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1 Journal of Fundamental and Applied Sciences ISSN Research Article Special Issue Available online at ASSESSMENT OF THE NUTRITIONAL STATUS OF HOSPITALIZED OLDER ADULTSIN HOSPITALS AFFILIATED TO SHAHID BEHESHTI UNIVERSITY OF MEDICAL SCIENCES B. Payvar Quchan higher health education center, Mashhad University of medical sciences, Mashhad, Iran Published online: 15 May 2016 ABSTRACT Malnutrition is a clinical disorder and a very common risk factor in older adults that once was viewed as a part of normal aging process, but in fact it can be identified, prevented and treated and its early diagnosis provides the possibility of timely intervention. Therefore, assessment of the nutritional status of older adults and identification of causes and contributing factors could be of great help in designing and implementing appropriate interventions. This study aimed to determine the nutritional status of hospitalized older adults in the cardiac intensive care units(cicu) of hospitals affiliated to Shahid Beheshti University of Medical Sciences so that by identifying contributing factors in this case, necessary measures can be taken to promote health among older adults. This study was descriptive analytic study. 254adults aged 60 years hospitalized in the cardiac intensive care units (CICU) were selected and assessed using the Mini Nutritional Assessment questionnaire. Data analysis was then performed software SPSS. Research findings showed that, of the 254 older adults, 43 (16.9%) were with malnutrition, 95 (37.4%) at risk of malnutrition and 116 (45.7%) well- nourished. Age, gender, education, marital status, occupation, source of income, body mass index (BMI), chronic disease and intake of more than three drugs appeared to be significantly associated with nutritional status. Author Correspondence, Payvarbahar525@gmail.com doi: Journal of Fundamental and Applied Sciences is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. Libraries Resource Directory. We are listed under Research Associations category.

2 B. Payvar et al. J Fundam Appl Sci. 2016, 8(3S), The results of study revealed that a high percentage of elderly people have nutritional problems which can endanger their health, therefore, it is necessary that appropriate nursing measure be taken to prevent the risks. Keywords: Nutritional status, Older Adults, Hospitalization 1. INTRODUCTION Nowadays with medical, economic and social advances, the mortality rate has decreased and life expectancy has increased. In fact, over time, the world is experiencing aging of its population so that this century has been defined by World Health Organization (WHO) as ageing century. The expansion of primary health care, improvements of socio-economic conditions, and, ultimately, the emergence of new technologies in prevention, diagnosis and treatment of diseases are the most important factors in the increase of the adult population aged 60 years and above which is defined by the WHO as elderly (Malek Afzali & et al, 2006). Adults aged 60 years accounted for approximately 10% of the world s population in 2000, and this rate is projected to grow to 21%, or roughly 1 in 5 persons, by 2050 (Bandayrel & Wong, 2011), therefore, ageing population is increasing in Iran and all countries of the world. According to the 2011 census in Iran, the number of older adults was reported to be approximately (Statistical Centre of Iran, 2011). Although older adults in many countries live much better than before, the major concerns are the growth of ageing population, increased prevalence of chronic disease and inability a condition which is associated with ageing process, and special attention is needed (Shojaei Tehrani & Malek Afzali, 2008). The impacts of ageing causes significant change in health status and body system performance, including the digestive tract. These changes including reduced saliva secretion, dysphagia, delayed postprandial gastric emptying, reduced gastrointestinal motility on the one hand (Nieuwenhuizen et al., 2010), and chronic diseases, frequent hospitalization, drug consumption, loneliness, depression, lack of oral health and poor quality of life, on the other hand, can impact and overshadow older adults' nutritionand they are more at risk of malnutrition (Marchi et al., 2008; Appleton, 2009). However, nutrition is one of the most important components of health so that the results of the epidemiological studies suggest that malnutrition is strongly associated with high mortality in older adults(ulger et al.,2010). Nutritional status in older age is an important issue but in developing countries, very little attention has been paid to it. The nutrition factor has a significant effect on mortality, inability

3 B. Payvar et al. J Fundam Appl Sci. 2016, 8(3S), and quality of life in older adults. They are also suffer from nutritional disorder because of the reasons mentioned above. These factors can cause deterioration of physical conditions in older adult and predispose them to serious diseases and ultimately contribute to older adults risk of hospitalization that provide breeding grounds for diseases including osteoporosis, diabetes, cardiovascular diseases and hypertension placing huge health costs on governments, and therefore creating many problems of social, health and economic nature that will take careful planning to deal with them. Meanwhile, in addition to creating concern and anxiety, the state of being sick in older adults will also increase the time spent for those who are around him/her. A study conducted on older adults residing in nursing home care have shown that these adults had deficiency in receiving energy and protein (Azar, 2000). Studies have revealed that malnutrition is an independent factor for hospitalization in older adults (Oliveira et al,. 2009; Morely, 2012). It seems that despite the increased awareness in the prevention of cardiovascular diseases, the prevalence of cardiovascular diseases has increased due to the ageing population and, therefore, the need for bed in CCU is increased (Talebizadeh et al, 2009).With advancing age, both under nutrition and chronic diseases become more common. Malnutrition may lead to ill health, and ill health to Malnutrition (Gariballa, 2004). Various studies reveal that nutrition is an important determinant of health in older adults and has a well-known role in common diseases of older adults such as cancer, cardiovascular diseases and dementia (Dumbrell & Wells, 2006). Loss of appetite, weight loss, and malnutrition mainly can be seen in hospitalized older adults. Furthermore, acute diseases can cause a reduction in protein levels and essential nutrients of the body which will lead to a deterioration of the general health status in older adults (Solemdal, 2012). In a cross-sectional study conducted in Portugal, assessment on 1144 patients revealed that 36% of older adults were at malnutrition risk and 9.7% were malnourished (Amaral & et al, 2010). The causes of malnutrition in hospitalized older adults are loss of appetite, reduced snack intake in men, changes in health status, digestive problems, taking numerous drugs, depression and reduced cognitive function ( Feldblum et al., 2009). Nutrition and diet therapy are the main components of survival and health for patients during disease progression, and physicians, nurses and nutritionists are responsible for patients nutritional needs (Atashzadeh et al., 2007). G iven that nurses are in a very good position to identify signs of nutritional deficiency and to take action for change, close contact with patients and their families enables nurses to observe physical condition, eating food, weight changes and response to treatment. Early diagnosis of

4 B. Payvar et al. J Fundam Appl Sci. 2016, 8(3S), patients with malnutrition or at risk of malnutrition has positive effects on short-term and longterm health outcomes (Potter & Perry, 2013). This study, therefore, examined the nutritional status and its associated factors in older adults hospitalized in CICU. Research method This research was an analytical - descriptive study. In the present study, 254 adults aged 60 hospitalized in CICU of hospitals affiliated to Shahid Beheshti University of Medical Sciences (Shahid Modarres Hospital; Imam Hossein Hospital; Torfeh Hospital; Labbafinejad hospital; Loghman-e-Hakim Hospital) were selected and examined. Patients participating in the study were all over the age of 60, they were hospitalized at least one day and they were all mentally healthy. Data were collected using MNA questionnaire. This questionnaire a validated clinical tool for the assessment of nutritional status in older adults (Vellas et al., 2006). The MNA is a comprehensive tool that has been developed to assess the nutritional status of older adults (Guigoz et al., 2006). It is an 18-item questionnaire comprising anthropometric measurements (BMI, mid-arm and calf circumference, and weight loss) combined with a questionnaire regarding dietary intake (number of meals consumed, food and fluid intake, and feeding autonomy), a global assessment (lifestyle, medication, mobility, presence of acute stress, and presence of dementia or depression), and a self-assessment (self -perception of health and nutrition) (Guigoz et al., 2002). It has been translated into several languages and validated in many clinics around the world (Ali Abadi et al., 2006). In Iran, it has been translated into Persian and has been determined to be appropriate after standardization of MNA among Iranian population (Maghsoodnia, 2003). In this study, we evaluated the correlation of questionnaire using retest method. The intra-class correlation coefficients (ICC) were analyzed in three specific areas of screening and the total score that were acceptable reported 0.89, 0.95 and 0.95, respectively. In the present study, in order to assess the anthropometric measurement such as BMI, patient s body weight with minimum clothes and without shoes were estimated by using digital scale with 100g precision. The height, arm, waist and hip circumferences were estimated with non-elastic metric tape with 0.1 cm precision. In order to estimate BMI, the following equation was used: BMI = weight (kg) height 2 (m)

5 B. Payvar et al. J Fundam Appl Sci. 2016, 8(3S), The height and the weight for patients who are unable to stand and to get out bed, weight and height were obtained indirectly using the following equation: Equation for indirect estimation of body weight (Vizmanos et al., 2010): Weight (men) = (0.98 calf circ.) + (1.16 knee height) + (1.73 MUAC 1) + (0.37 sub scapular skinfold) Weight (women) = (1.27 calf circ.) + (0.87 knee height) + (0.98 MUAC) + (0.4 sub scapular skinfold) Equation for indirect estimation of height: Height (men) = (1.40 demi-span in cm) Height (women) = (1.35 demi-span in cm) After collecting questionnaires and listed values, data were analyzed to extract the results. In order to analyze data, results were first described using frequencies and percentage. Conceptually, qualitative variables were tested using the Chi-square test and Fisher's exact and quantitative variables were tested using Analysis variance test when assumptions of normality are met, and Kruskal-Wallis test were used when assumptions of normality are not met. Confidence level for all tests was considered 0.95% and data analysis were all performed using Software SPSS Version 20. Findings In a sample of 254 older adults, 50.4% were male and 49.6% were female with mean age of74.55 ± This study revealed that 43 (16.9%) were with malnutrition, 95 (37.4%) at risk of malnutrition and 116 (45.7%) well - nourished. Distribution of older adults is given in Table 1according to demographic characteristics.

6 B. Payvar et al. J Fundam Appl Sci. 2016, 8(3S), Table 1. Distribution of older adults according demographic characteristics Demographic characteristics Number (%) Gender male 128 (50.4%) female 126 (49.6%) Place of living city 186 (74.4%) village 65 (25.6%) Marital status single 4 (1.6%) married 162 (63.8%) divorced 3 (1.2%) widowed 84 (33.1%) Education level None 75 (29.5%) Elementary (Primary) school 60 (23.6%) Secondary school 39 (15.44%) High school and higher 80 (28.3%) Occupation Unemployed 72 (28.3%) free 13 (5.1%) Employee 52 (20.5%) housewife 48 (18.9%) other 69 (27.2)

7 B. Payvar et al. J Fundam Appl Sci. 2016, 8(3S), Table 2. Comparison of continuous variables in malnutrition index (based on variance analysis) Normal Malnutrition At risk of Well-nourished P-Value Variables Mean (SD) malnutrition Mean (SD) Mean (SD) Age (8.05) (8.51) (6.29) <0.001 Body weight (1.30) (1.43) (1.21) <0.001 height 160 (7.52) 161 (6.65) 166 (7.23) <0.001 Waist circ (2.48) (1.90) (1.63) <0.001 Hip circ (1.90) (1.71) (1.69) <0.001 Calf circ (4.90) (4.02) (3.53) <0.001 Normal Mean scores variables Arm circ <0.001

8 B. Payvar et al. J Fundam Appl Sci. 2016, 8(3S), Table 3. The relationship between nutritional status and qualitative variables Variable Malnutrition At risk of Wellnourished P- (43) number - malnutrition value percentage (95) number - percentage (16) number - percentage Gender Male 16(37.2%) 44(46.3%) 68(58.6%) Female 27(62.8%) 51(53.7%) 48(41.4%) Marital Single 0(0%) 0(0%) 4(3.4%) <0.001 Status Married 15(34.9%) 54(56.8%) 94(81%) Widowed 2(4.7%) 41(43.2%) 17(14.7%) Divorced 2(4.7%) 0(0%) 1(0.9%) BMI Underweight 13(30.2%) 6(6.3%) 0(0%) <0.001 Normal 25(58.1%) 56(58.9%) 63(54.3%) Weight Overweight 2(4.7%) 25(26.3%) 39(33.6) Obesity 3(7%) 8(8.4%) 14(12.1%) Chronic Yes 38(88.4%) 70(73.7%) 67(57.8%) <0.001 disease No 5(11.6%) 25(26.3%) 49(42.2%) intake of yes 28(65.1%) 58(61.1%) 29(25%) <0.001 more than No 19(34.9%) 37(38.9%) 87(75%) three drugs DISCUSSION AND CONCLUSION This study aimed to determine the nutritional status and its associated factors on 254 older adults hospitalized in CICU. In examining demographic characteristics, samples of the study included 128 male (50.4%) and 126 female (49.6) with mean of ± The results of the study suggested that 43 (16.9%) were with malnutrition, 95 (37.4%) at risk of malnutrition and 116 (45.7%) well- nourished which are consistent with results of the study by Ghorbani et al. (2011) on older adults hospitalized in medical and surgical units in Qazvin (13.4% with malnutrition and 42.9% at risk of malnutrition). This rate is slightly different compared to the results in older

9 B. Payvar et al. J Fundam Appl Sci. 2016, 8(3S), patients in Egypt (18% with malnutrition and 56% at risk of malnutrition) (Esmayel et al., 2013) and in Santiago (38% with malnutrition and 40.7% at risk of malnutrition) (Hirsch et al., 2008)which may be probably due to cultural differences and type of food used in different countries. In 36 studies conducted on 8596 hospitalized older adults, 23% ± 0.5 were with malnutrition, 46% ± 0.5 at risk of malnutrition. Furthermore, other studies conducted on older adults using MNA reported that the prevalence of malnutrition were 1% in healthy older adults and 4% in older adults referred to care center and 5% in older adults residing in care centers for people with Alzheimer, 20% in hospitalized older adults and 37% in patients in nursing homes (Guigoz, 2006). The nutritional status of hospitalized patients is directly associated with their clinical status. The causes of malnutrition in hospitalized older adults are loss of appetite, reduced snack intake in men, changes in health status, digestive problems, taking numerous drugs, depression and reduced cognitive function (Feldblum et al., 2009) The findings of this study for older adults showed 7.5% with underweight (BMI< 18.5), 56.7% in normal weight range (BMI = ), 26% in overweight range (BMI = ) and 9.8% with obesity (BMI>30). The mean BMI among these subjects was ± In a study by Karimzadeh et al. conducted in Qazvin, the mean age of participants was ±7.8 and the mean BMI of samples was ± in the present study, there is a significant association between nutritional status and BMI (P-value = 0.001)) which is consistent with results by Pasdari in Kermanshah (2011), Kuzuya (2005) in Japan and Denini et al. (2013) in Italy. The findings revealed that ageing is associated with malnutrition that were consistent with the results in studies by Denini (2013), So derhamn et al. (2012), Kuzuya (2005), Ghorbani (2011) and Hirsch et al. (2008). Korfali (2009) conducted a study on patients admitted to hospitals in Turkey and reported that 25% of patient > 60 were with malnutrition. It is worth mentioning that the results of this study was different from the results by Ghanbari (2012) and Marchi (2008) who found that there is no association between age and nutritional status. In this study, gender factor was also associated with nutritional status so that the results revealed that females are at more risk than men. These results were consistent with the results by Ghanbari (2012), Marchi (2008) and Aliabadi (2006). In a similar study conducted by Castel et al. (2006), 48.1% of females and 32.5% of males were with malnutrition. Harriet et al. (2010) also reported that the rate of malnutrition were 8.6% in females 5.6% in males and 7.1% in total population. Despite the higher BMI among females in that study, it seems that the causes of malnutrition were biological

10 B. Payvar et al. J Fundam Appl Sci. 2016, 8(3S), differences and their dietary habits. It should be noted that in studies conducted by Es haghi (2007), Denini (2013) and Vandrooy (2010), there was no significant difference in nutritional status between males and females. In this study, nutritional status was not associated with place of living (city or village). These results were not consistent with results by Aliabadi (2006). In the study conducted by Aliabadi on free elderly people in Khorasan Razavi, the results showed that rural people had malnutrition more than urban residents. In another study conducted by Esmayel (2013), 61.9% people were at risk of rural malnutrition. In several studies (Aliabadi, 2006; Ghanbari, 2012; Marchi, 2008), education has been associated indirectly with nutritional status and in this study nutritional status was associated with education level which higher education may lead to higher income and ultimately better lifestyle, and thereby improve nutritional status. It can be noted that Denini (2013) found no association between education level and nutritional status in older adult, whose results were contrary to the results of this study. In the present study, the prevalence of malnutrition and risk of malnutrition were more in lonely older adults, residents of nursing home and those who lived with their friends and acquaintances and those who lived with their spouse and children (51.7%) had better nutritional status. These results were consistent with the results by Aliabadi (2006). Studies have shown that social isolation is associated with inadequate intake of calories (Ferry et al., 2005) and people who live alone are less likely to consume protein, fruits and vegetables and consume meals less than others (Ramic et al., 2011). The results of nutritional status in terms of occupation revealed that malnutrition is more likely in people who were unemployed and there is a significant association between occupation and nutritional status and this variable can impact on nutritional status. These findings were consistent with the findings in conducted study by Aliabadi (2006). The nutritional status in older adults under study were significantly associated with their income source so that the percentage of malnutrition in older adults who were supported by the Relief Committee or Welfare Committee were more than other older adults with various income sources. Considering that the payment received by older adults from these centers are very low, cannot satisfy their needs involving food and drug, these results are not unexpected. In line with the results of this study, Es haghi (2007), Aliabadi (2006) in their studies have pointed out the association between income source and nutritional status in older adults. In this study, marital status is another factor that is associated with nutritional status in older adults, so that married older adultshas more favorable nutritional status than other and most of those who has low score on MNA were

11 B. Payvar et al. J Fundam Appl Sci. 2016, 8(3S), widowed. These results were not consistent with the studies by Ghanbari (2012), Marchi (2008) and Denini (2013). The results of this study indicate the association between nutritional status in older adults and all the aforementioned variables. In addition, mean of height, body weight, waist and hip and arm circumference were greater in group with normal nutrition and were lower in groups with malnutrition. It can be concluded that each of these indicators can be significantly as a criterion for determining malnutrition. These results were consistent with conducted studies by (Hirsch et al., 2008) and Pasdari (2011). Cereda et al. (2008) showed in the study that the prevalence of malnutrition is directly associated with low BMI, low weight and inability to move. The result obtained from the study revealed a significant association between nutritional status in older adults and factors related to health condition such as the number of hospital stay, underlying disease, intake of more than three drugsa day. No significant association was found between nutritional status and nutritional supplementsconsumption in such a way that 55.8% of older adults with malnutrition had reported history of hospitalization between 1 to 2 times during the past three months. The findings also revealed that there is a significant association between nutritional status and chronic disease and people with chronic disease are more susceptible to malnutrition than others and this can be an effective and supportive factor for health. In other words, normal nutrition is effective on people s health. In the study conducted by Oliveira (2009), 85% of people with malnutrition had chronic diseases. Solemdal et al (2012) reported the role of chronic disease in malnutrition. The reason for this relationship is that with ageing process, malnutrition and chronic diseases are both common and malnutrition may lead to ill health, and ill health to Malnutrition (Gariballa, 2004). It is worth noting that the results of the study are contrary to the results by Ghanbari (2011) and Marchi (2008) that these two researchers did not reported any significant association between chronic disease and the prevalence of malnutrition or risk of malnutrition. There are several studies pointing out the role of polypharmacy or multiple drug consumption on nutritional status on older adults. The reason for this is that drug treatment can leads to loss of appetite, nausea, diarrhea, weight changes, changes in taste and reduced saliva secretion, and all these complications increases the prevalence of malnutrition in older adults (J yrkka et al., 2011). According to what was said, we decided to examine the association between intake of more than three drugs and malnutrition in older adults that the results revealed that intake of more than three drugs a day can cause malnutrition or increase the risk of malnutrition. These results were not consistent with the study conducted with

12 B. Payvar et al. J Fundam Appl Sci. 2016, 8(3S), Denini (2003). In addition, in this study no significant association was found between nutritional status and nutritional supplements consumption which were contrary to study conducted by Aliabadi (2006) in wh ich the percentage of malnutrition in nutritional supplements consumers were more than those who did not consume nutritional supplements. The researcher argued that this could be for two reasons: older adults who were consuming nutritional supplements had malnutrition before and started and then are advised to take supplements by physicians or older adults who consume these supplements had lower amount of food consumption and replaced these supplements. Ultimately, according to the results of this study, a high percentage of older adults suffer from nutritional problems which can endanger their health, therefore, it is necessary to take nursing appropriate measure for identifying people at risk of malnutrition, nutritional correction, prevention of associated risks. REFERENCES 1. Es haghi S.R. et al., The nutritional status of older adults in Isfahan, Iranian Journal of Ageing, (5), 2007; Azar M, Abstracts of articles in 5 th Iranian nutrition congress, Pasdari et al. determining the nutritional status in older adults supported by governmental centers in Kermanshah based on MNA and its correlation with biochemical markers of Journal of Kermanshah University of Medical Sciences. 2011, 15(3), Potter C. et al. Potter and Perry s nursing fundamentals, Translated by Najafi T. et al., 8 th edition, first print. Tehran, Jame e negar Salemi publication, Darvishpoor Kakhki A; Abed Saeidi J; Delavar A; Saeidozakerin A. Measuring tools for health status and quality of life in older adults, Journal of medicine. 33(3), 2008, Talebizadeh N. et al. epidemiologic model of ischemic heart disease in Iran. Payesh journal, 2009, 8 (2), Aliabadi M, et al 2007, Prevalence of malnutrition and its related factor on older adults in Razavi Khorasan province in. International journal of food industries. 2006, 2(3), 2007,

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