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Impact of Functional Capacity on Nutritional Status of Hospitalized Elderly in Qazvin, Iran


1 Department of Nursing, Qazvin University of Medical Sciences, Qazvin, IR Iran
2 Metabolic Diseases Research Center, Qazvin University of Medical Sciences, Qazvin, IR Iran
*Corresponding author: Azam Ghorbani, Metabolic Diseases Research Center, Qazvin University of Medical Sciences, Qazvin, IR Iran. Tel: +98-2833360084, Fax: +98-2833326033, E-mail: ghorbani_az@yahoo.com.
Biotechnology and Health Sciences. 2016 February; 3(1): e34470 , DOI: 10.17795/bhs-34470
Article Type: Research Article; Received: Nov 8, 2015; Revised: Dec 23, 2015; Accepted: Dec 26, 2015; epub: Feb 22, 2016; ppub: Feb 2016

Abstract


Background: Lack of independence and unwanted dependence on others for activities of daily living (ADL) and decreased functional capacity affect nutritional status of the elderly.

Objectives: The aim of this study was to determine the impact of functional capacity on malnutrition status in hospitalized elderly patients in the Qazvin city of Iran.

Patients and Methods: This cross sectional study was conducted on patients 60 years or older hospitalized in two teaching hospitals of Qazvin, Iran, from May to October 2011. The nutritional status was assessed using the mini nutritional assessment (MNA) questionnaire. Functional capacity of the elderly was assessed using self-report questionnaires of ADL and Instrumental Activities of Daily Living (IADL). Data were analyzed using the Chi-square test and logistic regression analysis.

Results: Of the 322 participant, 171 (53.1%) were male. The mean age was 70.36 ± 7.8 years. Based on MNA, 96 patients (29.8%) had normal nutritional status, 138 (42.9%) were at risk of malnutrition and 43 (13.4%) had malnutrition. Dependency on ADL and IADL was significantly associated with malnutrition and risk of malnutrition. In the logistic regression analysis, IADL was associated with malnutrition (OR: 1.19, 95% CI: 1.07 - 1.33; P < 0.001).

Conclusions: Risk of malnutrition as well as reduced functional ability was high among the hospitalized elderly of Qazvin. Nutritional status assessment of older adults is necessary, particularly when they are admitted to hospitals.

Keywords: Aged; Nutrition Assessment; Activities of Daily Living; Malnutrition

1. Background


The phenomenon of population aging is one of the most important economic, social and health challenges of the 21st century (1). Average annual growth of the elderly population in Iran was about 3.9%, between 2006 and 2011, which will reach 26% by 2050 (2). Life expectancy for Iranian males and females is estimated to be 72.2 and 73.9 years, respectively (3). Aging is associated with various physiological and psychological changes and makes older adults vulnerable to poor nutrition, which is followed by a higher risk of malnutrition (4, 5). Poor nutrition is associated with low quality of life, morbidities and higher mortality due to chronic diseases, sensory defects (vision or hearing loss), taking multiple drugs, poor socioeconomic status, physical disability, sedentary lifestyle and depression. All of these factors make older adults more likely to be malnourished and more prone to hospitalization (6-8). Malnourishment is a serious and common problem among older adults and can result in weakened physiological and functional conditions and physical performance (5, 9). Unintentional and unexplained weight loss is considered as a major indicator of malnutrition among the older population (10). Lack of independence and unwanted dependence on others for activities of daily living (ADL) as well as decreased functional capacity affect nutritional status of the elderly (4). Reduced functional capacity is defined as a defect in self-care skills, which, in many cases, can lead to prolonged hospital stays and increased mortality as well as high costs of care (11). Several studies have shown a close relationship between nutritional status and functional capacity, particularly among older adults (9, 12, 13). However, the current knowledge about the relevance of functional capacity and nutritional status is not enough for the Iranian population. Hospitalized olderly need more attention due to their morbidities and related disabilities. On the other hand, hospital admission as an access point provides an opportunity for early identification and treatment of malnutrition. Evaluation of the nutritional status of elderly is extremely important considering the growing population of older adults in Iran, and lack of studies on the association of nutritional status and functional capacity of hospitalized olderly.

2. Objectives


The aim of this study was to determine the impact of functional capacity on malnutrition status in hospitalized elderly of Qazvin, Iran.

3. Patients and Methods


This cross sectional study was conducted on olderly patients hospitalized in the medical and surgical wards of two teaching hospitals of Qazvin from May to October 2011. The ethics committee of Qazvin University of Medical Sciences approved the study. All participants provided a written informed consent. Inclusion criteria were age ≥ 60 years and ability for verbal communication to answer the questions. Patients who had a history of severe mental diseases resulting in hospitalization within the last six months were excluded. The sample size was calculated using the following formula:



Considering Z as the statistic corresponding to the level of confidence, α: 0.05, precision (d): 6%, and prevalence of malnutrition (P): 55% (14), the calculated sample size (n) was 275. During the study period, all hospitalized patients that met the inclusion criteria (364) were selected to increase the study power. To avoid the influence of confounding factors such as changes in the patient’s body mass index (BMI) due to hospital diets, treatment process and drugs, data collection was carried out during the first 24 hours after hospital admission. Demographic characteristics of the participants were recorded using their medical files. Two trained interviewers filled out the questionnaires. The nutritional status was assessed using the mini nutritional assessment (MNA) questionnaire (15). The MNA is a validated and widely used assessment tool that is effective for evaluating the nutritional status of older adults in various settings. The validity and reliability of the Persian version of this questionnaire have been previously confirmed by the study of Amirkalali et al. (16). The questionnaire consists of 18 items in four categories, including anthropometric data, general assessment, nutritional assessment and self-assessment. Scores of ≥ 24 are considered as normal nutritional status; 17-23 indicates the risk of malnutrition; and scores of < 17 are considered as malnutrition (15). Functional capacity of elderly was assessed using the ADL self-report questionnaire (17). Khoei et al. translated and validated these scales for the Iranian elderly population, previously (18). The ADL questionnaire includes questions about eating, putting on and taking off clothes, tasks related to adornment and grooming (such as combing hair, etc.), walking and mobility, and going to the bathroom and toilet. The instrumental activities of daily living (IADL) was assessed using six questions about using the telephone, shopping, preparing meals, housekeeping and laundry, taking medications as prescribed (i.e. self-medicating), and managing money. These activities are rated on a three-point scale, ranging from independent (without help 1) to relatively dependent (with a little help 2); to completely dependent (not able to do 3). Higher scores indicate greater dependence (19). Data were recorded as mean ± standard deviation (SD) or as numbers (percentages). Categorical variables were analyzed using the chi square test. Association of MNA scores, ADL and IADL was assessed using the Spearman correlation coefficient. A logistic regression analysis was used to examine the association of nutritional status and ADL and IADL. Scores of ≥ 24 were considered as normal nutritional status and scores of < 24 were considered as abnormal nutritional status for logistic regression analysis. P values of less than 0.05 were considered significant.

4. Results


Of the 364 eligible patients, 322 patients participated in the study. Of these 322 participants, 171 (53.1%) were male, and 216 (67.1%) and 106 (32.9%) were hospitalized in internal wards and surgical wards, respectively. The mean age was 70.36 ± 7.8 years and the mean BMI was 25.88 ± 4.88 kg/m². Based on MNA, 96 patients (29.8%) had normal nutritional status, 138 (42.9%) were at risk of malnutrition and 43 (13.4%) had malnutrition. Characteristics of the study subjects by nutritional status are shown in Table 1. Malnutrition was associated with a BMI of lower than 19, severe loss of appetite, weight loss in three months, and inability of motion (P < 0.001). The functional autonomy status for ADL and IADL among hospitalized elderly by nutritional status is shown in Tables 2 and 3. Overall, 29.2% of the participants had complete or some dependency for at least one component of the ADL while 86.6% needed assistance for at least one component of the IADL. Furthermore, 61.01% of the participants had complete or some dependency on meal prepation. Dependency was significantly associated with malnutrition and risk of malnutrition.


Table 1.
Characteristics of the Study Subjects by Nutritional Statusa,b

Table 2.
Functional Autonomy for Activity of Daily Living (ADL) Among Hospitalized Elderly by Nutritional Statusa,b

Table 3.
Functional Autonomy for Instrumental Activity of Daily Living (IADL) Among Hospitalized Elderly by Nutritional Statusa,b

There was a negative significant correlation between MNA scores and ADL scores (r: -0.405, P < 0.001) and IADL scores (r: -0.492, P < 0.001). In the logistic regression analysis, IADL was associated with malnutrition. The higher the dependency for IADL, the higher the probability of malnutrition (OR: 1.19, 95% CI: 1.07 - 1.33; P < 0.001). However, there was not such association between ADL and malnutrition. Upper BMI (OR: 0.869, 95% CI: 0.809 - 0.934; P < 0.001), the ability to leave home (OR: 0.122, 95% CI: 0.052 - 0.291; P < 0.001), and independent living (OR: 0.424, 95% CI: 0.207 - 0.869; P = 0.019) were protective factors of malnutrition.

5. Discussion


Aging is associated with dependency in ADL due to reduced functional and physical abilities, so it can affect nutritional status of the elderly. Hospitalized old patients are expectedly at risk of malnutrition and nutritional disorders (20, 21). In the present study, 42.9% of the patients were at risk of malnutrition and 13.4% were malnourished. In a study by Tanjani et al. on a representative sample of elderly in Iran, 41.3% were at risk of malnutrition and 5.5% were malnourished (22). In another study, Amirkalali et al. reported 43.4% risk of malnutrition and 3.2% malnutrition in nursing home elderly (16). In the study of Kaiser et al. on 24 data sets from 12 countries and in four settings (hospital, rehabilitation, nursing home and community), the overall prevalence of malnutrition and at risk of malnutrition was 22.8% and 46.2% in elderly people, respectively. However, the prevalence of malnutrition in hospital settings was 38.7% (20). In a study by Andre et al. on 370 elderly people in Congo, malnutrition was found in 28.4% of the participants, while 57.8% were at risk of malnutrition (5). The present study showed an association between nutritional status and functional capacity among elderly, which is consistent with other studies (5, 21, 23-25). There was an interrelationship between nutritional status and functional capacity. It is known that functional impairment increases the vulnerability and may affect food consumption negatively. Lack of functional autonomy to look after one self, to prepare proper foods, and to eat foods is a factor that can result in malnutrition. However, the association of nutritional condition with physical performance, fatigue, and falling is not completely conceived because of the limitations of most studies or use of self-reported tools to evaluate physical function (26). In the present study, there was a significant relationship between BMI and nutritional status, which is consistent with previous studies (5, 24, 27, 28). Oliveira et al. stated that BMI is the best anthropometric indicator of nutritional status in the elderly while arm circumference alone is not a good indicator (8). In the study of Cereda et al., malnutrition and poor functional capacity were associated with low BMI, poor nutritional habits, severe weight loss, reduced food intake and disability (13). In the present study, 29.2% of the participants needed help for at least one component of the ADL, which was consistent with the results of the study of Danielewicz et al. (25). In another study by Mattos et al. from the Netherlands, only 15% of older adults needed help for their activities of daily living (29). In the present study, 61.01% of the participants had some kind of dependency in meal predation. Such results clearly denote the need of elderly for support from family members or health-care providers. However, the reality is that there are almost no formal services to take care of the elderly in their daily activities in rural areas and family members are their only source of support. Functional dependence may affect personal values, interpersonal communication, and emotions of older adults as well as their nutritional condition. Lack of adequate nutrition is one of the causes of malnutrition whereas physical and functional limitations lead to a lack of adequate food intake (8). Decreased functional capability causes dependence in ADL and can strongly influence nutritional status of the elderly (4). In the present study, there was a significant association between malnutrition and risk of malnutrition with reduced functional capacity and dependency of the elderly. In contrast, other studies have shown that nutritional condition and MNA can be considered as an indicator or predictive factor for functional capacity of older adults (9, 11, 13). In a study on old Taiwanese individuals, by brief nutritional assessment, lower nutritional status predicted a higher risk of dependency on others for ADL and IADL. Hence, the assessment of nutritional status may be a predictive factor for reduced functional capacity in the elderly (10). In the present study, the dependency of older adults in IADL was associated with 1.19 times decrease in the likelihood of malnutrition. It might be rational to consider IADL and BMI as the predictors of nutritional status of hospitalized elderly patients. Many studies have indicated that BMI, IADL and reduced food intake are powerful predictors for the nutritional status of the elderly (4, 9, 13). In the study of Cereda et al., the poorer functional status was found to be associated with low BMI, sarcopenia and reduced oral intake, and the MNA identified at risk elderly needing more care, specialy for eating (13). It has also been confirmed that the prevalence of malnutrition is associated with the level of dependence in older populations and all the ADL and IADL variables are significantly more prevalent among the malnourished elderly (8). On the other hand, it has been shown that functional incapacity is positively associated with health conditions and sociodemographic factors among the elderly (30, 31). The present study had some limitations including its cross sectional design. More comprehensive studies with larger sample sizes are needed in different hospital wards and in different variable settings to establish the association of nutritional status and functional capacity in the elderly.


5.1. Conclusion

Risk of malnutrition as well as reduced functional ability is high among the hospitalized elderly of Qazvin. Currently, there is no specific nutritional status screening for the elderly population during hospital admissions. Nutritional status assessment of the older adults is necessary particularly when they are admitted to hospitals. Considering the high prevalence of malnutrition among the hospitalized elderly in the present study, early detection of malnutrition among elderly is important to improve their nutritional status by appropriate and on time interventions. Hospital admission prepares a good opportunity to interact with older adults and teach them about proper nutrition and functional capacity to improve their quality of life. Establishing comprehensive and social programs for the elderly is also a necessity for the upcoming years.

Acknowledgments

The authors would like to thank the participants involved in the study and the research department of the Qazvin University of Medical Science for endorsing the project. The authors would also like to thank Mrs. Zahra Mohammadi and Mrs. Mahsa Khoshpanjeh for their help in preparing this paper.

Footnotes

Authors’ Contribution: Study concept and design: Azam Ghorbani, Leila Dehghankar; analysis and interpretation of data: Sonia Oveisi; drafting of the manuscript: Akram Shahrokhi; critical revision of the manuscript for important intellectual content: Akram Ghorbani, Neda Esmailzadehha and Akram Shahrokhi; acquisition of data: Sonia Oveisi; statistical analysis: Sonia Oveisi and Neda Esmailzadehha; administrative, technical and material support: Leila Dehghankar; study supervision: Azam Ghorbani.
Funding/Support: This study was supported by a grant from the research department of Qazvin University of Medical Sciences.

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Table 1.

Characteristics of the Study Subjects by Nutritional Statusa,b

Variables Malnutrition At Risk of Malnutrition Normal Nutritional Status χ2
BMI, kg/m2 46.08
< 19 10 (62.5) 4 (25) 2 (12.5)
19 - 20.99 4 (15.4) 22 (84.6) 0
21 - 22.99 4 (10.8) 18 (48.6) 15 (40.5)
23 ≤ 25 (12.6) 94 (47.5) 79 (39.9)
The appetite in the last three months 86.49
Intensive decline in appetite 12 (57.1) 9 (42.9) 0
Medium decline in appetite 27 (22.3) 75 (62) 19 (15.7)
Without decline in appetite 4 (3) 54 (40) 77 (57)
Weight loss in three months 100.1
> 3 kg 9 (25.7) 25 (71.4) 1 (2.9)
1 - 3 kg 5 (8.5) 37 (62.7) 17 (28.8)
Without weight loss 3 (2.9) 32 (30.5) 70 (66.7)
No information 26 (33.3) 44 (56.4) 8 (10.3)
Ability of motion 89.03
Enclosed in a bed or chair 13 (68.4) 6 (31.6) 0
Able of get out of bed/chair but can not leave the house 22 (35.5) 32 (51.6) 8 (12.9)
Able to leave the home 8 (4.1) 100 (51) 88 (44.9)
a Values are expressed as No. (%).
b P Value < 0.001.

Table 2.

Functional Autonomy for Activity of Daily Living (ADL) Among Hospitalized Elderly by Nutritional Statusa,b

Variables Total Malnutrition (n = 43) At Risk of Malnutrition (n = 138) Normal Nutritional Status (n = 96) χ2
Eating 63.61
Independence 224 21 (9.4) 113 (50.4) 90 (40.2)
Some dependence 20 5 (25) 13(65) 2 (10)
Complete dependence 23 16 (69.6) 5 (21.7) 2 (8.7)
Dressing 79.50
Independence 238 21 (8.8) 122 (51.3) 95 (39.9)
Some dependence 22 8 (36.4) 13 (59.1) 1 (4.5)
Complete dependence 17 14 (82.4) 3 (17.6) 0
Grooming 92.43
Independence 233 20 (8.6) 119 (51.1) 94 (40.3)
Some dependence 26 7 (26.9) 17 (65.4) 2 (7.7)
Complete dependence 18 16 (88.9) 2(11.1) 0
Walking 78.81
Independence 224 17 (7.6) 115 (51.3) 92 (41.1)
Some dependence 31 10 (32.3) 18 (58.1) 3 (9.7)
Complete dependence 22 16 (72.7) 5 (22.7) 1 (4.5)
Transferring 93.94
Independence 220 15 (6.8) 113 (51.4) 92 (41.8)
Some dependence 34 10 (29.4) 20 (58.8) 4 (11.8)
Complete dependence 23 18 (87.3) 5 (21.7) 0
Bathing 64.43
Independence 230 20 (8.7) 118 (51.3) 92 (40)
Some dependence 23 7 (30.4) 13 (56.5) 3 (13)
Complete dependence 24 16 (66.7) 7 (29.2) 1 (4.2)
Toileting 65.41
Independence 238 22 (9.2) 123 (51.7) 93 (39.1)
Some dependence 19 7 (36.8) 10 (52.6) 2 (10.5)
Complete dependence 19 14 (73.7) 4 (21.1) 1 (5.3)
a Values are expressed as No. (%).
b P Value < 0.001.

Table 3.

Functional Autonomy for Instrumental Activity of Daily Living (IADL) Among Hospitalized Elderly by Nutritional Statusa,b

Variables Total Malnutrition (n = 43) At risk of malnutrition (n = 138) Normal nutritional status (n = 96) χ2
Phone use 27.23
Independence 141 8 (5.7) 74 (52.5) 59 (41.8)
Some dependence 43 7 (16.3) 24 (55.8) 12 (27.9)
Complete dependence 93 28 (30.1) 40 (43) 25 (26.9)
Shopping 68.75
Independence 140 4 (2.9) 64 (45.7) 72 (51.4)
Some dependence 57 8 (14) 35 (61.4) 14 (24.6)
Complete dependence 80 31 (38.8) 39 (48.8) 10 (12.5)
Meal preparation 33.21
Independence 108 4 (3.7) 54 (50) 50 (46.3)
Some dependence 76 10 (13.2) 42 (55.3) 24 (31.6)
Complete dependence 93 29 (31.2) 42 (45.2) 22 (23.7)
Cleaning 33.94
Independence 97 3 (3.1) 47 (48.5) 47 (48.5)
Some dependence 80 10 (12.5) 43 (53.8) 27 (33.8)
Complete dependence 100 30 (30) 48 (48) 22 (22)
Self-medicating 39.5
Independence 174 14 (8) 83 (47.7) 77 (44.3)
Some dependence 51 9 (17.6) 33 (64.7) 9 (17.6)
Complete dependence 52 20 (38.5) 22 (42.3) 10 (19.2)
Handling money 45.23
Independence 129 6 (4.7) 57 (44.2) 66 (51.2)
Some dependence 23 2 (8.7) 13 (56.5) 8 (34.8)
Complete dependence 125 35 (28) 68 (54.4) 22 (17.6)
a Values are expressed as No. (%).
b P Value < 0.001.