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
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
References (42)
- et al.
Treatment of protein-energy malnutrition in chronic nonmalignant disorders
The American Journal of Clinical Nutrition
(2001) - et al.
At which body mass index and degree of weight loss should hospitalized elderly patients be considered at nutritional risk?
Clinical Nutrition
(1998) - et al.
Nurses knowledge and attitudes regarding nutrition in the elderly
The Journal of Nutrition, Health & Aging
(2009) - et al.
Feeling hindered by health problems and functional capacity at 60 years and above
Archives of Gerontology and Geriatrics
(2007) - et al.
Mini-mental state. A practical method for grading the cognitive state of patients for the clinician
Journal of Psychiatric Research
(1975) - et al.
Factors associated with nutritional status in a group of people in an early stage of dementia
Clinical Nutrition
(2003) - et al.
Who will become malnourished? A prospective study of factors associated with malnutrition in older persons living at home
The Journal of Nutrition, Health & Aging
(2009) - et al.
Nutritional risk and cognitive impairment in the elderly
Archives of Gerontology and Geriatrics
(2009) - et al.
Difference in nutritional risk between mild cognitive impairment group and normal cognitive function elderly group
Archives of Gerontology and Geriatrics
(2009) - et al.
Nutrition risk factors for institutionalization in a free-living functionally dependent elderly population
Journal of Clinical Epidemiology
(2000)