Unintended Weight Loss in Older Adults

UWL: Food, Appetite and Environment (2009)

Citation:

Woo J, Chi I, Hui E, Chan F, Sham A. Low staffing level is associated with malnutrition in long-term residential care homes. Eur J Clin Nutr. 2005; 59: 474-479.

PubMed ID: 15688081
 
Study Design:
Cross-Sectional Study
Class:
D - Click here for explanation of classification scheme.
Quality Rating:
Positive POSITIVE: See Quality Criteria Checklist below.
Research Purpose:

To examine the factors associated with poor nutrition and to determine whether resource constraints (as reflected by staffing levels) play any role.

Inclusion Criteria:

Residence in one of 10 private or four subvented randomly selected nursing homes in Hong Kong with more than 100 residents.

Exclusion Criteria:
  • Resident was fed by tube
  • Resident was hospitalized
  • Resident moved
  • Resident was out of the facility on home leave
  • Resident died.
Description of Study Protocol:

Recruitment

Unstated except that nursing homes were randomly selected.  

Design

1,699 subjects were interviewed by trained research assistants using the MDS-RAI 2.0, which had been translated into Chinese. The research assistants reviewed medical records for key information before the interview and also measured height and weight and calculated BMI. History data were confirmed with nursing home staff. 

Statistical Analysis

  • Chi-square for association of categorical variables and BMI
  • Student's T-test for continuous variables
  • Multiple logistic regression was used to determine independent factors associated with nutrition.
Data Collection Summary:

Timing of Measurements

  • Single measurements on the day of the study
  • Residents assessed using Resident Assessment Instrument 2.0.   

Dependent Variables

  • Weight loss more than 5% in previous month per history
  • Leaving 25% of food uneaten per history
  • BMI (patients were weighed by trained research associates; height was measured and BMI calculated electronically)
  • Eating problem.

Independent Variables

None.

Control Variables

None.

Description of Actual Data Sample:

Initial N: 1,914

Attrition (final N): 1,817 (588 male, 1,232 female) responded; 1,699 had nutritional information

Age: 83.5 years±8.42 years

Ethnicity: Unspecified, but it is expected that most were Chinese

Other relevant demographics: None noted

Anthropometrics: The BMI of those subjects in subvented homes was significantly higher (23.0±9.10 vs. 21.5±4.91, respectively; P<0.001) in sub-vented homes than in private homes

Location: Hong Kong.

Summary of Results:

Variables
 
BMI>18.5
(N=1,155)  
BMI<18.5
(N=379)
P-Value
 
N
Percentage
N
Percentage
Staff Numbers
Staff
25.8±13.8
 
23.5±12.8
 
0.004
Nurses
6.5±5.2
 
5.8±5.2
 
0.043
Type of Institution
Sub-vented
419
36.3
109
28.8
0.008
Private
736
63.7
270
71.2
 
Sex
Male
389
33.7
87
23
<0.001
Female
766
66.3
292
77
 
Age (years)
82.6±8.6
 
86.4±7.0
 
<0.001
Resident characteristics
ADL independent
404
35
79
20.8
<0.001
Dementia, ADL independent
62
5.4
8
  2.1
0.008
Help with feeding
204
17.7
108
28.5
<0.001
Partially dependent
408
35.3
161
42.5
0.012
Total dependent ADL
0
 
0
 
 
Stroke
No
786
68.1
280
73.9
0.033
Yes
369
31.9
99
26.1
 
COPD
No
1,086
94
329
86.8
<0.001
Yes
69
6
 50
13.2
 
Depression
No
1,088
94.2
367
96.8
0.044
Yes
67
5.8
12
3.2
 

 

Author Conclusion:
  • Poor nutrition continues to be a problem in long-term care in Hong Kong
  • Body weight should be recorded as the single most important nutritional indicator
  • It is independently associated with increasing age, female sex, presence of chronic obstructive airway disease, limitations in activities of daily living and low staffing levels.
Funding Source:
Reviewer Comments:
  • Resident Assessment Instrument 2.0 was validated and a reliable measure
  • Authors note that homes with 100 or more residents were chosen for cost-effectiveness.
Quality Criteria Checklist: Primary Research
Relevance Questions
  1. Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) N/A
  2. Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? Yes
  3. Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? Yes
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies) Yes
 
Validity Questions
1. Was the research question clearly stated? Yes
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? Yes
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated? Yes
  1.3. Were the target population and setting specified? Yes
2. Was the selection of study subjects/patients free from bias? Yes
  2.1. Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? Yes
  2.2. Were criteria applied equally to all study groups? Yes
  2.3. Were health, demographics, and other characteristics of subjects described? Yes
  2.4. Were the subjects/patients a representative sample of the relevant population? Yes
3. Were study groups comparable? Yes
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) N/A
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? Yes
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) Yes
  3.4. If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? Yes
  3.5. If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) N/A
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? N/A
4. Was method of handling withdrawals described? Yes
  4.1. Were follow-up methods described and the same for all groups? Yes
  4.2. Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) Yes
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? Yes
  4.4. Were reasons for withdrawals similar across groups? N/A
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study? N/A
5. Was blinding used to prevent introduction of bias? Yes
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? N/A
  5.2. Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) Yes
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? N/A
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status? N/A
  5.5. In diagnostic study, were test results blinded to patient history and other test results? N/A
6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? N/A
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied? N/A
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? N/A
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? N/A
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? N/A
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? N/A
  6.6. Were extra or unplanned treatments described? N/A
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? N/A
  6.8. In diagnostic study, were details of test administration and replication sufficient? N/A
7. Were outcomes clearly defined and the measurements valid and reliable? Yes
  7.1. Were primary and secondary endpoints described and relevant to the question? Yes
  7.2. Were nutrition measures appropriate to question and outcomes of concern? Yes
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? N/A
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? Yes
  7.5. Was the measurement of effect at an appropriate level of precision? Yes
  7.6. Were other factors accounted for (measured) that could affect outcomes? Yes
  7.7. Were the measurements conducted consistently across groups? N/A
8. Was the statistical analysis appropriate for the study design and type of outcome indicators? Yes
  8.1. Were statistical analyses adequately described and the results reported appropriately? Yes
  8.2. Were correct statistical tests used and assumptions of test not violated? Yes
  8.3. Were statistics reported with levels of significance and/or confidence intervals? Yes
  8.4. Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? N/A
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? Yes
  8.6. Was clinical significance as well as statistical significance reported? No
  8.7. If negative findings, was a power calculation reported to address type 2 error? N/A
9. Are conclusions supported by results with biases and limitations taken into consideration? Yes
  9.1. Is there a discussion of findings? Yes
  9.2. Are biases and study limitations identified and discussed? Yes
10. Is bias due to study's funding or sponsorship unlikely? Yes
  10.1. Were sources of funding and investigators' affiliations described? Yes
  10.2. Was the study free from apparent conflict of interest? Yes