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University of Arizona College of Nursing, Tucson.
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Abstract |
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Methods. The study was guided by the Quality Nutrition Outcomes–Long Term Care Model, which posits a pathway whereby organizational issues influence nutritional status, consisting of body mass index (BMI), serum albumin levels, and prealbumin levels, and subsequent quality of life, morbidity, and health care utilization. A cross-sectional design was used to analyze Minimum Data Set assessment data already collected from a previous study. The sample for this analysis was 311 nursing home residents, aged 65 years or older, who lived in three nursing homes in eastern Washington.
Results. Of the participants, 38.6% were malnourished. PCM (measured by BMI) influenced quality of life for these residents in that there was a significant relationship between BMI and functional status (eating, personal hygiene, and toilet use) and BMI and psychosocial well-being (initiative or involvement, unsettled relationships, and past roles). Depression was not a significant indicator of low BMI in these nursing home residents.
Conclusions. Low BMI, indicating PCM, was found to negatively influence quality of life in this study. Understanding the relationship between quality of life and PCM could lead to improved quality of life for older adults in nursing homes and guide future innovative intervention studies aimed at preventing PCM.
UP to 85% of the older adults living in our nation's nursing homes suffer from protein-calorie malnutrition (PCM) (1). If current national population projections are correct, the number of nursing home residents with malnutrition will dramatically increase, leading to increased hospital stays, increased costs to health care facilities, and considerable mortality (2). Early identification and treatment can reduce or prevent hospital stays, reduce complications, and decrease mortality (3). The purpose of this article is to describe the influence of PCM on quality of life in nursing homes, using archived data from the Minimum Data Set (MDS). The MDS, a part of the Resident Assessment Instrument, consists of 120 items organized into 23 sections. The MDS includes a core set of demographic, clinical, and functional status items that forms the foundation of the comprehensive assessment for all residents in long-term care facilities. Nursing home staff must complete the MDS when assessing nursing home residents on admission, quarterly, and after a significant change of condition (4). These archived data were collected during a previous study, but not analyzed.
Organizing Framework
The study was guided by the Quality Nutrition Outcomes–Long Term Care Model (QNO–LTC) (Figure 1). The QNO–LTC Model (not yet published) was adapted from the Quality of Health Outcomes Model developed by the American Academy of Nursing Expert Panel on Quality of Health Care (5). The Academy model includes multiple contextual factors that influence health care delivery. The QNO–LTC Model also is based in part on Perrow's theory of complex organizations (6). The QNO–LTC Model posits a pathway whereby organizational issues influence nutritional status (Body Mass Index, serum albumin levels, and prealbumin levels), and subsequent quality of life, morbidity, and health care utilization.
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Inadequate staffing was found to influence food intake in a study by Kayser-Jones (9). As a part of a larger anthropological study, 100 residents were followed for a period of 6 months or until their eating problem resolved. Inadequate staffing was the most significant barrier to food intake for these residents. In a similar but different study, 74 residents from three nursing homes received a 2-day, or six-meal, trial on one-on-one feeding assistance (10). One half (50%) significantly increased their oral food and fluid intake during mealtime. The intervention required significantly more staff time to implement (average 38 minutes per resident per meal vs 9 minutes rendered by regular nursing home staff). These data suggest that increased staffing levels are needed during mealtimes.
Food and food service quality also can influence food intake. In a 1994 study of 132 hospitalized patients, seven dimensions were identified that represented patients' perceptions of food service. Food quality was the best predictor of patient satisfaction with meals and food service, followed by customization and attitude of the staff who deliver menus (11). In a study aimed at enhancing food flavor and thereby improving food intake, Mathey and coworkers (12) performed a 16-week parallel group intervention consisting of sprinkling flavor enhancers over the cooked meals of the intervention group (n = 36) and not over the meals of the control group (n = 31). On average, the body weight of the intervention group increased (+1.1 ± 1.3 kg; p <.05) compared with that of the control group (-0.3 ± 1.6 kg; p <.05). Enhancing food flavor was an effective way to improve dietary intake and body weight in these nursing home residents.
Resident Characteristics
Resident characteristics are defined as those variables that describe the resident population. These variables include age, gender, and any one of the 120 items found on the MDS. Resident characteristics (Figure 1) from the MDS that have been shown to be predictors of PCM (13–15) are posited to negatively influence nutritional status, and therefore they are predicted to influence long-term outcomes (quality of life, morbidity, and health care utilization).
Nutrition Status
For this study, poor nutrition status was defined as PCM. PCM is defined as "undernutrition resulting from inadequate intake, digestion, or absorption of protein or calories" (16). PCM is caused by chronic deficient food intake and is characterized by catabolism of fat and muscle tissue; lethargy; generalized weakness; and weight loss (17).
PCM has been classified according to body mass index (BMI). BMI is defined as weight in kilograms divided by height in meters squared (18). According to the Nutrition Screening Initiative guidelines, a BMI of <22 indicates illness or malnutrition (18). Weight loss, an indicator of PCM, has been shown to increase the mortality of nursing home residents (19–21). For example, Ryan and colleagues (22) found that residents (n = 24) who lost at least 5% of their body weight in 1 month were 4.6 times more likely to die within 1 year. Body weight is therefore a useful tool to identify residents at increased risk of dying.
Long-Term Outcomes
The long-term outcomes found on the QNO–LTC include quality of life, morbidity, and health care utilization. For this article, only quality of life is discussed.
No consensus exists on a universal definition of quality of life. The suggested components of quality of life are life satisfaction, self-esteem, general health and functional status, and socioeconomic conditions (23). In a study to define and measure quality of life for nursing home residents (24), 11 outcome domains were identified that constitute psychosocial quality of life. They were as follows: autonomy or choice; dignity; privacy; individuality; enjoyment; meaningful activity; relationships; sense of sincerity, safety, or order; comfort; spiritual well-being; and functional competence.
Quality of life also was studied by a group of Finnish researchers who developed a theoretical model that described quality of life for older people (25). The model included health, functional capacity, and coping mechanisms as intra-individual conditions for quality of life. After analyses, they defined quality of life as a sense of well-being, meaning, and value. Quality of life for this study was defined as functional status, depression, and psychosocial well-being, all found within the QNO–LTC model.
Functional status.-- This is defined as the ability to perform activities of daily living (ADLs). These include bed mobility, transfer skills, ability to walk, self-feeding skills, ability to dress self, use of the toilet, completion of own personal hygiene, and bathing (26). Inadequate food intake can affect the functional status of elderly residents in nursing homes (27,28). Residents that do not consume adequate calories or protein may not have the energy or strength to access food and water independently, ask for additional food or water, or feed themselves. For example, in a sample of 98 nursing home residents, signs of malnutrition seemed to predict worsening functional status (27). For elderly residents in nursing homes, improving food intake is one of the easiest and most advantageous ways of improving functional status (29).
Depression.-- This is defined as feeling sad, worthless, or hopeless about the future (30). The overall incidence of depression in the elderly is approximately 10% (30). In the nursing home, inadequate food intake and subsequent nutritional deficiencies can cause depression in older adults (31). Nursing home residents commonly are deficient in calcium, vitamin D, vitamin B6, zinc, folate, and vitamin B12 (31). Vitamin B6 deficiencies are known to cause depression and confusion in older adults (31). Improving food intake may ameliorate nutritional deficiencies in nursing home residents, thereby preventing the development of depression.
Psychosocial well-being.-- This is a measurement of the resident's emotional adjustment to the nursing home, including his or her general attitude, adaptation to surroundings, and changes in relationship patterns (26). Psychosocial well-being is a gauge to measure resident's adaptation to the nursing home. Depression is at the far end of that gauge. Residents who are well adjusted to nursing home life may eat more food, resulting in a higher BMI (32). Conversely, residents exhibiting a poor adjustment to the nursing home may eat less food, resulting in a lower BMI. In this study, the relationship between PCM (BMI < 22) and quality of life is reported.
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Methods |
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Setting and Recruitment
A convenience sample of 311 nursing home residents aged 65 years or older was recruited from three nursing homes in eastern Washington state. Sample characteristics are described in Table 1.
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Results |
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Discussion |
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The QNO–LTC model depicts a pathway by which nutritional status (an intermediate outcome) influences long-term outcomes such as quality of life. In the model, quality of life is measured by functional status, the presence of depression, and psychosocial well being. In this study, impaired functional status was a significant indicator of low BMI. For example, residents with a higher BMI needed less assistance while eating and less assistance with personal hygiene. Residents with better functional status had a higher BMI and were better able to access food and feed themselves. These results are similar to those reported by Buttar and coworkers (28), who used a much larger sample (N = 3955) from 254 nursing homes across 10 states. In this study, residents with worsened functional status after 6 months were more likely to have a low BMI. In light of these results, residents with poor functional status should be monitored closely for weight loss and decreased food intake. For elderly residents in nursing homes, improving food intake is one of the easiest and most advantageous ways of improving functional status (29).
Depression, another important measure of quality of life in nursing home residents, was not a significant indicator of low BMI, although 40% of sampled residents had a diagnosis of depression. Albeit unknown for these residents, this may be due to the appropriate treatment of depression with antidepressant medications among the sampled residents. In a previous study, antidepressant use was associated with normal weight and BMI (12). In the nursing home, the actual incidence of depression is unknown but at times is thought to be related to the gloomy institutionalized environment, and an assortment of losses, including function, independence, social roles, friends and relatives, and past leisure activities (33). In a study of 156 residents from one community nursing home, weight loss of 5 pounds or more occurred in 19% of residents. Depression was the most common cause of weight loss, accounting for 36% of the weight loss (34). Adequate treatment for depression may improve nutritional intake and prevent weight loss and PCM.
Residents who are well adjusted to nursing home life may eat more food, resulting in a higher BMI (32). In this study, residents who felt a sense of initiative or involvement within the nursing home were more likely to have a higher BMI. These same residents were more likely to identify with past roles and life status, perhaps affecting their overall sense of well-being. Of interest, the longer residents had resided within the nursing home, the more likely they were to complain about other residents. These residents possibly were more adjusted to nursing home life and more involved in the daily activities within the facility, and thus had increased opportunities for complaints. In all likelihood, these residents develop coping mechanisms as intra-individual conditions for quality of life.
Quality of life for nursing home residents takes on special significance as a result of the nursing home environment and the residents' health status. Early identification and intervention is the key to improved health and quality of life for nursing home residents. The MDS, used nationally by all nursing homes, provides standardized data that may be useful as a tool to enhance nutritional care and quality of life for residents. Although the MDS is used nationally, no research was identified that used MDS variables as indicators of quality of life. Early identification could lead to focused interventions aimed at enhancing quality of life for residents in nursing homes.
Utilizing MDS variables to trigger further assessment and treatment may be key to preventing weight loss in nursing home residents. The Council for Nutritional Clinical Strategies in Long-Term Care developed a structured approach aimed at improving the management of malnutrition in long-term care by using a best-evidence approach (35). The Clinical Guide to Prevent and Manage Malnutrition in Long-Term Care uses MDS variables as clinical triggers for further assessment and treatment. Nursing homes that use this clinical guide will undoubtedly benefit from the structured approach, even though further research is needed to validate its effectiveness in long-term care settings.
In conclusion, understanding the relationship between nutritional status (PCM) and quality of life as depicted in the QNO–LTC Model could lead to improved quality of life for older adults in nursing homes and guide future innovative intervention studies aimed at preventing PCM.
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Acknowledgments |
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Address correspondence to Neva Crogan, PhD, APRN, BC, Assistant Professor, University of Arizona College of Nursing, 1305 N. Martin Street, PO Box 210203, Tucson, AZ 85721-0203. E-mail: ncrogan{at}nursing.arizona.edu
Received July 12, 2002
Accepted August 8, 2002
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