Malnutrition and cognitive impairment among people 60 years of age and above living in regular housing and in special housing in Sweden: A population-based cohort study

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Abstract

Background

Malnutrition is a common problem among older people and associated with reduced functional and cognitive ability. Furthermore, malnutrition among people living in special housing, i.e. in nursing homes or sheltered accommodation, appears to be more common than among those living in regular housing, i.e. in their own homes. However, it is still unclear if the relationship between malnutrition and impaired cognitive ability is connected to living arrangement, i.e. if the relationship is stronger among those who live alone compared to those who cohabit in regular housing.

Objectives

The purpose with the present study was to describe the relationship between nutritional status and cognitive ability among people 60 years of age and above in Sweden, with a focus on housing and living arrangement.

Design

Population-based cohort study.

Setting and participants

The study focused on people living in regular or in special housing and comprised 1402 randomly selected individuals (60–96 years of age) who lived in one municipality in south-eastern Sweden and participated in SNAC-B (the Swedish study on Aging and Care – Blekinge), 2001–2003.

Methods

Data regarding demography, nutrition and functional and cognitive ability were collected through questionnaires, medical examinations and structured interviews.

Results

The relationship was the strongest between cognitive ability and nutritional status among those living in special housing. Regardless of housing and living arrangement, older people with a moderate or severe cognitive impairment risked (OR 2.59–16.00) being malnourished, irrespective of functional ability.

Conclusion

This study highlights that those with a moderate and severe cognitive impairment suffer a risk of developing malnutrition, irrespective of living and housing arrangement. The findings suggest that nurses in the social service and health care system need to consider changes in weight and nutritional intake as well as the individual needs of older people with cognitive impairment to avoid malnutrition.

Introduction

Malnutrition is a common problem among older people (Lee et al., 2009a) and covariation between advanced age and malnutrition has been proven (Poulsen, 2005). Lee et al. (2009a) argue that malnutrition can be partly attributed to cognitive impairment. However, their study concerned the relationship between malnutrition and cognitive impairment among people living in special housing and did not address people living in their own homes (regular housing). In special housing such as nursing homes, sheltered accommodation, or group accommodation, the person is offered care around the clock (Swedish Association of Local Authorities and Regions, 2009). However, it is not the form of housing arrangement, i.e. regular or special housing, as such that causes malnutrition, but rather that older people with cognitive and functional impairment more often live in special housing and that older people who live in regular housing are vulnerable if having some form of cognitive impairment. In other words, other circumstances related to housing arrangement may be linked to an increased risk of malnutrition.

Normal nutritional status is defined as a state where there is a balance between supply (energy intake) and demand (energy need) of nutrients (Dudek, 2007). According to this writer, an insufficient energy intake may lead to malnutrition and when various health problems in old age are added, many nutritional problems arise (Akner and Cederholm, 2001). Malnutrition is a common phenomenon among older people living in special housing (Saletti et al., 2000). In the study by Saletti et al. (2000), which included 872 individuals of the average age of 84.5 years, 36% appeared to suffer from malnutrition. Those living in special housing are more likely to suffer from malnutrition (21–71%) compared to those living in regular housing (6–21%) (Saletti, 2003). Among older people living in their own homes and assisted by home health care service, a large percentage (62%) risks suffering from malnutrition (Saletti et al., 2004). In a recent study performed by Saletti et al. (2005), these findings were confirmed when it was shown that almost half of all older people living in regular housing and aided by home health care risked malnutrition. Also, people who live alone in regular housing may experience an increased risk of developing malnutrition (McCormack, 1997, Whitehead and Finucane, 1997) as they are especially vulnerable if suffering from, e.g. functional disabilities related to health problems (Brownie, 2006). Other factors that may be related to malnutrition are being a woman and having a functional impairment related to advanced age (Fagerstrom et al., 2007, Hellstrom et al., 2004). However, despite the aforementioned studies, it is still unclear if the frequency of people suffering from malnutrition differs concerning living conditions. In other words, does the frequency of malnourished people who live alone in regular housing differ when compared to those who cohabit.

Cognitive ability can be defined as the ability to orient oneself in time and space and as the ability to remember things, solve problems and express oneself in language (APA, 2000). The concept cognitive impairment spans everything from mild cognitive impairment and the early stages of dementia to severe dementia (APA, 2000) and usually affects people of the age 65 and above (Fratiglioni et al., 1999). Research (Faxen-Irving et al., 2005, Johansson et al., 2009) points to the importance of noting and understanding cognitive impairment and putting it in relation to nutritional status. Despite this situation, only a few studies have examined the relationship between cognitive ability and malnutrition (Lee et al., 2009a). In Lee et al.’s (2009b) study of older people living in special housing, the difference in nutritional status between older people with normal and reduced cognitive ability was examined. This study showed that people with cognitive impairment were more likely to suffer from malnutrition in comparison to those with normal cognitive ability. A study presented by Lou et al. (2007b) also showed that about four fifth of older people with cognitive impairment and living in special housing (n = 55, 64–97 years of age) had a reduced body mass index (BMI ≤24). To sum up, malnutrition among older people living in special housing appears to be more common compared to those living in regular housing. However, it is still unclear if the relationship between malnutrition and impaired cognitive ability is stronger among those who live in special housing compared to those who live alone and those who cohabit in regular housing. The aim of this study was to investigate the covariation between malnutrition and cognitive impairment among people 60 years of age and above in Sweden, with a focus on housing and living arrangements.

Section snippets

Population

The sample consisted of 1402 people aged 60–96, who participated in a longitudinal and multi-center cohort study – the Swedish National study on Aging and Care (SNAC) – during the baseline survey that took place in 2001–2003. SNAC includes four centers (Lagergren et al., 2004). The sample in the present study originates from one of the centers – SNAC-B – located in southeastern Sweden. SNAC-B comprised one municipality (about 60,600 inhabitants) including both urban and rural areas. The sample

Results

The sample in SNAC-B consisted to 58.3% of women and to 41.7% of men and the mean age was 76.7 (SD10.2) years. The women were significantly older, lived alone more often and suffered more frequently from impaired functional ability (p-value < 0.001) (Table 1). However, there was no significant difference between genders in respect to BMI (p-value = 0.397) but there was in respect to nutritional status (p-value < 0.001). With that in mind, it should be noted that the highest internal dropout (12.8%)

Discussion

Irrespective of housing and living arrangement, it was found to be impaired cognitive ability, rather than impaired functional ability, that was associated with malnutrition. The strongest association was found among those who lived in special housing. Furthermore, to identify people risking malnutrition, it was moderate or severe cognitive impairment (MMSE score  19) rather than mild cognitive impairment (MMSE score = 20–24) that was useful to consider when identifying people risking

Conclusions

The present study shows that there is a relationship between cognitive impairment and malnutrition, especially among people living in special housing. Malnutrition tends to become a problem among older people with cognitive impairment. Even if this relationship was less pronounced among those who lived in regular housing, regardless of whether they lived alone or cohabited, an increased risk was also found here. Because of this, it is of the utmost importance that nurses who encounter older

Acknowledgements

Conflict of interest: None declared.

Funding: The Swedish National study on Aging and Care, SNAC (www.snac.org), is financially supported by the Ministry of Health and Social Affairs, Sweden, and the participating county councils, municipalities and university departments. In addition, this work was supported by the School of Health Science, Blekinge Institute of Technology. We are grateful to the participants, participating counties and municipalities.

Ethical approval: The Ethics Committee of

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