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Malnutrition Among Patients in Nursing Homes and Its Association with Dementia

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Malnutrition Among Patients in Nursing Homes and Its Association with Dementia FAGFELLEVURDERT MALNUTRITION AMONG PATIENTS IN NURSING HOMES Malnutrition among patients in nursing homes and its association with dementia TEKST Rosanna Echano Major, RNa, Maria Krogseth, MD, PhD b,c,d. a Tjølling Nursing Home, Municipality of Larvik, Norway b Oslo Delirium Research Group, Geriatric Department, Oslo University Hospital. Norway. c Old Age Psychiatry Research Network, Telemark Hospital Trust and Vestfold Hospital Trust, 3710 Skien, Norway. d University of South-Eastern Norway. Abstract Aim: To reveal the prevalence of malnutrition of risk for malnutrition was 68%, 28% and 35% among patients in nursing facilities using the scree- using MNA, MUST and NJ respectively. Using three ning tools Mini Nutritional Assessment (MNA), categories, the prevalence of high risk for malnutri- Malnutrition Universal Screening Tool (MUST), tion was 13%, 11% and 16% using MNA, MUST, and Nutritional Journal (NJ). The agreement bet- and NJ respectively. There was a positive associa- ween the tools, and the correlation between mal- tion between dementia severity and worse nutritio- nutrition and severity of dementia, were explored. nal status using MNA (p<0.001). This association was not significant using NJ (p=0.223), nor MUST Methods: 97 patients living in nursing facilities were (p=0.303). included. The patients’ nutritional status was assessed using MNA, MUST, and NJ. Severity of dementia was Conclusion: The prevalence of malnutrition among determined using Clinical Dementia Rating Scale patients living in nursing facilities varies according (CDR). to screening tool applied, and how the result is pre- sented. Risk of malnutrition increases parallel to the Result: When classifying patients’ nutritional status severity of dementia regardless of the screening into two categories (normal vs. risk), the prevalence tool, but intensity is more apparent with MNA. 14 Malnutrition among patients in nursing homes Introduction tion is associated with dementia as alternative tools (12, 13). Malnutrition or undernutrition (1) severity (8). However, there is also Despite the recognized impor- refers to a lack of intake or uptake of evidence that obesity exists among tance of malnutrition among patients nutrition leading to altered body patients with dementia (9). Today, living in nursing institutions, only a composition and body cell mass. Its more than 70 000 people in Nor- limited number of studies present consequence is diminished physical way are living with dementia (10). updated statistics on nutritional sta- and mental function, and impaired Most of these patients are old and tus among patients with dementia in clinical outcome from diseases (2). suffer from multiple diseases. In Norwegian nursing facilities. Previo- Older people are prone to malnutri- nursing homes, about 80% of the usly presented prevalence estimates tion due to both biological aging patients suffer from dementia (11). of malnutrition in this setting vary (3), and to chronic conditions asso- The Norwegian Directorate of from 33 to 69% depending on nutri- ciated with malnutrition such as Health, through the National Pro- tional screening tool used and group lung and heart diseases, gastrointe- fessional Guidelines for Prevention studied (14-16). stinal disorders, dental and oral pro- and Treatment of Malnutrition, Accordingly, the aim of our blems, polypharmacy, depression, recommends that all patients admit- study was to present the prevalence and dementia (4). Malnutrition has ted to health facilities, should of malnutrition among patients always been the focus among old undergo nutritional screening upon living in nursing facilities using the patients, although obesity also admission and regularly thereafter three commonly used nutritional occurs in this age group (5). Over- (12). The guideline recommends screening tools MNA, MUST, and weight and obesity are defined as several nutritional screening tools. NJ. We also explored the agree- abnormal or excessive fat accumula- For older patients, the tools Mini ment between these three instru- tion that may impair health (2). Nutritional Assessment (MNA) and ments, as well as whether the People with dementia are parti- the Malnutrition Universal Scree- prevalence of malnutrition varied cularly vulnerable to malnutrition ning Tool (MUST) are recommen- with severity of dementia. due to a variety of reasons such as ded. The Nutritional Journal (NJ)1, difficulty in procurement and pre- Subjective Global Assessment Methods paration of food, feeding difficulties, (SGA), and Nutritional Risk Scree- Population / Sample increased Figurerisk of infections1: Patient (6), flow and illustrating ning (NRS-2002) patient inclusion. are recommended Using a cross-sectional design, we changes in appetite (7). Previous included patients living in nursing CRPD (Communal residences for people with dementia) studies have found that malnutri- homes and communal residences 1 Ernæringsjournal Figure 1. Patient flow illustrating patient inclusion CRPD (Communal residences for people with dementia) Nursing home in Larvik CRPD in Larvik Nursing home in Sandefjord CRPD in Sandefjord n=16 n=25 n=25 n=48 Short term residents, n=4 Short term residents, n=3 Physical restlessness, n=1 Acute illness, n=1 No height measurement, n=2 Incomplete data, n=3 Patients included n=97 15 Malnutrition among patients in nursing homes for people with dementia, collecti- NJ. Weight, height, and circumfe- from the sum of these scores. A vely termed nursing facilities. Inclu- rence of arm and leg, measured total added score of 0 indicates low sion was conducted from December within the last four weeks before risk, 1 indicates medium risk, and 2016 to March 2017, and took place the registration was used. Weight 2 indicate high risk. in the two adjacent municipalities of was measured using weighing NJ identifies the patient’s BMI and Sandefjord and Larvik, Norway. chair. Height was measured with weight changes over time, as well as Inclusion criteria were perma- the patient in standing or lying other nutritionally related data such nent residence or three months position. Height measurement as decrease in appetite, dental pro- continuous residence in one or from medical record was used if blems, chewing or swallowing pro- more nursing facilities. Patients height measurement was difficult. blems, sore or dry mouth, nausea were included regardless of age. The original form of the MNA and vomiting, diarrhoea or constipa- Patients with short-term resi- with 18 parameters was used in this tion, oedema, grabbing or movement dence, patients who were acutely ill, study. MNA assesses patients’ weight problem, independence during patients who did not cooperate changes over time, body mass index mealtime, and vision. The assess- when measuring height and weight, (BMI) measured as kg/m2, mobility, ment is graded as good nutritional and patients who had missing and possible neuropsychological status, risk of malnutrition, and height measurement, were exclu- disorders. It also provides informa- severe malnutrition (19) ded. The sample size was determi- tion about the patient’s living situat- ned by practical considerations. ion, number of regular medications, Dementia Diagnosis and presence of wounds or skin sores, Severity Data collection number of meals daily, daily con- Dementia diagnoses registered in Nurses responsible for the regular sumption of nutrients and fluids, the patients’ medical records were care of the patients performed all independence during mealtime, used. No direct cognitive assess- measurements in which direct con- and a measurement of mid-arm and ment or diagnostic process was tact with the patients were necessary. calf circumference. The maximum done during the registration. All data were then collected by the score is 30, whereas a score less than Severity of dementia was deter- primary investigator (RM) through a 17 indicate malnutrition, 17 to 23,5 mined using the CDR (20). The series of interviews with the nurses indicate a risk of malnutrition, and a CDR assesses the patients’ memory, who performed the measurements. score from 24 to 30 indicate normal orientation, judgment, social acti- The registration forms, MNA, MUST, nutritional status. MNA also inclu- vity, home and leisure interests, NJ, Clinical Dementia Rating Scale des two questions were the patients and ability to care for oneself. The (CDR), and demographic data were are asked about their own health patients were categorized using the completed during the interviews. status compared to others, and their following scale: 0 = no dementia, self-view of nutritional status (17). 0.5 = uncertain, 1 = mild, 2 = Demographic data Regarding these two questions the moderate, and 3 = severe dementia. The patients’ age, gender, and length nurses, after discussing with other of stay in the institutions, were regis- caregivers, had to answer for those Ethical considerations tered. To avoid direct identification patients unable to speak for them- The project was submitted to the of the patients, their exact age was selves due to lack of language or Norwegian Center for Research not recorded. Age was divided in severe dementia. Data (NSD). Informed consent was eight categories: less than 65 years, MUST is a screening tool prima- not required as mapping of nutritio- 65-70 years, 71-75 years, 76-80 rily developed to identify malnutri- nal status is included in the routine years, 81-85 years, 86-90 years, tion in acute settings, and to help care in Norwegian nursing homes. 91-95 years, and more than 95 years.
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