Helena Soini

How well do nurses recognize malnutrition in elderly patients

Background and objective:Malnutrition is a common and underrecognized clinical problem among aged institutionalized patients. The aim of this study was to investigate how well nurses recognize malnutrition in elderly patients in long-term care hospitals in Helsinki.Subjects and methods:In this descriptive, cross-sectional study, the nutritional status of 1043 elderly patients was assessed with the Mini Nutritional Assessment (MNA), their body mass indices (BMIs) (kg m−2) were counted, and factors related to their nutritional care were queried using a structured questionnaire. In addition, we asked the opinions of 53 nurses on whether they considered their patients to suffer from malnutrition. All the long-term care hospitals in Helsinki, Finland participated in this study.Results:The mean age of the patients was 81 years. The nurses considered only 15.2% of the patients to be malnourished, although the MNA showed that 56.7% were malnourished (MNA<17 points). Those recognized as malnourished were truly anorectic, with a mean BMI of 17.2. Of those patients having a BMI<20 and MNA<17, the nurses considered only one-third to be malnourished. Of those having a BMI>24 but MNA<17, only 2% were recognized as having malnutrition. Even those patients considered to be malnourished received snacks and nutritional supplements less than the patients that the nurses considered to have normal nutritional status. However, only one in six of the malnourished patients received oral nutritional supplements.Conclusions:The nurses recognized malnutrition in their aged patients poorly. Nutrition education for nurses is urgently needed, as malnutrition and weight loss have been considered significant problems, and the benefits of nutritional care are well established.

Anticholinergic Drug Use and Mortality Among Residents of Long‐Term Care Facilities: A Prospective Cohort Study

Few studies have investigated the possible association between use of anticholinergic drugs and mortality. The objectives of this study were to investigate the prevalence and determinants of anticholinergic drug use and the possible association between anticholinergic drug use and mortality. Data were obtained from 53 long‐term care wards in Helsinki, Finland, in 2003. Medication, diagnostic, and mortality data were available for 1004 residents. Each residents anticholinergic load was calculated using the Anticholinergic Risk Scale (ARS). Cox proportional hazards models were used to investigate the risk of death among users with a mild anticholinergic load (ARS score 1–2) and high load (ARS score ≥3) compared with nonusers of anticholinergic drugs. Age, sex, and nutritional status were used as covariates. Among the 1004 residents, 455 (45%) were nonusers of anticholinergic drugs, 363 (36%) had a mild anticholinergic load, and 186 (19%) had a high anticholinergic load. One‐year all‐cause mortality rates were 28%, 29%, and 27%, respectively. Higher ARS scores were not associated with mortality (ARS score 1–2: hazard ratio 1.08; 95% confidence interval, 0.84‐1.41; ARS score ≥3: hazard ratio 1.05; 95% confidence interval, 0.75‐1.46). Anticholinergic drug use was common; however, high ARS scores were not associated with mortality. Further research is needed using alternative models and among different resident populations.

Nutritional guidelines for older people in Finland

BackgroundAgeing is associated with an increased risk of malnutrition, decreased nutrient intake, unintentional weight loss and sarcopenia, which lead to frailty, functional disabilities and increased mortality. Nutrition combined with exercise is important in supporting older people’s health, functional capacity and quality of life.ObjectiveTo identify nutritional needs in various groups of older individuals and to present the nutritional guidelines for older people in Finland.DesignA review of the existing literature on older people’s nutritional needs and problems. The draft guidelines were written by a multidisciplinary expert panel; they were then revised, based on comments by expert organisations. The guidelines were approved by the National Nutritional Council in Finland.ResultsThe heterogeneity of the older population is highlighted. The five key guidelines are: 1. The nutritional needs in different age and disability groups should be considered. 2. The nutritional status and food intake of older individuals should be assessed regularly. 3. An adequate intake of energy, protein, fiber, other nutrients and fluids should be guaranteed. 4.The use of a vitamin D supplement (20 μg per day) recommended. 5.The importance of physical activity is highlighted. In addition, weight changes, oral health, constipation, obesity, implementing nutritional care are highlighted.ConclusionsOwing to the impact that good nutrition has on health and well-being in later life, nutrition among older people should be given more attention. These nutritional guidelines are intended to improve the nutrition and nutritional care of the older population.

Sedative load and mortality among residents of long-term care facilities: a prospective cohort study.

AbstractBackground: Older people are often prescribed multiple drugs with sedative properties. Most research has focused on specific classes of sedative and psychotropic drugs. The cumulative effect of taking multiple drugs with sedative properties has been termed ‘sedative load’. Few previous studies have investigated the sedative load among residents of long-term care facilities. No previous studies have assessed the possible association between sedative load and mortality. Objective: The objective of this study was to describe the sedative load among residents of long-term care facilities, and to investigate a possible association between sedative load and mortality. Methods: This was a prospective cohort study. The study population comprised all 1444 residents of 53 long-term care wards in seven hospitals in Helsinki during September 2003. Of the eligible residents, 1087 residents or their proxies provided written informed consent to participate. Medical, medication and follow-up mortality data were available for 1004 residents. The main outcome measures were sedative load and all-cause mortality. Results: The mean age of the residents was 81.3 (SD 10.9) years, and the mean number of regularly used drugs per resident was 7.1 (SD 3.4). Fifteen percent of residents were categorized as non-users of sedative drugs, 32% as users of some drugs with sedative properties and 53% as residents with a high sedative load. There was a bivariate association between having a higher sedative load and younger age (p < 0.001), male sex (p = 0.006), not being widowed (p = 0.001), diagnosis of depression (p < 0.001), diagnosis of psychiatric illness other than depression (p < 0.001), not being diagnosed with dementia (p = 0.009) and a shorter duration of institutional care (p = 0.02). Unadjusted analysis revealed that having a higher sedative load was associated with increased survival (p = 0.04, log rank test). However, in the adjusted Cox proportional hazard model, only poor nutritional status (hazard ratio [HR] 1.55; 95% CI 1.32, 1.82), male sex (HR 1.37; 95% CI 1.12, 1.69), increasing age (HR 1.04; 95% CI 1.03, 1.05) and co-morbidity (HR 1.07; 95% CI 1.02, 1.13) were significantly associated with risk of death. Conclusions: There is a very high rate of sedative and psychotropic drug use among residents of long-term care facilities in Helsinki. However, having a high sedative load was not associated with an increased risk of death. Further research is needed to investigate the possible association between sedative load and mortality using alternative models and methods, and in different resident populations.

Dentition status, malnutrition and mortality among older service housing residents

BackgroundOral health status and oral health problems can affect eating habits and thus consequently the nutritional status of frail older people.ObjectivesTo assess older service house residents’ dentition and its associations with nutritional status and eating habits, and as well as to explore the prognostic value of dentition status for mortality.DesignA cross-sectional study with a three-year follow-up.MethodsIn 2007, we assessed the nutritional status of all residents in service houses in the two cities of Helsinki and Espoo in Finland (N=2188). Altogether 1475 subjects (67%) participated in the study; dentition status data were available for 1369 of them. Using a personal interview and assessment, trained nurses familiar to the resident collected the subjects’ demographic data, medical history, functional and cognitive status, information on dentition status, oral symptoms, eating habits and diets. We assessed nutritional status with the Mini Nutritional Assessment (MNA), and retrieved information on mortality from central registers on 6 July 2010.ResultsEdentulousness was common; more than half of the residents (52%) had lost all their teeth: 7% (n=94) were totally edentulous without prosthesis (Group 1), 45% (n=614) had removable dentures (Group 2), and 48% (n = 661) of the residents, had some natural teeth left (Group 3). Dentition status was associated with age, gender, education and disability. According to the MNA, 13% were malnourished, 65% were at risk for malnutrition, and 22% were well nourished. Edentulousness without prosthesis was associated with malnutrition, oral symptoms and infrequent use of oral care services. In Group 1, 52% were deceased during follow-up period. The respective figures for Groups 2 and 3 were 48% and 40% (p=0.004). However, in Cox regression analysis adjusted for age, gender, comorbidity and MNA score, dentition status no longer predicted mortality.ConclusionEdentulousness is still common among older service housing residents. Edentulousness without prosthesis was associated with poor nutritional status, oral symptoms and infrequent use of dental services. These findings suggest the need for co-operation between nursing staff and oral care services.

Risk of Death Associated With Use of PPIs in Three Cohorts of Institutionalized Older People in Finland

OBJECTIVES To (1) explore clinical and demographic characteristics of users and nonusers of PPIs in 3 cohorts of institutionalized older people in Finland, and (2) compare the risk of death associated with use of PPIs in each setting. DESIGN Cross-sectional assessment of 3 institutionalized cohorts with 1-year follow-up of all-cause mortality. SETTING AND PARTICIPANTS A total of 1389 residents of 69 assisted living facilities (first cohort), 1004 residents of long term care hospitals (second cohort), and 425 residents in acute geriatric wards or in nursing homes (third cohort). MEASUREMENTS Demographic, drug use, and diagnostic data were collected during structured assessments conducted by trained nurses or geriatricians. Cox proportional hazards models were used to compute unadjusted and adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between use of PPIs and mortality. RESULTS In the assisted living facility, the mortality was 20.2% (n = 74) and 20.4% (n = 208) among users and nonusers of PPIs, respectively (P = 0.94). PPIs were not associated with mortality in unadjusted or adjusted analyses. In the long term care hospitals, use of PPIs was associated with increased mortality (HR, 1.36; 95% CI 1.04-1.77) when adjusted for age, sex, comorbidity, use of SSRIs, and malnutrition. In the acute geriatric wards and nursing homes, use of PPIs was associated with increased mortality (HR, 1.90; 95% CI 1.23-2.94) when adjusted for age, sex, comorbidity, delirium, and use of aspirin and SSRIs. CONCLUSION PPIs were not associated with mortality among residents in assisted living facilities, but were associated with increased mortality in settings where residents experienced higher levels of disability and possible susceptibility to adverse drug events.

Sedative load among long-term care facility residents with and without dementia: a cross-sectional study.

AbstractBackground and Objective: People with cognitive impairment are particularly susceptible to adverse drug events linked to sedative and psychotropic drugs. A model to calculate sedative load has been developed to quantify the cumulative effect of taking multiple drugs with sedative properties. The objective of this study was to describe the sedative load and use of sedative and psychotropic drugs among long-term care facility residents with and without dementia. Methods: Cross-sectional data were collected from all 53 long-term care wards in Helsinki, Finland, in September 2003. Of the 1444 eligible residents, consent to participate was obtained for 1087 (75%) residents. Medication and diagnostic data were available for 1052 residents. All drugs were classified using the Anatomical Therapeutic Chemical (ATC) classification system. Sedative load was calculated for each resident using a previously published four-group model. Results: Of the 1052 residents, 781 (74.2%) were determined to have dementia. Residents with and without dementia had a similar sedative load (mean 3.0 vs 2.7, p = 0.267), but residents with dementia were taking fewer drugs than residents without dementia (mean 6.7 vs 7.4, p = 0.011). Residents with dementia were more frequent users of antipsychotics (42.8% vs 32.8%, p = 0.004), but less frequent users of antidepressants (35.6% vs 46.1%, p = 0.002) and sedative-hypnotics (22.8% vs 27.7%, p = 0.003) than residents without dementia. The most frequently used primary sedatives among people with dementia were temazepam (n = 122, 15.6%), oxazepam (n = 98, 12.5%) and lorazepam (n = 95, 12.2%). The most frequently used drugs with sedation as a prominent adverse effect or preparations with a sedating component among people with dementia were citalopram (n = 183, 23.4%), risperidone (n = 155, 19.8%) and olanzapine (n = 73, 9.3%). Conclusions: Residents with dementia were less frequent users of sedative-hypnotic drugs than residents without dementia. However, residents with and without dementia had a similar sedative load. Clinicians should be aware of the extent to which all individual drugs, not only those prescribed for intentional sedation, contribute to a resident’s sedative load. The very high rates of sedative and psychotropic use observed in long-term care facility residents highlight the need for new strategies to optimize drug use.

MALNUTRITION ACCORDING TO THE MINI NUTRITIONAL ASSESSMENT IN OLDER ADULTS IN DIFFERENT SETTINGS

L. Lacavé, S. Maugat, H. Tronel, O. Hoff, F. Gimenez, L. Mouchot, P. Jarno, H. Sénéchal, G. Gourvellec, F. L’Hériteau, F. Daniel, M.H. Metzger, L. Voisin, C. Gautier, B. Amadéo). Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Lietard: analysis and interpretation of data, preparation of manuscript. Metzger: acquisition of data. Thiolet: concept and design, interpretation of data. Coignard: concept and design, preparation of manuscript. Lejeune: acquisition of data, preparation of manuscript. Sponsor’s Role: None.

Eight-Year Trends in the Use of Opioids, Other Analgesics, and Psychotropic Medications Among Institutionalized Older People in Finland

IMPORTANCE It is recognized that pain has been undertreated and psychotropic medications overused in institutional settings. OBJECTIVE To investigate the change in prevalence of opioids, other analgesics, and psychotropic medications in institutional settings over an 8-year period. SETTINGS Institutional settings in Helsinki, Finland. PARTICIPANTS Older residents in nursing homes in 2003 (n = 1987) and 2011 (n = 1576) and in assisted living facilities in 2007 (n = 1377) and 2011 (n = 1586). OUTCOME MEASURES Comparable audits of medication use were conducted among institutionalized residents at 3 time points over 8 years. The prevalence of regular opioid, other analgesic, and psychotropic medications was compared across the 3 time periods. RESULTS Nursing home and assisted living facility residents were older; more disabled, had a higher prevalence of dementia, and greater comorbidity in the latter cohorts. The prevalence of regular opioid use was 11.8% and 22.9% in nursing homes in 2003 and 2011 (P < .001), and 8.6% and 17.3% in assisted living facilities in 2007 and 2011 (P < .001), respectively. The prevalence of regular acetaminophen and pregabalin/gabapentin increased and NSAIDs decreased in both nursing homes and assisted living facilities. The prevalence of regular antipsychotic use decreased from 42.6% to 27.8% in nursing homes (P < .001) but increased from 26.9% to 32.0% in assisted living facilities (P = .0017). The mean number of psychotropic medications (antipsychotics, antidepressants, anxiolytics, hypnotics) per resident decreased from 1.9 in 2003 to 1.0 in 2011 in nursing homes (P < .001) but increased from 1.1 to 1.2 in assisted living facilities (P = .040). CONCLUSIONS The prevalence of opioid use in institutional settings has doubled during the past decade. The prevalence of psychotropic medications has decreased in nursing homes but increased in assisted living facilities. The increase in opioid use may reflect improved recognition and treatment of pain. However, initiatives are needed to monitor opioid-related adverse drug events and ensure appropriate use of psychotropic medications, particularly in assisted living facilities.

Nutrition and psychological well-being among long-term care residents with dementia

ObjectivesTo examine the relationship between nutritional status of service housing and nursing home residents with dementia and their psychological well-being (PWB), and the associations of nutritional care and PWB.Design, participants and settingThis cross-sectional nutrition study was carried out in 2011. The study included all older long-term care residents (N=4966) living in nursing homes and service housing units (N=61) in Helsinki. The response rate of was 72%. Of the respondents, only persons who had a diagnosis of dementia were included in this analysis (N=2379).MeasurementsThe Mini Nutritional Assessment (MNA) tool and a structured questionnaire were used in assessing the residents. Six dimensions of PWB were included in the questionnaire. Information was also retrieved from medical records.ResultsOf residents 9% were wellnourished and 28% malnourished according to the MNA. PWB was good in 50% (score ≥ 0.80) and poor in 10% (score < 0.40) of the residents. Residents’ poor nutritional status, eating a little of the offered food, having meals alone and not having snacks were associated with poor PWB. Mild cognitive impairment was more often associated with poor PWB, whereas moderate or severe impairment was more often associated with good PWB.ConclusionNutritional status and nutritional care of residents with dementia were significantly associated with their psychological well-being. The residents suffering from malnutrition had the poorest psychological wellbeing.