Elderly people are at increased risk of malnutrition due to a variety of factors including sensory losses, loss of appetite, chewing and swallowing problems, mobility restrictions, cognitive impairment and depressive mood, acute and chronic diseases, and accompanying multimedication [
Generally, malnutrition is caused by an ongoing insufficient intake of energy and nutrients. In order to prevent malnutrition in persons who are persistently unable to eat adequate amounts of food, enteral nutrition by means of tube-feeding can be applied. Nutrition via a percutaneous endoscopic gastrostomy (PEG) is an established method for long-term enteral nutrition and is often used in nursing home residents not able to eat adequate amounts of food, although not without controversy [
Tube-feeding often goes along with gastrointestinal (GI) complaints like nausea and vomiting, constipation or diarrhoea [
Thus, the
In this cross-sectional study, all residents from 3 municipal nursing homes (NHs) in Bonn, Germany, were considered for inclusion if they were at least 65 years old, in long-term care, and not in a terminal state (judged subjectively by the responsible nurse). Subjects’ characteristics, nutritional status, health complaints, and dietary intake were assessed once in each participant between November 2004 and April 2006. The study was approved by the local ethics committee, and all participating subjects gave a signed consent.
Subjects’ characteristics were assessed in standardised personal interviews with the responsible qualified nurse, and included date of birth, gender, length of stay in the nursing home, route of feeding (oral or tube fed), and the following physical and mental aspects. The ability to perform basic
The
Both measurements were performed with a plastic tape measure and an accuracy of 0.1 cm and were utilised for the anthropometric questions in the MNA. Values below 21 cm (MAC) and below 31 cm (CC) were considered as reduced, respectively.
The presence of nausea/vomiting, constipation, diarrhoea, pressure sores, wound healing problems, and dehydration was assessed in a standardised manner by interviewing the responsible nurse. The frequency of infections, antibiotic treatment, and hospitalisation in the previous three months was collected from the medical folders in cooperation with the responsible nurse.
In a subgroup of 122 orally fed residents, dietary intake was monitored for three consecutive days by precisely weighing all offered food before and all leftovers after each meal, using a digital weighing machine. Due to the high work load related to this method, dietary assessment was restricted to the residents of two nursing units of each of the 3 nursing homes. Foods were coded and analyzed for nutrient composition using the German nutrient database (BLS II.3) [
All measurements and assessments were performed by the same trained person (LP).
Data analysis was performed using SPSS version 17.0 (SPSS Software, Munich, Germany). Categorical variables are reported as absolute numbers and percentages. Continuous variables are presented as mean ± standard deviation (SD), median, and 25th and 75th percentiles (P25–P75). Subjects’ characteristics and prevalence rates of malnutrition and of health complaints are reported in orally and tube-fed residents; the prevalence of health complaints and dietary intake is reported according to the MNA groups. Chi-square testing was used to detect differences between categorical variables. The normal distribution of continuous variables was tested by Kolmogorov-Smirnov test. Differences in continuous variables between subgroups are analysed by
Out of 382 persons residing in the institutions, 15 had to be excluded. Nine were younger than 65 years, four in a terminal state, and three in short-term care; one person was permanently hospitalized, one removed, and one deceased before data collection. 13 residents refused to participate. 350 residents agreed to take part, 283 women and 67 men with a mean age of 84.8 ± 8.0 years. The median length of stay in the institution was 2.7 years (1.3–4.9 years).
27 residents (7.7%) had a PEG
All together, a considerable proportion of the residents were disabled. About one-third was in need of care (37.4%), immobile (34.9%), and/or showed signs of depression (38.0%), respectively. In nearly two-thirds (61.4%), signs of dementia were reported. Most of the participants (55.0%) suffered from 5 or more chronic diseases and nearly three-fourths (70.9%) took 5 or more prescribed medications. Nevertheless, health status of 83.1% of the study population was judged as fair or moderate. The most prevalent medical diagnoses were hypertension (43.3%), dementia (39.8%, as routinely documented by a practitioner), and cardiac insufficiency (32.1%). Diabetes mellitus was prevalent in 24.4%, osteoporosis in 15.8%, and kidney disease in 9.2%. 13.2% suffered from a previous stroke, 7.4% from a tumor and 6.3% from respiratory disease.
The subjects’ characteristics are shown in Table
Characteristics of orally and tube-fed nursing home residents.
Oral nutrition ( | Tube-feeding ( | |
---|---|---|
Female sex | 81.4 | 74.1 |
Age, years (mean ± SD (median)) | 85.0 ± 8.1 (86.0) | 81.9 ± 6.2 (82.0) |
Age ≥ 85 years (%) | 55.1 | 40.7 |
ADL, p. (median (P25–P75)) | 55 (20–85) | 0 (0–5) *** |
ADL | ||
Independent (70–100 p.) (%) | 41.8 | 0.0 *** |
In need of help (35–65 p.) (%) | 26.0 | 0.0 |
In need of care (<35 p.) (%) | 32.2 | 100.0 |
Mobility | ||
Mobile (%) | 59.4 | 0.0 *** |
Moderately mobile (%) | 10.8 | 3.7 |
Immobile (%) | 29.7 | 96.3 |
Dementia | ||
No [%] | 40.2 | 15.4 ** |
Mild [%] | 20.1 | 11.5 |
Severe [%] | 39.6 | 73.1 |
Depression | ||
No (%) | 61.4 | 69.2 |
Mild (%) | 22.1 | 7.7 |
Severe (%) | 16.5 | 23.1 |
Health status | ||
Fair (%) | 58.2 | 25.9 *** |
Moderate (%) | 27.2 | 29.6 |
Poor (%) | 14.6 | 44.4 |
No. of chronic diseases | 5 (3–6) | 5 (4–7) |
≥5 chronic diseases (%) | 53.7 | 70.4 |
No. of medications | 6 (4–8) | 5 (4–8) |
≥5 medications (%) | 70.9 | 70.4 |
***
ADL = Activities of daily living, SD = standard deviation, P = percentile.
According to the MNA, more than one-forth (26.7%) of the total group suffered from malnutrition (MNA < 17 p.) and one-half (52.9%) was at risk (MNA 17–23.5 p.). Malnutrition was significantly more prevalent in tube-fed compared to orally nourished residents (
Nutritional status of orally and tube-fed nursing home residents.
Oral nutrition ( | Tube-feeding ( | ||
mean ± SD ( | mean ± SD ( | ||
median (P25–P75) | median (P25–P75) | ||
MNA (p.) | 19.9 ± 4.6 (307) | 16.0 ± 2.7 (26) | |
20.5 (17.0–23.0) | 16.0 (14.0–18.0) *** | ||
MNA | |||
<17 p. (%) | 24.1 | 57.7 *** | |
17–23.5 p. (%) | 53.7 | 42.3 | |
>23.5 p. (%) | 22.1 | 0.0 | |
BMI (kg/m²) | 25.6 ± 5.2 (308) | 24.9 ± 4.9 (26) | |
25.3 (22.0–28.4) | 25.0 (22.0–28.4) | ||
BMI <20 kg/m² (%) | 13.6 | 11.5 | |
BMI <22 kg/m² (%) | 25.3 | 23.1 | |
MAC (cm) | 25.3 ± 3.9 (315) | 24.8 ± 4.2 (27) | |
24.8 (22.9–27.6) | 24.9 (22.4–27.8) | ||
MAC <21 cm (%) | 12.7 | 14.8 | |
CC (cm) | 31.2 ± 4.8 (315) | 27.4 ± 4.5 (26) *** | |
30.9 (28.0–34.2) | 27.8 (25.3–29.8) | ||
CC <31 cm (%) | 50.2 | 76.9 ** |
***
MNA = Mini Nutritional Assessment, p. = points, BMI = body mass index, MAC = midarm circumference, CC = calf circumference, SD = standard deviation.
Constipation was reported in 43.0% of all residents, nausea/vomiting in 13.4%, and dehydration and wound healing problems in 10.6%, respectively. Diarrhoea (6.3%) and pressure sores (3.7%) were less frequent. Constipation and nausea/vomiting were significantly more frequent in tube-fed residents (Table
Health complaints of orally and tube-fed nursing home residents.
Oral nutrition | Tube-feeding | ||||
( | ( | ||||
% | % | ||||
Constipation | 133 | 41.3 | 17 | 63.0 * | |
Nausea/vomiting | 38 | 11.8 | 9 | 33.3 ** | |
Diarrhoea | 21 | 6.5 | 1 | 3.7 | |
Pressure sore | 8 | 2.5 | 5 | 18.5 | |
Wound healing problems | 34 | 10.5 | 3 | 11.1 | |
Dehydration | 36 | 11.1 | 1 | 3.7 | |
Infection | 70 | 21.7 | 8 | 29.6 | |
Antibiotic use | 51 | 15.8 | 6 | 22.2 | |
Hospitalization | 45 | 13.9 | 7 | 25.9 |
**
Prevalence of health complaints in well-nourished residents (MNA > 23.5 p.;
The weighing records revealed a mean daily energy intake of 1535 ± 413 kcal (6.42 ± 1.72 MJ) and a protein intake of 54.2 ± 0.9 g/d. Expressed per kg BW the residents consumed 25.5 ± 7.3 kcal and 0.89 ± 0.27 g protein. Dietary intake according to MNA is presented in Table
Dietary intake in nursing home residents with malnutrition, at risk of malnutrition and without malnutrition.
Well-nourished | At risk MNA | Malnourished | |
---|---|---|---|
Energy (kcal/d) | 1516.5 ± 431.2 | 1566.7 ± 420.2 | 1502.8 ± 398.0 |
Energy (kcal/kg BW) | 21.9 ± 5.3 | 24.3 ± 7.0 | 29.3 ± 7.4 ***,§§ |
Protein (g/d) | 56.4 ± 20.3 | 56.0 ± 19.0 | 50.4 ± 14.8 |
Protein (g/kg BW) | 0.81 ± 0.23 | 0.86 ± 0.27 | 0.98 ± 0.28 * |
***
§§
MNA = Mini Nutritional Assessment, p. = points, BW = body weight.
In this cross-sectional study, nutritional status was studied for the first time in a large sample of nursing home residents in Germany. A considerable proportion of the residents were found to be malnourished or at risk of malnutrition.
Prior to that, only two smaller studies addressed the nutritional situation of institutionalized elderly in Germany. One was restricted to 50 apparently healthy women living in two old peoples’ homes and reported a generally good nutritional status [
One strength of the present study is its high participation rate, meaning that the results are representative for the participating institutions. This could be achieved mainly because participation was strongly recommended and supported by the nursing home management. In addition, all information except four anthropometric measurements was collected in cooperation with the nursing staff, implying only minimal burden for the participants. Detailed data were assessed in personal interviews with the responsible nurses. These interviews were scheduled on office days destined for documentation. Thus, enough time was available despite usually high work loads for nursing staff. All nurses were familiar with their dedicated residents and well informed about their personal characteristics and health situation, so that reliable information could be obtained. For the MNA, it has recently been reported that application by the nursing staff is even superior to direct interviews with the residents, because more complete and detailed, and, especially in demented subjects, more reliable information can be obtained [
As characteristic for the nursing home population, considerable proportions of the residents were physically and mentally impaired with multiple chronic diseases, multimedication, and a reduced level of self-sufficiency (Table
Regarding dementia, different prevalence rates are noticeable according to the nurses’ perception (61.4%) and the diagnosis found in the medical records, routinely documented by a practitioner (39.8%). Presumably, the prevalence was underestimated by physicians, who often miss to diagnose mental impairments [
As currently recommended [
Regarding BMI, about one quarter of the residents showed values below 22 kg/m², and a BMI below 20 kg/m² was observed in 13.5%—somewhat less frequent than reported in other nursing home populations [
CC was reduced in more than half of the residents (52.2%). This clearly indicates reduced leg muscle mass and protein stores, caused by disuse of the leg muscles, and reflects the low mobility level in our population. In community-living elderly, a CC below 31 cm was identified as best clinical marker of sarcopenia and associated with disability and reduced leg function [
In tube-fed residents, complete ADL dependence and the high prevalence of immobility and dementia are striking (Table
Regarding tube-feeding of NH residents, there is an ongoing discussion about its benefits and risks. Especially in case of severe dementia the benefit of enteral nutrition is questioned [
Despite scoring the highest for the five questions regarding appetite and diet quality, a low total MNA score and, thus, a high prevalence of malnutrition were observed in tube-fed residents. This is in line with a number of earlier studies, which have reported a reduced nutritional status in elderly patients at the time of tube placement. These studies, however, referred to low BMI and albumin values [
Gastrointestinal disorders, common in the elderly, may result in complications and can cause major morbidity [
In our study,
All other health complaints were much less common.
The prevalence of
Infections, antibiotic use, and hospitalizations were relatively common in our study population (15–20%; Table
Interestingly, BMI (neither <20 nor <22 kg/m²) was not related to health complaints (with the exception of dehydration that was significantly more frequent in subjects with reduced BMI; data not presented), suggesting that the MNA reflects general health condition better than the BMI, again strengthening its usefulness in multimorbid geriatric persons.
Mean dietary intake, assessed by precise weighing of all food for three consecutive days in a subgroup of 122 residents, was 1535 kcal and 54 g protein per day. In several studies in recent years, very similar figures were reported for NH residents [
Unfortunately, nutrient intake of tube-fed residents was not assessed in detail in our study. Those residents who were fed completely by tube received either 1 or 1.5 L of a standard tube-feed, and thus, had at least a basic supply of energy and all essential nutrients. Again, adequacy is difficult to estimate because requirements are not exactly known.
In contrast to our expectations and in contrast to Vellas et al. [
In conclusion, malnutrition is widespread among nursing home residents also in Germany and related to common health complaints but not to currently reduced dietary intake. According to the MNA, enterally nourished residents are markedly more often affected by malnutrition than orally nourished residents. On the other hand, our data show that a normal body mass can be maintained or achieved by tube-feeding, indicated by BMI and MAC, that is not reflected by the results of the MNA. Our data suggest that the MNA rather reflects general condition and nutritional risk than current body stores or dietary intake of energy and protein.