determine whether inadequate in-hospital nutrient intake is a co-contributor to the risk of subsequent morbidity.

DESIGN

Cohort study.

SETTING

Geriatric Rehabilitation Unit (GRU) of a Veterans Administration hospital.

PATIENTS

Three hundred fifty randomly selected admissions to the GRU, of whom 99% were male, and 75% were white. The average age of the study patients was 76 years.

MEASUREMENTS

At admission, each patient completed a comprehensive medical, functional, neuro-psychological, socio-economic, and nutritional assessment. While remaining in the hospital, each subject was monitored on a daily basis for the development of complications. Complete calorie counts were obtained at least every other day, and the average pre-complication daily nutrient intake was expressed as a percent of predicted requirements as determined using the Harris-Benedict equation.

RESULTS

Of the 96 variables evaluated, the strongest predictor of subsequent complications was the Katz Index of ADL score, followed by serum albumin, usual weight percent, number of prescription medications, presence of renal disease, individual income, the presence of decubiti, dysphagia, and mid-arm muscle circumference. When all nine of these variables were included in the logistic regression analysis, the final model had a sensitivity of 70%, a specificity of 71%, and an overall predictive accuracy of 71%. When tested using the data from the previous study, the model differentiated the patients who developed a complication from those who had not a sensitivity of 76.7, a specificity of 76.1, and an overall predictive accuracy of 76.3. There was no difference in the pre-complication average daily nutrient intake between the complication and the no-complication groups (79% vs 75% of predicted requirements, P > 0.2).

CONCLUSIONS

Protein-energy undernutrition appears to be a strong independent risk factor for in-hospital morbidity. However, in-hospital nutrient intake may not be a significant determinant of risk.

Undernutrition in the nursing home: prevalence, consequences, causes and prevention

Approximately 5% of Americans over age 65, or 1.5 million individuals, currently reside in the nation's 20,000 nursing homes. The authors present material that lead to three conclusions about this population. First, nutritional deficiencies are common underlying causes of adverse clinical outcomes. Second, nutritional deficiencies are frequently not recognized. Third, opportunities for preventing or correcting undernutrition exist, provided that the significant and reversible nature of the nutrient deficiencies are identified.

Malnutrition in institutionalized elderly: how and why?

OBJECTIVE

To determine the prevalence of undernutrition and overnutrition in long-term care elderly patients and the functional, behavioral, environmental, nutritional, and medical variables associated with this prevalence.

DESIGN

Cross-sectional, observational.

SETTING

Long-term care hospital in Canada.

SUBJECTS

Two hundred elderly patients (n = 166 male), average age 78.5 years.

MEASUREMENTS

Assessment of nutritional status and presence of specific behavioral, medical, environmental, and functional characteristics known to impact on nutritional status. Nutritional status was determined by weight, % weight loss, BMI, skinfolds, arm circumference, area measurements, and % body fat. Multiple regression analyses were performed to identify the factors associated specifically with undernutrition and overnutrition in this population.

RESULTS

Severe undernutrition was present in 18% (n = 36) and severe overnutrition in 10% (n = 20). Mild/moderate undernutrition was present in 27.5% (n = 55) and mild/moderate overnutrition in 18% (n = 36). Overnutrition was positively associated with primary diagnosis and number of medications and negatively associated with poor appetite, number of feeding impairments, protein intake, and mental state. Undernutrition was positively associated with dysphagia, slow eating, low protein intake, poor appetite, presence of a feeding tube, and age and negatively associated with primary diagnosis.

CONCLUSIONS

Undernutrition exists at a level that is high (45.5%) but not unusual for this type of institutional setting. Behavioral, environmental, and disease-related factors greatly influence nutritional status. Undernutrition appears to be affected by nutritional factors more than overnutrition. Efforts should be directed toward influencing some of these factors to decrease undernutrition in the institutionalized elderly.

Oral nutritional supplement use in elderly nursing home patients

OBJECTIVES

To determine why elderly nursing home patients receive liquid oral protein supplements, what nutritional assessment is utilized, and whether there is evidence of effectiveness.

DESIGN

Retrospective, case control study comparing patients over 65 years of age, at two nursing homes, who were served oral supplements (OS) at least twice daily (n = 56), with a random sample of non-supplemented, non-tube fed patients (n = 53). Comparisons included medical diagnoses, medications, morbidity and mortality, weight changes, laboratory test results, and functional and behavioral status.

RESULTS

Nursing home patients were begun on OS (median time after admission = 2 months, range = 0-72 months) primarily because of weight loss (71%) and poor appetite (16%). Supplemented patients were below an age-adjusted body weight on admission, unlike controls, and continued to lose weight until OS were started. On OS, weight was slowly regained over 9-10 months in a majority of patients to approximate admission weight. Some patients on OS showed improvement in albumin, total lymphocyte count, cholesterol, or hemoglobin, but too few patients had sufficient lab tests to verify any consistent effect. Mortality was higher in OS patients (8 vs 2, P = 0.057), who were also somewhat older (87.9 vs 84.5 years), but there was no statistical difference in infection or hospitalization rate.

MEASUREMENTS

Nutritional assessment in these nursing homes consisted almost exclusively of (1) serial measurement of weight, (2) comparison of weight to (a) "ideal body weight" and (b) previous weight, and (3) a subjective evaluation of food consumption. No other anthropometric evaluations or laboratory tests were conducted for nutritional assessment.

CONCLUSIONS

The diagnosis of and intervention in under-nutrition in nursing home patients is frequently disorganized. In addition, nutritional assessment, either for screening or for following intervention, is hampered by the lack of convenient and unambiguous assessment tools. OS use is associated with weight gain in many nursing home patients and also improves other nutritional parameters in selected individuals.

Nutrition and nutritional requirements for the older adult

Establishing reliable nutrient requirements for individuals over the age of 65 years is a difficult task. Research on nutrient requirements in the aged is sparse and often contradictory. However, there are important clues in the literature suggesting that requirements for certain nutrients are altered with age and that preventable nutrient deficiencies exist. Energy expenditure and caloric intake typically decline with age. Unless nutrient density of the diet improves, a parallel decline in vitamin and mineral intake is inevitable. Deficiencies or suboptimal intakes of water-soluble vitamins, vitamin D, calcium, zinc, copper, chromium, and water are reported in groups of older adults. Marginal nutrient deficiencies in this population may easily go undetected and contribute to morbidity.

Observations on the prevalence of protein-calorie undernutrition in VA nursing homes

OBJECTIVE

To determine the prevalence of underweight and hypoalbuminemia in Veterans Affairs nursing home residents and the frequency with which physicians, nurses, and dietitians documented their awareness of the presence of underweight and hypoalbuminemia.

DESIGN

Retrospective survey of medical records.

SETTING

Twenty-six Department of Veterans Affairs nursing homes located in the Department's Central Region.

PATIENTS

2811 residents.

MAIN OUTCOME MEASURES

(1) Prevalence of underweight (defined as body weight less than 80% of standard) and hypoalbuminemia (defined as serum albumin less than 3.5 g/dl); (2) frequency with which physicians, nurses, and dietitians documented the prevalence of underweight and hypoalbuminemia in the records.

RESULTS

Three hundred thirty-two (11.8%) of the patients were underweight and 772 (27.5%) were hypoalbuminemic. The prevalence of the two conditions varied widely across nursing homes. The prevalence of low serum albumin ranged from 5% to 58% in the 26 institutions, and the prevalence of body weight less than 80% of standard ranged from 2% to 20%. In the Region as a whole, the dietician's notes in the medical charts mentioned underweight in an average of 95% of affected cases but mentioned the suboptimal albumin level in only 82% of the hypoalbuminemic individuals. In the nurses's notes, these figures were only 80% and 45%, respectively, and in the physician's notes, only 62% and 46%, respectively. The frequency of documented awareness of underweight and hypoalbuminemia by nurses and physicians varied tremendously across the 26 facilities (as few as 7% of the undernourished cases in one nursing home, 100% of the affected individuals in another).

CONCLUSIONS

This study showed a high prevalence of calorie and protein undernutrition in the nursing home residents of VA nursing homes, wide variation in the prevalence across nursing homes, and frequent lack of documentation of these nutritional deficiencies by physicians and nurses.

Easily measurable adverse outcome indicators in a Veterans Affairs nursing home

Indicator data were collected from October 1986 through April 1987 for 356 residents of the nursing home at the North Chicago, Illinois, Veterans Administration Medical Center. Measures of prevalence, incidence, and rates of change were studied for 17 adverse outcome indicators of four main types: death, undernutrition, skin breakdown, and loss of activities of daily living (eating, mobility, transfer, and toileting). Indicator values can be calculated from data routinely collected for administrative and other clinical purposes and can be used to help nursing home administrators monitor trends in the physical status of residents and to establish and track compliance with quality assurance goals.

Nature, nurture, nutrition: interdisciplinary programs to address the prevention of malnutrition and dehydration

Malnutrition and dehydration are common problems in nursing home patients. One explanation for this may be the large number of patients requiring feeding assistance. The Dysphagia Team at the Department of Veterans Affairs Medical Center in Miami, Florida served as the primary source in the expansion of a nutritionally supportive environment to assist in the prevention of malnutrition and dehydration in patients with feeding/swallowing disorders. "Silver Spoons," a program in which volunteers provide supervised feeding, "Happy Hour," a time each day during which an atmosphere is provided that encourages socialization and hydration, and "Second Seating," during which lunch is provided for patients who require modification of eating style, food texture, or timing are described. Analysis of the program's outcomes show it to be timely, pleasing to patients, and cost-effective.

Weight change, survival time and cause of death in Dutch elderly

Weight change, subsequent survival time and cause of death are reported from the Dutch Longitudinal Study among the Elderly. Data consist of a national sample of persons aged 65-99 years. Six hundred and fifty-eight subjects were examined in the baseline years 1955-1957 and were re-examined 5 years later. Vital status and cause of death were ascertained for 604 of these subjects through 1983. Those subjects who experienced a decline in body mass index (BMI, kg/m(2)) during the period of observation, were likely to be in poorer health and have a shorter survival time than those subjects with stable weight, regardless of initial BMI. Weight gain was associated with shorter survival time only in the age group 65-74 and in those with heart disease. Weight loss, on the other hand, was most likely to result in decreased survival time among those ultimately dying of stroke, pneumonia/influenza or heart disease. As such, weight loss may be an indicator of the severity of disease. The noted associations remained, even when those surviving less than two years were omitted from the analyses. Thus, in longer survivors, weight loss may be associated with decreased vitality and decreased ability to survive once a disease becomes apparent.