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Purpose: The purpose of this study was to describe nutritional risk and low weight in community-dwelling elderly.
Method: This cross-sectional exploratory study used in-depth interviews conducted on older adults with a body mass index <24 kg/m2. Depression, mental state, nutrition, and demographic data were measured.
Results: These elders (n = 130) were mostly female (55%, n = 71), married, white (84%, n = 109), and had a greater than a high school education. In a multivariate logistic regression analysis, 3 variables were statistically significantly associated with being severely underweight: those who self-reported having an illness or condition that changed the kind and/or amount of food eaten, unintentional weight loss of 10 lb in the last 6 months, and needing assistance with traveling outside the home.
Conclusion: Awareness of the high nutritional risk should prompt consideration of early, appropriate assessment and therapy to prevent malnutrition and a declining quality of life.
The number of people older than 60 years will globally rise 22% by 2050.1 With this major demographic shift, a significant demand will be placed on the healthcare delivery system.2 As the older generation increases in number, healthcare encounters for unintentional weight loss and low weight become more frequent. The burden of economic cost of low weight in the older adult is well documented, and preventive nutritional management in the older adult is cost-effective.3-5
Nutritional problems can result from interactions of physiological, psychosocial, and cognitive causes, which frequently result in lowered weight in elders. Unintentional weight loss and low weight in the older adult can lead to adverse health outcomes; such as frailty, loss of independence, and functional decline.6-8 Maintaining a healthy weight decreases early admission to long-term care facilities, length and number of hospitalizations, and healthcare cost for older adults.5,9-11 Health maintenance and aging without disabilities are the ultimate goal for elders and their healthcare providers (HCP). Healthcare provider is defined as the interdisciplinary staff of caregivers, including nurse practitioners and advanced nurses.
The country is currently preoccupied with obesity in all age groups, which justifiably is a major public health problem. Nevertheless, low weight in older people is routinely ignored and may be an even greater health risk. Research on weight in elders indicates that both overweight and underweight measured by body mass index (BMI) are associated with increased risk of morbidity and mortality.12 Recent unintentional weight loss is common among community-dwelling elders and needs to be considered an adverse health indicator even among obese elders.12 Weight loss is not a normal part of aging and usually represents an underlying disease process.13 In older adults, apart from intentional weight reduction in overweight and obese individuals, loss of body weight usually leads to poor health outcomes.14-17
Although there is some controversy in the literature about what the ideal weight is for older adults, most authorities in the field consider satisfactory weight for those 65 years and older as a BMI between 24 and 27 kg/m2.18,19 In older adults, the lowest mortality rate and best functional ability are associated with a BMI between 22 and 30kg/m2 for women, and a BMI between 23 and 30 kg/m2 for men.20 A BMI that is in the 19- to 23-kg/m2 range is a major indicator of nutritional risk; furthermore, a BMI of 19 kg/m2 or less increases risk for malnutrition.18,21,22 Unintentional weight loss, which increases nutritional risk, is a loss of 10 lb (4.6 kg) in 6 months, 5% per month or 1% to 2% per week.18,23
For the purposes of this article, low weight in both men and women 65 years and older is a BMI greater than 18 kg/m2 and less than or equal to 24 kg/m2. Intentional weight loss is defined as weight loss as a result of purposeful dieting, and unintentional weight loss is weight loss occurring without food restriction.
This article describes nutritional risk in community-dwelling elderly people (65 years and older) and discusses issues associated with this problem. These findings will increase our understanding of the factors that contribute to unintentional weight loss and low weight.
A literature review was completed on nutritional risk and low weight in community-living older adults to guide the development of this research protocol (reference identifies authors). A conceptual model used to guide this study was derived from this literature review (reference identifies authors).
This cross-sectional, descriptive study was completed between September 30, 2004 and September 30, 2005.
The sample included community-dwelling older adults (n = 130), age 65 years and older, with a BMI <24 kg/m2. Participants were recruited from 3 counties, in both rural and urban settings, in the Western United States.
A 6-month ethnographic pilot study was conducted between September 2003 and March 2004 and reported elsewhere (reference identifies authors). The findings from this pilot study were considered in the development and design of the research reported here. The pilot study confirmed that low-weight, older community-dwelling adults are willing to participate and be engaged in taped interviews, thus confirming feasibility of this type of study.
Sites included 3 Veterans Administrative (VA) outpatient clinics, 1 clinic was located in each county and supplemented with community-based recruitment. A letter was sent to the HCPs in the VA clinics and in community medical offices. A flyer was posted in the clinics and medical offices, as well as areas frequented by older adults, such as senior centers. Inclusion criteria were as follows: age 65 years and older, under the care of an HCP, and identified as having a risk factor for poor nutritional status (BMI <24 kg/m2). Exclusion criteria were as follows: the diagnosis of dementia (Folstein Mini-Mental Examination score of 23 or less), congestive heart failure, or cancer; bedridden or unable to stand for measurement of height; currently hospitalized; hospitalized in the past 30 days; or residing in a skilled nursing facility and non-English speaking.
After written consent was obtained, an appointment was made at a time convenient for the participant, and a single interview (lasting 1-1.5 hours) was conducted in the participant's home. The following variables were included: (a) sociodemographic characteristics (age, sex, ethnicity, conjugal status, education, religion, yearly income, social support, and type of residence); (b) current lifestyle (current smoking status, use of alcoholic drinks, and physical activity); (c) health indicators (number of medical diagnosis and medications); (d) health service indicators (doctor visits and hospitalizations in the past 12 months); (e) Geriatric Depression Scale (GDS); (f) DETERMINE Your Nutritional Health Checklist, Nutrition Screening Initiative (NSI) Levels I and II (eating habits, living environment, functional status, and clinical features); (g) anthropometric measurement (weight, height, midarm circumference, triceps skinfold, and BMI); and (h) semistructured interview. The interview data were reported elsewhere (reference identifies authors). Medical diagnosis and medications were obtained from patient medical records and VA Computerized Patient Resource System when available; otherwise, they were self-reported.
The GDS was designed to rate depression in the elderly, is reliable and valid in this population, and is simple to administer.24 A score of 0 to 10 is normal, scores of 11 or higher yield a sensitivity of 84% and a specificity of 95% for depression in elders, and scores of 14 or higher yield a sensitivity of 80% and a specificity of 100% for depression.24
The GDS was compared with 3 existing depression scales Research Diagnosis Criteria, Self-Rating Depression, and Hamilton, Rating Scale for Depression, by doing an analysis of variance.24 Each analysis was highly significant (GDC: F2,97 = -99.48, P < .001); Self-Rating Depression: F2,97 = 44.75, P < .001; Hamilton, Rating Scale for Depression: F2,97 = 110.63, P < .01) and provided evidence for the validity of the GDS as a measure of depression.24
The Mini-Mental State Examination (MMSE) is a 30-item instrument used to screen cognitive deficits and aid in the diagnosis of dementia.25 Those with dementia were excluded from this study, and this tool was used to screen for this exclusion. The MMSE takes only 10 minutes to administer and score and has documented to be valid and reliable in an older adult population.25
The MMSE is a reliable and valid tool for screening cognitive deficits. The scores for 3 separate diagnostics groups agreed with the clinical opinion of the presence of cognitive difficulty, and the scores dispersed in a fashion agreeing with severity of the difficulty providing data to support validity.25 Concurrent validity was determined by correlating MMSE scores with the Wechsler Adult Intelligence Scale, Verbal and Performance scores. For the MMSE versus Verbal IQ, Pearson r was 0.776 (P < .0001), and for MMSE versus Performance IQ, Pearson r was 0.660 (P < .001).25 The MMSE is reliable on 24-hour (Pearson coefficient, 0.887) and 28-day retest (Pearson coefficient, 0.827) by single and multiple examiners (Wilcoxon T was not significant, and product moment correlation for test 1 versus test 2 was 0.98).25
The Nutritional Screening Initiative (NSI) was developed through a collaborative effort of the American Dietetic Association, the American Academy of Family Physicians, and the National Council of Aging.18 The DETERMINE checklist screen permits identification of older adults at high nutritional risk. Levels I and II are completed by healthcare professionals and assists with diagnosis.
Nutritional Screen: (DETERMINE Your Nutritional Health) The word DETERMINE was used to remind the patient of the warning signs for poor nutritional health (Disease, Eating poorly, Tooth loss/mouth pain, Economic hardship, Reduced social contact, Multiple medicines, Involuntary weight loss/gain, Needs assistance in self care, Elders years above age 80).18 The nutritional screen is initiated with a 10-item checklist that is answered yes/no and is associated with the nutritional well-being of older adults.26 Points are given for each answer; for example, "I don't always have enough money to buy the food I need." is assigned 4 points for a positive answer. A score of 0 to 2 reflects good nutritional health, 3 to 5 reflects moderate nutritional risk, and 6+ reflects high nutritional risk.18 The checklist is not a diagnostic tool but provides a valid, quick screening measure of potential nutritional risk.26 Those that are identified at risk for poor nutritional status based on the checklist will proceed to level I.
NSI Level I: The next step is the level I screen, which differentiates older adults who need further assessment by calculating the BMI and change of body weight and evaluation of eating habits, living environment, and functional status. If the older adult has a positive answer for 1 or more statements on this screen, the individual may be at risk for poor nutritional state.18 If the participant has a significant, involuntary weight loss or has a BMI below 22, further detailed screening is warranted.18
NSI Level II: The final step, the level II screen, is designed to obtain more diagnostic information and needs a more skilled administrator because it confirms the level I screen and includes anthropometric measurements, evaluation of drug use, clinical features, eating habits, living environment, and functional tests.18 The functional test in this screen are the MMSE (score of 23 or less is suggestive of dementia) and GDS (scores of 11 or higher yield is suggestive of depression in elders).18 Anthropometric measurement includes a BMI of <24 or >27, a midarm circumference <10th percentile, and triceps skinfold <10th or >95th percentile.18 Major indicators would include functional test and anthropometric measurement results described above. Subjects exhibiting 1 or more major indicators are identified as having poor nutritional status.18 Minor indicators include use of 3 or more drugs, presence of clinical features (such as problems with mouth, teeth, or gums), problems with eating habits (such as usually eats alone), problems with living environment (such as lives on income less than $6,000 per year), and problems with functional status (such as needs assistance with eating).18 This instrument includes the evaluation of laboratory data.
The NSI DETERMINE checklist and NSI Levels I and II have not been independently validated. Data to document sensitivity and specificity of the NSI levels I and II do not exist. It predicts overall perceived health status in noninstitutionaized older adults and identifies persons whose estimated nutrient intake falls below the recommended dietary allowances.26 This instrument (DETERMINE, NSI Levels I and II) supplies a large amount of descriptive data, including medical and social-cultural information, that allowed this study to thoroughly describe low weight in community-dwelling, older adults.
This study was approved by the University of California, San Francisco, and Stanford University's institutional review boards. A mutually agreeable time was arranged for the interview at the subject's home. In a subsequent face-to-face meeting, the informed consent that clearly outlined confidentiality, freedom to withdraw, voluntary participation, and anonymity was reviewed with all potential subjects and each subject signed a consent form. All participant data were handled confidentially. Confidentiality was maintained by the following: (1) recording all patient information by identification number; (2) a separate list of names linking patients to identification numbers were kept in a separate file away from all other data files; (3) data files were kept in a locked file cabinet; only the researcher had access to the locked file; and (4)data will be retained for 3 years and then shredded; (5)patient identities will not be used in any reports or publications resulting from this study. All data were obtained by the first author.
Descriptive statistics were used to characterize the study sample and to describe low weight.27 Demographic data were analyzed using mean and standard deviations for the continuous variables and frequencies and percentages for the categorical variables.28 A logistic regression analysis estimated the independent association of self-report of having an illness or condition that changed the kind and/or amount of food eaten; having lost 10 lb, without wanting to, in the last 6 months; and needing assistance with traveling outside the home, with the outcome variable low weight reported as BMI <19 kg/m2.28 The results from the multivariate logistics regression are reported as odds ratios (OR) with 95% confidence intervals (CI) for a series of models. Sample t test was used for comparison between means and Pearson chi-square for proportions. All data were analyzed by SPSS 12.0 (2003, Chicago, Ill). Content analysis was used to evaluate the key concepts from the open-ended questions.29 These data were reported elsewhere (reference identifies authors).
A convenience sample of 130 at risk for low weight (BMI < 24 kg/m2), community-living, older adults was interviewed. All participants (n = 130) met the inclusion criteria: age 65 years and older, under the care of an HCP, and identified as having a risk factor for poor nutritional status (BMI < 24 kg/m2). Table 1 shows that most subjects were female (n = 71), married (n = 70), white (n = 109), with an income >$6,000 per year (n = 115), and with greater than a high school education (n = 59). One third lived alone, and almost half reported exercising (participating in a continuous physical activity) a minimum of 3 times a week for 20 minutes. The average (mean) time since their last office visit to an HCP was 31/2 months (SD, 3.5), and most HCPs were physicians (n = 124, 96%). All participants reported being weighed when they visited their HCPs office.
Most scored at moderate to high nutritional risk (78%, n = 100) on the Nutritional Screening Initiative DETERMINE (NSID) (Table 1). The data obtained from the NSI are described in Table 2. Forty percent had a history of a bone fracture and 24% currently reported bone pain. One third had depressive symptoms (27%) and all were cognitively intact, required for the study (Table 1). The average number of daily medications was 6 (SD, 3.0) (included prescription, over-the-counter medication, and/or vitamins/mineral supplements). Few had oral problems: reported a problem with their mouth, teeth, or gums (13%); with chewing (15%); and with swallowing (9%) (Table 3). A bivariate analysis was initially conducted (Table 4), which was subsequently used in the multivariate model.
A multivariate logistic regression analysis was used to estimate the OR and 95% CI for a series of models to identify factors associated with very low BMI. The first model tested 6 factors associated with low weight (BMI <19 kg/m2): (a)has an illness or condition that changed the kind and/or amount of food eaten; (b) without wanting to, lost 10 lb in the last 6 months; (c) usually or always needs assistance with traveling (outside the home); (d) eats fewer than 2 meals per day); (f) GDS categorized as depressed/not depressed; and (g) eats fruit or drinks fruit juice once or not at all daily. Three of 6 variables remained robust independent predictors in all analyses: (a) has an illness or condition that changed the kind and/or amount of food eaten, (b) unintentionally lost 10 lb in the last 6 months, and (c) usually or always needs assistance with traveling (outside the home).
A final exploratory model yielded the following statistically significantly independent associations with severe underweight (Table 5): (1) has an illness or condition that changed the kind and/or amount of food eaten [OR = 4.7, CI: 1.6, 13.1]; (2) without wanting to, lost 10 lb in the last 6 months [OR = 4.0, CI: 1.5, 10.7]; and (3) usually or always needs assistance with traveling (outside the home) [OR = 4.0, CI: 1.5, 11.3].
Nutritional risk is prevalent in community-living older adults residing in 3 counties on the western United States. Our study included men (45%) and older adult's residing in rural and urban communities, which increased generalizability.
The salient findings of this study are the 3 statistically significant contributions to risk prediction that this study identified: (a) subjects who self-report having an illness or condition that changed the kind and/or amount of food eaten are 4.7 times greater likelihood of being severely underweight; (b) if the subject reports having lost 10 lb, without wanting to, in the last 6 months, they are 4 times more likely to be severely underweight (BMI <19 kg/m2); and (c) those needing assistance with traveling outside the home are 4 times more likely to be severely underweight.
The finding that those reporting an illness or condition that changed the kind and/or amount of food eaten was associated with low weight is consistent with the current understanding of aging since the incidence of chronic disease increases with age. Eighty percent of elders have 1 chronic disease, and 50% have 2 or more.30 Of those with chronic disease, 90% could improve with nutritional intervention.30 Chronic disease predisposes elders to weight loss due to anorexia, early satiation, malabsorption, increased metabolism, increased energy expenditure, and impaired functional status.31 The most commonly identified causes of weight loss are depression, cancer, and gastrointestinal disorders.32 Diseases occurring in fragile socioeconomic environments can rapidly compromise nutritional status.31
The loss of 10 lb in 6 months is an indicator for risk of low weight.18 Most agree that a weight loss of 5% over 6 months is clinically important and should be investigated.14,33-35 This study reinforces what other studies have found related to decreased function, such as the need for assistance with traveling outside of the home. Other researchers report that disability and reduced quality of life can result from low weight.3,36 Even in healthy populations of elders, only 40% of men and 22% of women were able to perform all activities of daily living at ages 75-80 years,37 and among elders age 65 years and older, 33% need assistance with activities of daily living.37 Limitations in activities are a major cause of weight loss in older adults.38 Nutritional status in community-living older adults is associated with functional status, which influences the older person's ability to live independently.39
Our study does not support earlier reports indicating that poor oral health is associated with low weight.11,40-42 Approximately 50% of elders have lost teeth by the age of 65 and have resultant chewing problems that can affect food consumption.11 Fifty percent of elders are edentulous resulting in chewing difficulty and gingival disease from denture wearing.11 Gingival and dental disease is reported as the primary cause of 7% of undernutrition in older adults.11,42 Presence of periodontal disease is associated with weight loss in older, well-functioning adults.42
An important limitation of our study is the lack of diversity in ethnicity and functional and socioeconomic status. Our sample included 84% whites and thus lacks generalizability. Studies have shown that Hispanic elders (n = 1,006) in rural settings had a higher prevalence of nutritional risk factors than non-Hispanic whites.43 Researchers examined inner city older African Americans (n = 415) and found them to be at high nutritional risk.44Another study found that 32% of men had a 90% greater risk for poor nutritional status compared with women.45 Furthermore, some studies reported that lower socioeconomic status can contribute to involuntary weight loss in older patients.6,40,44 Future studies need to include diverse elders who are below poverty level to improve generalizability.
A limitation of the study is that all elderly including obese, average weight, and underweight were not studied. This study focused only on defining characteristics of persons who are low weight and underweight.
The use of a descriptive and cross-sectional design limits the causal inference from this study. This may have resulted in the participants having a better ability to maintain a stable weight than those who were excluded. The nonrandom nature of this sample and those who agreed to be interviewed may be healthier and better educated, have better cognitive function and nutritional status, and a have greater interest in research. Because subjects with poorer cognitive and nutritional status may not participate, there may be an underestimation of the true risk in the older population, leading to a limitation in generalizing to the entire population.
The NSI checklist is routinely used to screen for nutritional risk in the older adult. This 1-page screening tool was designed to identify eating, economic, and lifestyle behaviors that may contribute to the development of nutritional problems.26 Not surprisingly, the participants in this study scored at moderate to high nutritional risk (n = 100, 78%) on the NSID. It is important to note that the NSID is a screening tool, rather than a diagnostic measure, used to identify individuals at potential nutritional risk.26 The DETERMINE checklist is intended for the public and is not meant for clinical diagnosis. The major complaint is that most subjects usually have a positive score resulting in the subject needing following-up with a professional (48% were classified as high nutritional risk, and 50% were incorrectly labeled as a high risk).26 One can argue that over-referral can be considered positive because it allows the subject an opportunity to discuss issues with their HCP about nutrition.
This study adds the following new information to the care of older adults: (a) it is apparent that most elders are weighed with each office visit to an HCP (see Table 1), which would enable the monitoring of weight loss trends and the use of a screening tool to identify those at higher risk for weight loss; (b) those who have trouble traveling outside the home and those who self-report having an illness or condition that changed the kind and/or amount of food eaten should be assessed more frequently and subsequently assessed for further weight loss; and (c) nutritional problems can result from highly individualized interactions (physiological, cognitive, and psychosocial). Targeting interventions to these behaviors and risk factors may improve nutritional status and overall health of these elders.
In summary, weight loss is a sentinel event with devastating consequences among community-living elders. The goal is to modify nutritional risk factors to assure independent living, to delay institutionalization, and to decrease the risk of morbidity and mortality. This study reported that older adults who were more likely to be severely underweight (BMI <19 kg/m2) were those who self-reported having an illness or condition that changed the kind and/or amount of food eaten, unintentionally lost 10 lb (4.6 kg) in the last 6 months, and reported needing assistance with traveling. Our knowledge of nutritional status of older adults is far from complete. There is a need for replication of our study and for further research with a larger, ethnically diverse sample to increase our understanding of the factors that contribute to unintentional weight loss and low weight and for the development of appropriate preventive and treatment strategies to improve the health of the older adult.
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This article has been designated for CE credit. A closedbook, multiple-choice examination follows this article, which tests your knowledge of the following objectives:
1. Explain the nutritional risk and low weight in community-dwelling elderly.
2. Describe the results and findings of the study presented in this article.
Editor's Note: In 2007, we will publish 6 articles for which 1 to 3 credit hours may be earned as part of a CNS's learning activities. Examination questions are provided at the end of this article for your consideration. See the answer/enrollment form after the article for additional information regarding the program.
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