MALNUTRITION RISK AND ITS ASSOCIATIONS WITH FUNCTIONAL, COGNITIVE AND PSYCHOLOGICAL STATUS AMONG ELDERLY IN LONG-TERM CARE FACILITIES PALESTINE

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1 1 MALNUTRITION RISK AND ITS ASSOCIATIONS WITH FUNCTIONAL, COGNITIVE AND PSYCHOLOGICAL STATUS AMONG ELDERLY IN LONG-TERM CARE FACILITIES PALESTINE Manal M. H. Badrasawi, PHD. Nutrition and Health Research Group. Faculty of Applied Sciences PPU

2 Outline 2 Introduction and Rationale Aim and justification Methodology Results and Main Findings Conclusion Recommendations

3 Background 3 The worldwide aging population has significantly increased in number for the last decades. There are around 810 million older adults age 60 and above in the world in 2012 and this number is expected to reach more than 2 billion by year 2050, that is because of increasing life expectancies and decline infertility rate and mortality worldwide (WHO, 2015)

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5 Background 5 In the Arab countries as a whole, life expectancy has increased from 42.7 years between 1945 and 1950, to 66.5 years between 2000 and It is predicted to reach 77 years by 2050 (Saxena, 2008). According to the Palestinian Central Bureau of Statistics, the elderly made up 4.4 % of the Palestinian population (4.8% in the West Bank and 3.9% in Gaza) with increase in the life expectancy (PCBS 2017).

6 6 WHO- Aging report

7 Background 7 It was reported that 23% of the total world burden of disease is related to disorders in people aged 60 years and older. Although the developed countries have higher percentage of elderly people, the highest proportion of disability was recorded in low-income and middleincome regions (Prince et al., 2015). Alongside of functional impairment, depressive Symptoms and poor quality of life have high prevalence among elderly in both gender (Doumit, Nasser, & Hanna, 2014)

8 8 Background

9 Background 9 Malnutrition risk increases with age, as it is one of the most pertinent conditions with adverse effect on elderly health (Kaiser et al., 2010). Malnutrition can lead to cognitive impairment and functional status deterioration (Furuta et al., 2013), in addition to depression, higher infection rates, longer hospital stays, higher mortality rates and higher costs of care (Van Lancker et al., 2012). Despite significant medical advances, malnutrition among elderly it remains a significant and highly prevalent public health problem of developed and developing countries. (Guyonnet & Rolland, 2015).

10 Background 10 As the number of elderly people increases, the number of elderly who suffer from physical, functional or mental disability also increasing, which necessitate long term nursing facilities in many cases. (Furuta et al., 2013) This growing number requires a proper research and planning to meet their needs and standby all challenges they face to grow up with dignity.

11 Background 11 Malnutrition is prevalent among elderly in long term care facilities, it was estimated to be present in 30% 60% of LTC residents in US, with negative consequences for health, wellbeing, and quality of life (Cowan, Roberts, Fitzpatrick, While, & Baldwin, 2004). Despite malnutrition in highly prevalence in LTC facilities, it is underreported and undertreated. This high prevalence of malnutrition is due to multiple comorbidities, reduction in food intake, changes in the hormonal level due to aging, loss of appetite and risk of acute diseases, added to poor nutritional care practices in in the long term care facilities. (Pezzana et al., 2015; Van Lancker et al., 2012)

12 Justification 12 In this perspective, there is a need to explore the prevalence and risk of malnutrition and its implications on cognitive and function status among institutionalized elderly worldwide with main focus in developing countries. In Palestine, the studies that approach the health status of institutionalized elderly people in Palestine are very sparse, up to our knowledge the present study is the first study attempt to determine the nutritional status and the risk of malnutrition and its correlation with cognitive, functional and psychological status among Palestinian elderly living in long term care facilities in Palestine.

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14 Methodology 14 Study design Study Population Study location Cross sectional study Palestinian elderly live in long term care facilities 7 main cities in West bank; Jericho, Beit Jala, Beitlham, Ram Allah, Nablus, Jenin and Tolkarem Sample size Calculated 103, Final sample size 99 Sampling method Purposive sampling Collected data Scoiodemographic data Medical history Nutritional status Psychological status (depression) Cognitive function

15 Methodology 15 Parameters Assessment tools and method Nutritional Status assessment Functional Status Anthropometric measurements ( Weight, height, MUAC, WC, HC and CC) ( Nee & Lieman 2013) Meals patterns Food sufficiency Overnight fasting Mini Nutritional assessment ( Normal, 8-11 at risk, 0-7 malnourished) (Vellas et al., 1999) BMI: calculated and categorized according to WHO cut-off points Activity of daily living: using Validated Arabic version of KATZ (Nasser & Doumit, 2009) Psychological status Validated Arabic version of GDS ( Geriatric depression scale 15) Chaaya et al., 2008) Cognitive function Statistical analysis Using SPSS version 22 Using Validated arabic version of MMSE (mini mental status examination) Albanna et al., 2017)

16 Results, Subjects recruitment LTC houses were invited to participate in the study 4 houses refused participate Nablus: Three LTC houses (2 NGO, 1 Private), Jericho: One LTC house Governmental, Ram Allah:Three LTC houses (NGO) Tolkarem: One LTC house (NGO), Beitlaham: One LTC house (NGO) Biet Jala: One LTC houses (NGO) Jenin: One LTC house (NGO) 66 subjects were Excluded: 20 were not available at the house during data collection 5 refused to participate 41 ( history of dementia or psychiatric disease 7 houses agreed to participate Total residents number is subjects included in the final analysis.

17 Results- Sample characteristics 17 Gender Men Women Marrital status single married Divorced Widow/Widower 55% 45% 9% 24% 20% 47% Mean: 70.7±8.6 years, Range: 60-95, period of residency (38±18) months

18 Results- Sample characteristics 18 Parameter Men (n=45) Women (n=54) Total (n=99) P value Age <70 years 36 (80) 29 (54) 65 (65.7) 0.01* >70 years 9 (20) 25 (46) 34 (34.3) Marital Status Single (46.5) 0.01* Married (20.2) Divorced (9.1) Widow/widower (24.2) Level of Education No Formal Education (19.5) 0.026* Primary School (42.9) Secondary school (10.8) Diploma (5.70) University degree (3.80) * Significant at p<0.05 using Chi square test

19 Results- Medical history * * Significant at p<0.05 using Chi square test Men Women Total

20 Results-Nutritional Status- BMI Under weight Normal weight Over weight Obese Total Men Women * Significant at p<0.05 using Chi square test

21 Results- Malnutrition according to MNA Total Men Women 10 0 Normal At risk of malnutrition malnourished * Significant at p<0.01 using Chi square test

22 Results-Nutritional status 22 The meals number was same in all subjects as they consumed the meals following the LTC houses which are three main meals and 2 snacks. Meal skipping was reported in 5.9% of the participants The overnight fasting ranged from hours. The food sufficiency was reported to be always in all participants. The majority of the participants take their meals with company 74.5% 21.7% reported decrease or loss of appetite reported chewing problems.

23 Results 23 Functional, cognitive and psychological status of the participants parameter Total Men Women P value MMSE 19.2± ± ± * GDS 6.5± ± ± ADL 4.3± ± ± * Significant at p<0.05 using one way Anova test

24 24 Results- Association between MNA and other parameters MNA Normal Risk of malnutrition Malnourished P GDS Normal * Moderate Sever MMSE MMSE * MMSE< ADL Fully independent NA Moderate Sever functional impairment * Significant at p<0.01 using Chi square test

25 Conclusion and recommendations 25 Malnutrition has considerable prevalence among the study sample (24.2%) Around half of the participants were at risk of malnutrition (49.5%) Men have high prevalence of being malnourished The malnutrition was associated with cognitive decline, depression and functional status. Hence, there is a need to provide the elderly people living in long-term care facilities with health programs to enhance their overall health and decrease the level of dependency as well.

26 References 26 Cowan, D. T., Roberts, J. D., Fitzpatrick, J. M., While, A. E., & Baldwin, J. (2004). Nutritional status of older people in long term care settings: current status and future directions. International journal of nursing studies, 41(3), Doumit, J. H., Nasser, R. N., & Hanna, D. R. (2014). Nutritional and health status among nursing home residents in Lebanon: comparison across gender in a national cross sectional study. BMC public health, 14(1), 629. Furuta, M., Komiya Nonaka, M., Akifusa, S., Shimazaki, Y., Adachi, M., Kinoshita, T.,... Yamashita, Y. (2013). Interrelationship of oral health status, swallowing function, nutritional status, and cognitive ability with activities of daily living in Japanese elderly people receiving home care services due to physical disabilities. Community dentistry and oral epidemiology, 41(2), Hung, C.-W., Chen, Y.-C., Hsieh, W.-L., Chiou, S.-H., & Kao, C.-L. (2010). Ageing and neurodegenerative diseases. Ageing research reviews, 9, S36-S46. Lee, R. D., & Nieman, D. C. (1996). Nutritional assessment. Mahfouz, E., Mohammed, E., & El-Rhman, T. A. (2013). ASSESSMENT OF NUTRITIONAL STATUS OF ELDERLY POPULATIONS IN RURAL MINIA, EGYPT. Journal of Aging Research & Clinical Practice, 2(3). Nasser, R., & Doumit, J. (2009). Validity and reliability of the Arabic version of activities of daily living (ADL). BMC geriatrics, 9(1), 11. Onder, G., Carpenter, I., Finne-Soveri, H., Gindin, J., Frijters, D., Henrard, J. C.,... Liperoti, R. (2012). Assessment of nursing home residents in Europe: the Services and Health for Elderly in Long TERm care (SHELTER) study. BMC health services research, 12(1), 5. Pezzana, A., Cereda, E., Avagnina, P., Malfi, G., Paiola, E., Frighi, Z.,... Amerio, M. (2015). Nutritional care needs in elderly residents of long-term care institutions: Potential implications for policies. The journal of nutrition, health & aging, 19(9), Prince, M. J., Wu, F., Guo, Y., Robledo, L. M. G., O'Donnell, M., Sullivan, R., & Yusuf, S. (2015). The burden of disease in older people and implications for health policy and practice. The Lancet, 385(9967), Saxena, P. C. (2008). Ageing and age-structural transition in the Arab countries: Regional variations, socioeconomic consequences and social security. Genus, Sourdet, S., Rougé-Bugat, M., Vellas, B., & Forette, F. (2012). Frailty and aging. The journal of nutrition, health & aging, 16(4), Van Lancker, A., Verhaeghe, S., Van Hecke, A., Vanderwee, K., Goossens, J., & Beeckman, D. (2012). The association between malnutrition and oral health status in elderly in long-term care facilities: a systematic review. International journal of nursing studies, 49(12), Vellas, B., Guigoz, Y., Garry, P. J., Nourhashemi, F., Bennahum, D., Lauque, S., & Albarede, J.-L. (1999). The Mini Nutritional Assessment (MNA) and its use in grading the nutritional state of elderly patients. Nutrition, 15(2), WHO. (2015). World report on ageing and health: World Health Organization. Youssef, R. (2005). Comprehensive health assessment of senior citizens in Al-Karak governorate, Jordan.

27 Acknowledgment I would like to sincerely acknowledge the great Participation from my dearest students ( third year) at Therapeutic Nutrition program PPU, in data collection and the field work. Alaa Jaradat Mohammed khodour Razan Lahlalyah Zaheera Khodour Raheeq Mahmoud Azza Abdul Wahab

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