Malnutrition associated with illness or aging is a widely spread problem in hospitals and nursing homes. Malnutrition is defined as an imbalance between nutrition intake and requirement, that leads to change in the metabolism, restriction in mobility (e.g. muscle strength) and loss of body mass 1. In 1988, Windsor et al. already indicated that an unintentional loss of weight loss is a sure indication for a bad prognosis 2. In Austria, as in other industrial nations, lots of patients have normal weight or are even overweight; a reason why not enough attention is paid to unintentional loss of weight loss or appetite and inadequate nutrition intake. Malnutrition is associated with a higher morbidity rate, limited quality of life and an increased mortality rate 3, 4, thus causing immense costs for the health care system. In England, for the first time the economical consequences have been estimated. The costs of malnutrition and its consequences were calculated at more than 7 billion pounds per year in 2006, 10.5 billion US dollars. This problem was also taken on by the European Council and resulted in the publication of the resolution on “Food and Nutritional Care in Hospitals” (English Edition): http://www.ake-nutrition.at/uploads/media/Resolution_ of_the_Council_of_Europe_english.pdf
Age and Health
Life expectancy has distinctly increased in previous decades in industrial states nations and also in some of the so-called third world countries, with a current average of 79 years in the European Union. On average, women live six years longer 5. Due to this longer life expectancy, age-related changes and problems become more significant. Illnesses such as diabetes mellitus type II, cardiovascular diseases and dementia increase with age. The aging process is associated with loss of function and reduced performance. Age-related physiological changes in the regulation of nutrition intake and in the gastro-intestinal tract lead to deterioration of the nutritional status. Deterioration of the health status and of nutritional intake is further associated with chronic malnutrition, impaired quality of life, increased morbidity, mortality and long-term care 6.
Malnutrition in elderly people requiring care
The Survey in Europe on Nutrition and the Elderly, a Concerted Action (SENECA) study, a longitudinal study investigation of nutritional status and health behaviour of 70-75 year olds and people living at home or in nursing homes in nine towns across Europe, found a high malnutrition risk despite low prevalence 7. In healthy, elderly people living independently, one assumes a prevalence of malnutrition of up to 10%. In hospitals, 40-60% of elderly patients are affected by malnutrition, in nursing homes, the situation is dramatic, up to 85% 8, 9,10,11 of the residents may be affected by malnutrition. For German-speaking countries the United States, there is little specific prevalence data. Tannen et al. reported a prevalence of malnutrition – defined by the body mass index (BMI) <20 kg/m2 of 15.1% in German nursing homes 12. Bucher et al. found in 2004 a BMI of <18.5 kg/m2 in 19.5% of residents with tube-feeding living in nursing homes in Germany 13. In Austria, Kulnik and Elmadfa, using the Nestlé Nutrition Institute’s Full-Mini Nutritional Assessment (MNA, a validated method for the evaluation of malnutrition) found a prevalence of malnutrition of nursing home residents of 37.8% 14. In a Medicare-approved nursing home, Shaver et al. assessed nutritional status using a variety of parameters and found malnutrition prevalence of 85% among residents 15. After measuring visceral and somatic protein stores, Pinchcofsky-Devin and Kaminski reported 52% of residents in two metropolitan nursing homes to have a poor nutritional status 16. Silver et al. found 46% of residents over the age of 65 were < 90% average body weight (ABW) and 23% were ≤ 80% ABW in an academic nursing home in California 17. Malnutrition or unintentional weight loss and loss of independence when eating is associated with an up to 4.6-fold increased risk of mortality in nursing home residents 15,16,17,18,19,20. It not only affects physical and psychosocial functions, and thus leads to a reduction in quality of life, but also burdens the expenditure of the health system increases the costs of health care 13, 18,19,20,21,22,23,24,25.
There are many causes for the high prevalence of malnutrition of the sick and people not living independently. The physiological changes of feeling hungry and thirsty with age are often intensified by swallowing disorders, dysphagia, and dementia, and thus contribute to deterioration in health. A lack of knowledge or awareness in those affected, their families and the health care team often prevent a risk of malnutrition in residents/patients being detected early enough and nutritional therapy being initiated. In addition to information and training, structural physical factors such as quality of the offered food, eating environment, the amount of time capacity of the nursing staff has to for assistance with eating, feeding, also have an influence on food intake and the nutritional status. Therefore, particularly in nursing homes, the amount of food consumed can be rather a challenge due to the care situation, the old age of the residents and the often limited staff resources.
So far, only a small selection of nursing home residents have been examined in the United States and Europe (except in the Netherlands) 26. The question of the nutritional status situation and food consumption, or a risk of malnutrition in United States, Austrian, and European nursing homes, especially in the context of the outcome (morbidity, mortality), is therefore inevitable.
In order to address this problem with more attention among those affected and their relatives, as well as the practitioners/health workers, the Austrian Association for Clinical Nutrition, together with the European umbrella organization (ESPEN, European Society for Clinical Nutrition and Metabolism) launched the “nutritionDay in Europe” (Currently known as nutritionDay Worldwide) in 2006. nutritionDay in the U.S. was launched in 2009 with the support of the American Society of Parenteral and Enteral Nutrition and in 2010 the support of the American Dietetic Association.
The project is based on the assumption that in order to effectively implement changes at the level of structures dealing with direct care of residents, it is necessary to know the relevant facts and to use them to obtain support of the facility, as well as resident organization advocacy groups in order to effectively implement changes at the level of operations which deal directly with resident care. Overall, 47,382 hospital patients have been under examination through nutritionDay Worldwide since the year 2006. In regard to geriatric institutions, it was requested to adjust that the questionnaires be modified to meet the specific needs and situations of the nursing homes.
2. Rationale of the Study
In order to ensure optimal nutritional care of nursing home residents and therefore have a lasting positive affect on their quality of life, morbidity and mortality, it is necessary:
- to collect data on the quality of nutritional care in nursing homes by means of a simple method that requires no specialization in data acquisition.
- to acquire knowledge on the prevalence of risk factors of malnutrition in nursing home residents in general and on individual nursing units, also in conjunction with the outcome after six months, and to forward the same to the individual nursing units.
- to allow comparison with other facilities (with similar profile) with the help of a benchmarking system.
- to assess the effectiveness of introduced changes in terms of quality management and quality improvement.