Malnutrition and falls risk in community-dwelling older adults

Global prevalence of falls in the older adults: a comprehensive systematic review and meta-analysis

BACKGROUND

With increasing life expectancy, declining mortality, and birth rates, the world's geriatric population is increasing. Falls in the older people are one of the most common and serious problems. Injuries from falls can be fatal or non-fatal and physical or psychological, leading to a reduction in the ability to perform activities of daily living. The aim of this study was to determine the prevalence of falls in the older people through systematic review and meta-analysis.

METHODS

In this systematic review and meta-analysis, the data from studies on the prevalence of falls in the older people in the world were extracted in the databases of Scopus, Web of Science (WoS), PubMed and Science Direct, and Google Scholar, Magiran and Scientific Information Database (SID) without any time limit until August 2020. To analyze the eligible studies, the stochastic effects model was used, and the heterogeneity of the studies with the I² index was investigated. Data analysis was conducted with Comprehensive Meta-Analysis software (Version 2).

RESULTS

In the review of 104 studies with a total sample size of 36,740,590, the prevalence of falls in the older people of the world was 26.5% (95% CI 23.4-29.8%). The highest rate of prevalence of falls in the older people was related to Oceania with 34.4% (95% CI 29.2-40%) and America with 27.9% (95% CI 22.4-34.2%). The results of meta-regression indicated a decreasing trend in the prevalence of falls in the older people of the world by increasing the sample size and increasing the research year (P < 0.05).

CONCLUSION

The problem of falls, as a common problem with harmful consequences, needs to be seriously considered by policymakers and health care providers to make appropriate plans for preventive interventions to reduce the rate of falls in the older people.

A Technological-Based Platform for Risk Assessment, Detection, and Prevention of Falls Among Home-Dwelling Older Adults: Protocol for a Quasi-Experimental Study

BACKGROUND

According to the United Nations, it is estimated that by 2050, the number of people aged 80 years and older will have increased by 3 times. Increased longevity is often accompanied by structural and functional changes that occur throughout an individual's lifespan. These changes are often aggravated by chronic comorbidities, adopted behaviors or lifestyles, and environmental exposure, among other factors. Some of the related outcomes are loss of muscle strength, decreased balance control, and mobility impairments, which are strongly associated with the occurrence of falls in the elderly. Despite the continued undervaluation of the importance of knowledge on fall prevention among the elderly population by primary care health professionals, several evidence-based (single or multifaceted) fall prevention programs such as the Otago Exercise Program (OEP) have demonstrated a significant reduction in the risk of falls and fall-related injuries in the elderly within community settings. Recent studies have strived to integrate technology into physical exercise programs, which is effective for adherence and overcoming barriers to exercise, as well as improving physical functioning.

OBJECTIVE

This study aims to assess the impact of the OEP on the functionality of home-dwelling elderly using a common technological platform. Particularly, the impact on muscle strength, balance, mobility, risk of falling, the perception of fear of falling, and the perception of the elderly regarding the ease of use of technology are being examined in this study.

METHODS

A quasi-experimental study (before and after; single group) will be conducted with male and female participants aged 65 years or older living at home in the district of Porto. Participants will be recruited through the network COLABORAR, with a minimum of 30 participants meeting the study inclusion and exclusion criteria. All participants will sign informed consent forms. The data collection instrument consists of sociodemographic and clinical variables (self-reported), functional evaluation variables, and environmental risk variables. The data collection tool integrates primary and secondary outcome variables. The primary outcome is gait (timed-up and go test; normal step). The secondary outcome variables are lower limb strength and muscle resistance (30-second chair stand test), balance (4-stage balance test), frequency of falls, functional capacity (Lawton and Brody - Portuguese version), fear of falling (Falls Efficacy Scale International - Portuguese version), usability of the technology (System Usability Scale - Portuguese version), and environmental risk variables (home fall prevention checklist for older adults). Technological solutions, such as the FallSensing Home application and Kallisto wearable device, will be used, which will allow the detection and prevention of falls. The intervention is characterized by conducting the OEP through a common technological platform 3 times a week for 8 weeks. Throughout these weeks, the participants will be followed up in person or by telephone contact by the rehabilitation nurse. Considering the COVID-19 outbreak, all guidelines from the National Health Service will be followed. The project was funded by InnoStars, in collaboration with the Local EIT Health Regional Innovation Scheme Hub of the University of Porto.

RESULTS

This study was approved on October 9, 2020 by the Ethics Committee of Escola Superior de Enfermagem do Porto (ESEP). The recruitment process was meant to start in October, but due to the COVID-19 pandemic, it was suspended. We expect to restart the study by the beginning of the third quarter of 2021.

CONCLUSIONS

The findings of this study protocol will contribute to the design and development of future robust studies for technological tests in a clinical context.

TRIAL REGISTRATION

ISRCTN 15895163; https://www.isrctn.com/ISRCTN15895163.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/25781.

Identifying and Managing Malnutrition, Frailty and Sarcopenia in the Community: A Narrative Review

Malnutrition, frailty and sarcopenia are becoming increasingly prevalent among community-dwelling older adults; yet are often unidentified and untreated in community settings. There is an urgent need for community-based healthcare professionals (HCPs) from all disciplines, including medicine, nursing and allied health, to be aware of, and to be able to recognise and appropriately manage these conditions. This paper provides a comprehensive overview of malnutrition, frailty and sarcopenia in the community, including their definitions, prevalence, impacts and causes/risk factors; and guidance on how these conditions may be identified and managed by HCPs in the community. A detailed description of the care process, including screening and referral, assessment and diagnosis, intervention, and monitoring and evaluation, relevant to the community context, is also provided. Further research exploring the barriers/enablers to delivering high-quality nutrition care to older community-dwelling adults who are malnourished, frail or sarcopenic is recommended, to inform the development of specific guidance for HCPs in identifying and managing these conditions in the community.

Relationship Between Oral Health and Fractures in Community-Dwelling Older Japanese Adults

OBJECTIVE

To investigate the relationship between poor oral health and the incidence of fall-related fractures in older Japanese individuals.

DESIGN

A 9-year prospective cohort study.

SETTING AND PARTICIPANTS

Participants comprised 937 community-dwelling older Japanese adults aged 70 years or older. They all lived in the Tsurugaya district, a suburban area of Sendai city, and underwent comprehensive geriatric assessment, including an oral examination, in a public facility.

MEASUREMENTS

The exposure variables were related to oral health status (posterior occlusal support, number of remaining teeth, and occlusal force). The outcome measure was the incidence of fall-related fractures, which was determined by National Health Insurance data. Analyzed covariates included age, sex, medical history, smoking, alcohol drinking, educational level, depressive symptoms, cognitive impairment, physical function, body mass index, and history of falls. Statistical relationships were examined by calculating hazard ratios (HRs) at 95% confidence intervals (CIs) using the Cox proportional hazard model.

RESULTS

In the multivariate analysis, the HRs of fall-related fractures were significantly higher in those with unilateral posterior occlusal support (HR, 2.72; 95% CI, 1.13-6.55) and no posterior occlusal support (HR, 2.58; 95% CI, 1.29-5.15) than in those with bilateral posterior occlusal support. The HRs (95% CIs) of fall-related fractures in individuals with 10-19 and 1-9 teeth and edentulous individuals were 1.77 (0.81-3.89), 2.67 (1.24-5.75), and 2.31 (1.01-5.28), respectively, compared to those with ≥20 teeth.

CONCLUSIONS AND IMPLICATIONS

Poor oral health status is a risk factor for the incidence of fall-related fractures in community-dwelling older Japanese individuals. The findings suggest that attention should be focused on oral health status to further understand the risk of fall-related fractures among community-dwelling older adults.

Poor Appetite and Eating Difficulties Can Predict the Long-Term Risk of Falling: A Longitudinal Study in Middle-Aged and Older Adults

OBJECTIVES

This study investigates whether self-reported nutritional status affects falling among middle-aged and older adults.

METHOD

We used 8-year follow-up data from the Taiwan Longitudinal Study on Aging. At baseline, respondents' appetite, changes in amount of food intake, and eating difficulties were assessed in a questionnaire-based survey in addition to anthropometric measurements (body mass index, mid-arm circumferences, and involuntary body weight loss). Their associations with falls in the follow-up were examined using multivariable log-binomial regression.

RESULTS

The study included 2,519 respondents aged 50 years and older. Poor appetite (prevalence ratio [PR] = 1.25, 95% confidence interval [CI] = [1.07, 1.46]) and eating difficulties (PR = 1.16, 95% CI = [1.02, 1.32]) significantly predicted falling 8 years later with adjustments for sociodemographics, health behaviors, comorbidities, and anthropometric measures by taking into account probabilities of follow-up.

CONCLUSION

Poor appetite and eating difficulties can predict falling in the long-term independent of anthropometric measurements among middle-aged and older adults.

Combined Depression and Malnutrition As an Effective Predictor of First Fall Onset in a Chinese Community-Dwelling Population: A 2-Year Prospective Cohort Study

This study aims to explore the single and joint effects of depression and malnutrition on the incidence of first fall onset in a Chinese community-dwelling elderly population. This cohort study consisted of 739 residents without a history of falls who were aged 60 years and older (mean age: 67.08 ± 5.79 years, female: 58.2%). Depression was defined with the Geriatric Depression Scale (GDS)-30; a score of ≥11 was considered to be depressed, while malnutrition was defined with the Mini Nutritional Assessment where a score <17 was defined as malnourished. Over a 2-year follow-up period, older adults who experienced at least one fall were allocated to the first fall onset group. The prevalence of baseline falls was 21.36%. During the 2-year follow-up, incidence of first fall onset was 13.13%. After adjusting for all confounders, depression alone (adjusted odds ratio [OR] = 3.545, 95% confidence interval [CI] = 1.318-9.535) and malnutrition alone (adjusted OR = 2.204, 95% CI = 1.183-4.108) were observed to be independent risk factors for first fall onset, while comorbidity of depression and malnutrition showed progressively increased risk of promoting first fall (adjusted OR = 8.161, 95% CI = 3.591-18.545) than those with only depression or malnutrition or without both depression and malnutrition. Malnutrition mediated 56% effects in the association between depression and first fall onset, while depression mediated 76% effects in the promoting role of malnutrition in first fall. Depression and malnutrition were found to be independent causes for promoting first fall, while mental health and nutrition should be treated as commonly prior interventions to delay first fall onset. Meanwhile, for malnourished Chinese community-dwelling older adults, avoidance or treatment of depression should be addressed at first.

Nutritional strategies to reduce falls risk in older people

A literature review found an association between increased falls risk and malnutrition, sarcopenia, vitamin D deficiency and dehydration. Strategies to identify, prevent and treat these conditions can help to reduce falls risk in at-risk groups such as frail, older people. Nurses can reduce falls risk in older people by raising awareness of risk factors and embedding nutritional strategies in local falls reduction strategies.

A predictive model of isolated and recurrent falls in functionally independent community-dwelling older adults

BACKGROUND

Aging is associated with an increased risk of accidental falls. Falls in older people have been widely studied in nursing homes and in the elderly with poor functionality, but there have been few investigations into functionally independent community-dwelling older adults.

OBJECTIVE

To determine the predictive factors for falls in functionally independent community-dwelling older adults.

METHODS

A cohort trial-nested case-control study was carried out. The participants were community-dwelling people aged 70 and over who were treated in primary care centers from December 2012 to May 2014 in la Ribera (Valencia, Spain).

RESULTS

There were a total of 374 participants, with a mean age of 76.1 (SD 3.4) years (63.8% females). The subjects presented high functionality scores: Barthel 96.5 (SD 9.4), Lawton 7.2 (SD1.2), Tinetti 25.6 (SD 3.3). The mean number of prescribed drugs was 4.7 (SD 2.9). The cumulative incidence of falls was 39.2%, and 24.1% of these older adults suffered falls. The number of falls in the previous 12 months (OR=1.3; 95%CI: 1.11-1.53; p<0.001) and alpha-blockers (OR=6.72; 95%CI: 1.62-27.79; p=0.009) were predictors of falls. The presence of previous fractures (OR=9.55; 95%CI: 4.1-22.25; p<0.001), a body mass index of ≥30kg/m² (OR=1.09; 95%CI: 1.01-1.19; p=0.035), and who are using benzodiazepines and beta-blockers (OR=2.77; 95%CI: 1.53-5.02; p<0.001), were predictors of recurrent fallers.

CONCLUSIONS

Older people who use alpha-blockers, benzodiazepines and beta-blockers, had previous fractures, with increased body mass index are more likely to fall.

Is being malnourished according to the ESPEN definition for malnutrition associated with clinically relevant outcome measures in geriatric outpatients?

Background and aim

A body of evidence is supporting the association between (the risk of) malnutrition in relation to physical performance, muscle strength, risk for depression and cognitive status in geriatric outpatients. Associations between being malnourished according to the newly proposed ESPEN definition for malnutrition and clinically relevant outcome measures of the aforementioned variables have not been confirmed yet. Therefore, the aim of this study was to examine the association between being malnourished according to the ESPEN definition and clinically relevant outcome measures in geriatric outpatients.

Methods

Associations between malnutrition and handgrip strength (HGS, kg), short physical performance battery (SPPB-score, points), timed up and go test (TUG, seconds), and hospital anxiety and depression scale (HADS depression score, points), were analysed using linear regression. History of falls (falls, yes/no) and a low score on the Mini Mental-State Examination (MMSE-score ≤ 24 points) were analysed using logistic regression. All analyses were adjusted for age and gender.

Results

A total of 185 geriatric outpatients (60% women) were included. The mean age was 82 (± 7.3) years. Being malnourished (8.2%) according to the ESPEN definition was significantly associated with a lower HGS (− 3.38 kg, p = 0.031), lower SPPB score (− 1.8 point, p = 0.025), higher TUG time (1.35 times higher time, p = 0.020) and higher HADS depression score (2.03 times higher score, p = 0.007). Being malnourished tended towards an association with falls (OR 3.84, p = 0.087). No significant association was found with low MMSE score (OR 2.61, p = 0.110).

Conclusion

This study is the first to confirm the association between being malnourished, defined by the ESPEN definition and clinically relevant outcome measures in geriatric outpatients.

Nutritional Risk is Associated with Chronic Musculoskeletal Pain in Community-dwelling Older Persons: The PAINEL Study

Malnutrition is a risk factor for noncommunicable diseases related to ageing, and it can also contribute to musculoskeletal health. This study investigated whether nutritional risk is associated with chronic musculoskeletal pain in community-dwelling older persons. Nutritional risk was assessed by the DETERMINE Checklist. Chronic musculoskeletal pain was defined as the presence of pain in the past six months that did not disappear for at least 30 consecutive days. Multivariate logistic regression including confounding variables was used for the analysis. The sample was comprised of 383 participants (age 75.6 ± SD 6.1); the majority were at moderate-to-high nutritional risk (69%) and approximately one third presented chronic musculoskeletal pain (30%). The nutritional risk score was independently associated with chronic musculoskeletal pain: adding one unit in the risk score produces an 11% increment in the odds of presenting pain (OR 1.109, 95% CI 1.022-1.204). Individuals classified into moderate- or high-risk categories also had substantially higher odds (∼90%) of presenting chronic musculoskeletal pain when compared to those in the low-risk category, although our findings were only marginally significant. This is the first study to demonstrate the association between nutritional risk and chronic musculoskeletal pain above and beyond the contributed effects from relevant confounders.

Poor nutritional status is associated with a higher risk of falling and fracture in elderly people living at home in France: the Three-City cohort study

Falling and fractures are a public health problem in elderly people. The aim of our study was to investigate whether nutritional status is associated with the risk of falling or fracture in community-dwelling elderly. Poor nutritional status was significantly associated with a higher risk of both falling and fractures.

INTRODUCTION

Nutrition could play a role to prevent falls and fractures. The purpose of this study is to investigate whether a poor nutritional status is associated with the risk of falling and of fracture in community dwelling elderly.

METHODS

Baseline nutritional status of participants was assessed using the Mini Nutritional Assessment (MNA). After a follow-up of 12 years, 6040 individuals with available data for falls and 6839 for fracture were included. People who presented the outcomes at baseline were excluded. Cox models were used to evaluate the associations between nutritional status and the risks of fall or fracture.

RESULTS

The frequency of poor nutritional status (MNA ≤ 23.5), at baseline, was respectively 12.0% in the "fall study sample" and 12.8% in the "fracture study sample." Incident fall and fracture over 12 years were reported in 55.8 and 18.5% of the respective samples, respectively. In multivariate models controlled for sociodemographic data and several baseline health indicators, poor nutritional status was significantly associated with a higher risk of falling (hazard ratio (HR) = 1.66, 95% confidence interval (95% CI) 1.35-2.04 in men and HR = 1.20, 95% CI 1.07-1.34 in women) and with a higher risk of fracture (HR = 1.28, 95% CI 1.09-1.49).

CONCLUSION

Poor nutritional status was associated with a higher risk of both falling and fractures in French elderly community-dwellers. Early screening and management of the nutritional status may be useful to reduce the frequency of these events in older people.

Malnutrition and risk of falling among elderly without home-help service--a cross sectional study

OBJECTIVES

The aim of this study was to explore the frequency of malnutrition risk and associated risk of falling, social and mental factors among elderly without home-help service. The aim was also to explore factors associated with risk of falling.

DESIGN

A cross-sectional design was used.

SETTING

Elderly persons own homes.

PARTICIPANTS

Data were collected during preventive home visits to 565 elderly (age range 73-90 years) without home-help service. Those with complete SCREEN II forms were included in the study (n = 465).

MEASUREMENTS

MEASUREMENTS included rating scales regarding malnutrition risk (SCREEN II) and risk of falling (Downton). In addition, single-items: general health, satisfaction with life, tiredness, low-spiritedness, worries/anxiety and sleeping were used.

RESULTS

According to the SCREEN II, 35% of the sample had no malnutrition risk, 35% had moderate risk and 30% had high malnutrition risk. In an ordinal regression analysis, increased malnutrition risk was associated with being a woman living alone (OR 4.63), male living alone (OR 6.23), lower age (OR 0.86), poorer general health (OR 2.03-5.01), often/always feeling tired (OR 2.38), and an increased risk of falling (OR 1.21). In a linear regression analysis, risk of falling was associated with higher age (B 0.020), not shopping independently (B 0.162), and low meat consumption (B 0.138).

CONCLUSION

There are complex associations between malnutrition risk and the gender-cohabitation interaction, age, general health, tiredness, and risk of falling. In clinical practice comprehensive assessments to identify those at risk of malnutrition including associated factors are needed. These have to be followed by individual nutritional interventions using a holistic perspective which may also contribute to reducing the risk of falling.

Correlation between nutritional status and comprehensive physical performance measures among older adults with undernourishment in residential institutions

PURPOSE

The consequences of combined undernourishment and decreased physical performance in older adults are debilitating and increases cost of care. To date, the information regarding the association between nutritional status and physical performance does not provide a complete picture. Most studies used limited or self-reported measures to evaluate physical performance. The objective of this study was to examine the correlation between nutritional status and comprehensive physical performance measures among undernourished older adults who reside in residential institutions.

METHODS

Forty-seven older adults (26 males, 21 females) aged ≥ 60 (69.23 ± 8.63) years who were identified as undernourished from two residential institutions participated in this study. A battery of physical performance tests (10 m gait speed test, dominant hand grip strength test, timed five-repetition sit-to-stand test, ten step test, arm curl test, scratch test, and respiratory muscle strength test), biochemical profiles (serum albumin, hemoglobin, serum ferritin, and prealbumin levels), and falls risk using the short-form Physiological Profile Approach were performed. The Functional Ability Questionnaire and Geriatric Depression Scale were also administered.

RESULTS

The results demonstrated that generally older adults with undernourishment scored poorly on the physical performance tests, had depression, and a high risk of falls. Biochemical results demonstrated that 10.9% of the participants were anemic, 63% had hypoalbuminemia (<3.5 g/dL), and 21.7% were at risk of protein energy malnutrition with prealbumin level (100-170 mg/L). A significant correlation (P<0.05) was demonstrated between hand grip strength and ferritin, between self-reported mobility dependence and prealbumin levels, and between self-reported mobility tiredness and body mass index.

CONCLUSION

These results confirm that older adults with undernutrition have poor physical function, higher falls risk, and depression. Clinically, overall health that includes nutritional status, physical function, and depression level should be taken into consideration in the assessment and treatment of older adults residing at residential institutions.

Mini Nutritional Assessment and short-form Mini Nutritional Assessment can predict the future risk of falling in older adults - results of a national cohort study

BACKGROUND & AIMS

Falling is a major issue in geriatric health. Tools that identify individuals at risk of falling can help reduce the risk of falling. The study aimed to determine whether the full and short-form Mini Nutritional Assessment (MNAs) have the ability to predict the risk of falling in older adults.

METHODS

Subjects were 3118 ≥ 53-year old Taiwanese who completed both the 1999 and 2003 "Taiwan Longitudinal Study on Aging" surveys. We rated these subjects with normalized versions of the MNA and applied the standard cut-offs to define under-nutrition (≤23.5 and ≤11 points, respectively). We used multivariate logistic regression analysis and receiver operating characteristics to evaluate the ability of these tools in predicting the risk of falling three years later.

RESULTS

Older adults rated as at risk of malnutrition with the full MNA (OR = 1.87, 95% confidence interval = 1.33-2.63, p < 0.001) or the short-form (1.39, 1.07-1.80, p = 0.014) were associated with increased risk of falling three years later. Both versions significantly predicted the risk of falling and performed slightly better in ≥65-year old persons than in younger (53-64-year old) persons. The short-form performed relatively well compared to the full scale.

CONCLUSIONS

Results suggest that the full and short-form MNAs, in addition to rating the risk of malnutrition, also predict the risk of falling in older adults. Although the short-form is slightly less effective than the full scale in predicting the future risk of falling, its simplicity, effectiveness and efficiency make it ideal as a multipurpose screening tool in clinical settings.