Obesity and Nursing Home Care in the United States: A Systematic Review

Factors Associated With the Ability of US Nursing Homes to Accept Residents With Severe Obesity

OBJECTIVES

Severe obesity in nursing home (NH) residents is associated with specialized care needs, limited mobility, and challenges in daily living. The COVID-19 pandemic strained NH resources and exacerbated staffing shortages. This study aimed to assess the ability of US NHs to accept and care for residents with severe obesity post-COVID, as well as associated NH factors.

DESIGN

Cross-sectional nationwide survey of NH administrators (2021-2022).

SETTING AND PARTICIPANTS

290 NHs from a national sample (n = 224) and a targeted sample in Massachusetts and New Jersey (n = 66).

METHODS

A survey designed to assess how NHs approach admitting and caring for people with severe obesity before and after COVID was fielded from 2021 to 2022. Responses were linked to facility information from the Certification and Survey Provider Enhanced Reports, Minimum Data Set, Nursing Home Compare, Area Health Resources File, and US Diabetes Surveillance System. Multivariable logistic regression was used to assess the effect of organizational and survey response variables.

RESULTS

Of the 2503 surveys sent to US NHs, 1923 were sent to the national NH stratified sample, and 580 were sent to the MA/NJ sample. Overall, 12% (301 of 2503) of NHs surveyed responded. The response rates were similar between the 2 samples. Of 290 NHs with complete data, 34% reported being unlikely to accept residents with severe obesity after COVID-19, compared with 25% before the pandemic (P < .001). The main barriers to acceptance were staffing shortages and difficulties meeting equipment and space needs. NHs with higher proportions of Black residents were more likely to admit individuals with severe obesity.

CONCLUSIONS AND IMPLICATIONS

The decline in acceptance of residents with severe obesity during and after COVID-19 highlights potential challenges that this population faces in accessing care. Our results also raise concerns that an intersection of disparities may exist in Black patients with severe obesity.

Hospital-acquired pressure injury prevention in people with a BMI of 30.0 or higher: A scoping review

AIM(S)

To: (1) explore current best practices for hospital-acquired pressure injury prevention in high BMI patients; (2) summarize nurses' experiences in preventing and managing them; (3) explore the association between a high BMI and occurrence and severity of pressure injury.

DESIGN

Exploratory.

METHODS

Scoping review.

DATA SOURCES

Ovid MEDLINE, EBSCO CINAHL Plus, JBI Evidence Synthesis, Scopus, Embase, clinical registries and grey literature (search dates: January 2009 to May 2021).

RESULTS

Overall, 1479 studies were screened. The included studies were published between 2010 and 2022. Five interventional studies and 32 best practice recommendations (Objective 1) reported low-quality evidence. Findings of thematic analysis reported in nine studies (Objective 2) identified nurses' issues as insufficient bariatric equipment, inadequate staffing, weight bias, fatigue, obese-related terminology issues, ethical dilemmas and insufficient staff education in high BMI patients' pressure injury prevention. No association between hospital-acquired pressure injury occurrence and high BMI were reported by 18 out of 28 included studies (Objective 3).

CONCLUSION

Quality of evidence was low for the interventional studies and best practice recommendations.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Current (2019) International Pressure Injury Guideline to be used despite the low quality of evidence of most best practice recommendations.

IMPACT STATEMENT

This study addressed hospital-acquired pressure injury prevention in high BMI patients. Greater proportion of studies in this review found no association between high BMI and occurrence of hospital-acquired pressure injury. Nurses need educational interventions on pressure injury prevention in high body mass index people, sufficient staffing for repositioning and improved availability of bariatric equipment.

REPORTING METHOD

We adhered to relevant EQUATOR guidelines, PRISMA extension for scoping reviews.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution. WHAT DOES THIS PAPER CONTRIBUTE TO THE WIDER GLOBAL CLINICAL COMMUNITY?: Larger clinical trials are needed on repositioning frequency, support surfaces, prophylactic dressings and risk assessment tools to inform clinical practice guidelines on pressure injury prevention in high BMI people.

PROTOCOL REGISTRATION

Wound Practice and Research (https://doi.org/10.33235/wpr.29.3.133-139).

Targeting Energy Intake and Circadian Biology to Engage Mechanisms of Aging in Older Adults With Obesity: Calorie Restriction and Time-Restricted Eating

With the rise in obesity across age groups, it has been a hindrance to engaging in physical activity and mobility in older adults. Daily calorie restriction (CR) up to 25% has been the cornerstone of obesity management even though the safety in older adults remains incompletely understood. Although some adults can follow CR with clinically significant weight loss and improved health metrics, CR faces 2 obstacles-many fail to adopt CR and even among those who can adopt it short term, long-term compliance can be difficult. Furthermore, there is a continuing debate about the net benefits of CR-induced weight loss in older adults because of the concern that CR may worsen sarcopenia, osteopenia, and frailty. The science of circadian rhythm and its plasticity toward the timing of nutrition offer promise to alleviate some challenges of CR. The new concept of Time-Restricted Feeding/Eating (TRF for animal studies and TRE for human studies) can be an actionable approach to sustaining the circadian regulation of physiology, metabolism, and behavior. TRE can often (not always) lead to CR. Hence, the combined effect of TRE through circadian optimization and CR can potentially reduce weight and improve cardiometabolic and functional health while lessening the detrimental effects of CR. However, the science and efficacy of TRE as a sustainable lifestyle in humans are in its infancy, whereas animal studies have offered many desirable outcomes and underlying mechanisms. In this article, we will discuss the scope and opportunities to combine CR, exercise, and TRE to improve functional capacity among older adults with obesity.

Trends in Obesity Prevalence among US Older Adults in the Last Two Years of Life, 1998-2018

CONTEXT

The prevalence of obesity has grown in the US over the decades. The temporal trends of body mass index categories in the last two years of life are poorly understood.

OBJECTIVES

To describe the trends in body mass categories in the last two years of life over the past two decades controlling for other demographic changes.

METHODS

We performed a cross-sectional study of prospectively collected survey data from the nationally representative Health and Retirement Study (HRS) among decedents who died between 1998 and 2018. We categorized BMI into five categories and calculated the proportion of decedents with each BMI category during each four epochs (1998-2003, 2004-2008, 2009-2013, 2014-2018). We examined trends in regression models with survey wave groupings modeled as an orthogonal polynomial and adjusted for factors commonly associated with BMI: sex, age, race, ethnicity, education, and tobacco use.

RESULTS

The analytic cohort included 14,797 decedents. From 1998-2003 to 2014-2018 time periods, those categorized as having mild-to-moderate obesity in the last two years of life increased from 12.4% to 14.8% (linear trend P < 0.001), a 19% increase. Severe obesity increased from 1.9% to 4.3%, a 126% increase (linear trend P < 0.001). Underweight decreased from 9.9% to 5.9%, a 40% decrease (linear trend P < 0.001), adjusted for demographic factors. Adjusted quadratic temporal trends for BMI category were nonsignificant, except for in mild-to-moderate obesity.

CONCLUSION

Severe obesity has increased greatly while underweight has decreased. As obesity increases in the final years of life, it is critical to assess how the existing and future palliative services and end of life care system address body size and weight.

Challenges to Systems of Long-Term Care: Mapping of the Central Concepts from an Umbrella Review

The ageing of the population poses urgent challenges to the health and social protection sectors, including the need for greater adequacy and integration of health care services provided to older people. It is considered necessary and urgent to understand the state-of-the-art of community-based models of care for older people in institutional care and at home. This study aims to map the concepts that politicians and providers need to address through an umbrella review as a review method. Articles describing the structuring aspects of care models appropriate to the needs in long-term care and systematic reviews or meta-analyses targeting people aged 65 years or more were considered. A total of 350 studies met the inclusion criteria and were included in the review. The results identified the need to contribute to effective and more efficient integration and articulation of all the stakeholders, based essentially on professional care at the patient's homes, focused on their needs using the available technologies, empowering patients and families. Eight categories emerged that addressed factors and variables involved in care models for the long-term care needs of institutionalised and home-based older people as a guarantee of accessibility to healthcare and to enhance the well-being and quality of life of patients and family caregivers.

An exploration of the challenges of providing person-centred care for older care home residents with obesity

The aim of this study was to explore care home staff's views on the prevalence of obesity in older people and how well prepared they were for any rise in applications for placements. Thematic analysis was used to analyse focus group interview data collected from seven care homes/33 participants in N.E. England. Findings revealed rises in demand by older people with obesity for care home admittance, consistent with rising prevalence of obesity in this demographic nationally. Findings also highlight implications of rising prevalence of obesity in older people, particularly care home staff's ability to deliver person-centred care (PCC) and the importance of appropriate support/recognition of this as an emergent issue to be addressed at a higher executive level and by health/social care authorities. Ways of ensuring PCC are discussed. Given continuing trends towards rising prevalence of obesity in this population, the findings possess broader translational potential.

Prevalence Rates and Characteristics of Malnutrition, Frailty, and Other Nutrition and Muscle Mass-Related Conditions Document Potential Quality of Care Gap for Medicare Patients in US Skilled Nursing Facilities

Changes to the payment structure of the United States (U.S.) healthcare system are leading to an increased acuity level of patients receiving short-term skilled nursing facility care. Most skilled nursing facility patients are older, and many have medical conditions that cannot be changed. However, conditions related to nutrition/muscle mass may be impacted if there is early identification/intervention. To help determine the diagnosis and potential impact of nutrition/muscle mass-related conditions in skilled nursing facilities, this study evaluated 2016–2020 US Medicare claims data. Methods aimed to identify a set of skilled nursing facility claims with one or more specific diagnoses (COVID-19, malnutrition, sarcopenia, frailty, obesity, diabetes, and/or pressure injury) and then to determine length of stay, discharge status, total charges, and total payments for each claim. Mean values per beneficiary were computed and between–group comparisons were performed. Results documented that each year, the total number of Medicare skilled nursing facility claims declined, whereas the percentage of claims for each study diagnosis increased significantly. For most conditions, potentially related to nutrition/muscle mass, Medicare beneficiaries had a shorter length of skilled nursing facility stays compared to those without the condition(s). Furthermore, a lower percentage of these Medicare beneficiaries were discharged home (except for those with claims for sarcopenia and obesity). Total claim charges for those with nutrition/muscle mass-related conditions exceeded those without (except for those with sarcopenia). We conclude that although the acuity level of patients in skilled nursing facilities continues to increase, skilled nursing facility Medicare claims for nutrition/muscle mass-related conditions are reported at lower levels than their likely prevalence. This represents a potential care gap and requires action to help improve patient health outcomes and skilled nursing facility quality metrics.

Nursing home directors of nursing experiences regarding safety among residents with obesity

The prevalence of nursing home (NH) residents with obesity is rising. Perspectives of NH Directors of Nursing (DONs) who oversee care trajectories for residents with obesity is lacking. This study aimed to describe the experiences of NH DONs regarding care and safety for NH residents with obesity. An adapted version of Donabedian's structure-process-outcome model guided this qualitative descriptive study. Semi-structured interviews were conducted with 15 DONs. Data were analyzed using directed content analysis, and findings are presented under the model's constructs. We learned that admission decisions for NH referrals of patients with obesity are complex due to reimbursement issues, available space and resources, and resident characteristics. DONs described the need to coach and mentor Certified Nursing Assistants to provide safe quality care and that more staff education is needed. We identified novel findings regarding the challenges of short-term residents' experience transitioning out of care due to limited resources.

Association of body composition with functional capacity and cognitive function in older adults living in nursing homes

BACKGROUND

Older adults living in nursing homes have an increased risk of adverse outcomes. However, the role of body composition in vital health and quality of life parameters such as functional capacity and cognitive function is less studied in this group of older adults compared to community-dwelling counterparts.

OBJECTIVE

The aim of the present study was to examine the association of body composition with functional capacity and cognitive function in nursing home residents.

METHODS

Fifty-three older adults (82.8±7.3 years) were enrolled in this study and they underwent body composition evaluation, functional capacity and cognitive function measurements.

RESULTS

The results showed a high prevalence of obesity accompanied by functional capacity limitations and cognitive impairment in older adults living in nursing homes. Partial correlations, controlling for age, showed that body fat percentage was positively correlated with sit-to-stand-5 (r=0.310, p=0.025) and timed-up-and-go (r=0.331, p=0.017), and negatively correlated with handgrip strength test results (r=-0.431, p<0.001), whereas greater lean body mass was associated with better sit-to-stand-5 (r=-0.410, p=0.003), handgrip strength (r=0.624, p<0.001) and cognitive function performance (r=0.302, p=0.037).

CONCLUSIONS

These important associations reinforce the need to develop effective healthy lifestyle interventions targeting both lean mass and body fat to combat functional and cognitive decline in nursing home residents.

Health behavior among Polish institutionalized older adults: the effect of resiliency mediated by satisfaction with life

Aim

Resiliency and satisfaction with life are identified as factors related to health behavior in the general population. However, little is known about health behavior and its predictors in public nursing home residents. The purpose of the study was to establish the nature of the relationship between resiliency, satisfaction with life, and health behavior in institutionalized older adults in Poland.

Subject and methods

A cross-sectional study with purposive sampling was performed in public nursing homes in Poland. A total of 161 male and female senior residents aged 60 to 99 (Mean = 76.65, SD = 9.23) were examined. Mediation analysis was performed with the Hayes’ PROCESS macro.

Results

This study revealed that resiliency, satisfaction with life, and health behavior are positively associated with each other in older persons. Satisfaction with life plays a mediating role in the relationship between resiliency and health behavior in residents of long-term care institutions.

Conclusion

Our findings underscore the important role played by personal resources in strengthening interventions and supporting the efforts of nursing home residents to engage in health behavior.

The Use and Meaning of the Term Obesity in Rural Older Adults: A Qualitative Study

The term "obesity" is associated with societal stigma and discrimination. Eight individual semi-structured interviews and five focus groups with 29 community-dwelling, rural older adults with obesity, seven primary care clinicians, and four rural community leaders were completed using purposive and snowball sampling. Clinicians perceived that older adults are less affected by obesity stigma than younger adults, yet this was not observed by community leaders; however, older participants with obesity reported that they often felt ashamed and/or stigmatized because of their weight. There was also a disconnect between clinician and older adult understanding of obesity. For older adults with obesity, the word "obesity" was associated with negative connotations. Just as physiological aspects of obesity persist into older adulthood, so do psychological aspects, such as perceptions of stigma. The use of the word "obesity" in medical settings may hinder communication between clinician and older participants. Heightened awareness may change the dialogue around obesity.

Proposed cut-off points for anthropometric and bioelectrical measures based on overweight and obesity criteria in Spanish institutionalised elderly people

The increasing prevalence of obesity among the institutionalised elderly population and its severe consequences on health requires an early and accurate diagnosis that can be easily achieved in any clinical setting. This study aimed to determine new cut-off values for anthropometric and bioelectrical impedance measures that are superior to body mass index criteria for overweight and obesity status in a sample of Spanish institutionalised elderly population. A total of 211 institutionalised older adults (132 women, aged 84.3±7.3 years; 79 men, aged 81.5±7.3 years) were enrolled in the current cross-sectional study. Anthropometric and bioelectrical impedance measures included the body mass index, waist circumference, gluteal circumference, waist-hip ratio, sagittal-abdominal diameter, trunk fat, and visceral-fat ratio. In women, the waist circumference, gluteal circumference, sagittal-abdominal diameter, trunk fat, and visceral-fat index presented strongly significant specificity and sensitivity (area under the curve [AUC], p<0.0001) and elevated discriminative values (receiver operating characteristic [ROC] curves: 0.827 to 0.867) for overweight and obesity status. In men, the waist-hip ratio, waist circumference, gluteal circumference, sagittal-abdominal diameter, trunk fat, and visceral-fat ratio were strongly significant AUC (p<0.0001), with moderate-to-high values (ROC curves: 0.757-0.871). In conclusion, our findings suggest that gluteal circumference, waist circumference, and sagittal-abdominal diameter in women and trunk fat, visceral-fat ratio, and waist circumference in men may represent more suitable cut-off values superior to body mass index criteria for overweight and obesity in the Spanish institutionalised elderly population.

Addressing Obesity to Promote Healthy Aging

The population worldwide is aging and prevalence of obesity in this population is increasing. The range of consequences that effect these at-risk patients include increased risk of falls, fractures, reduced quality of life, and cognitive decline. This article describes the epidemiology of obesity, risks and benefits of weight loss, and importance of treating obesity to help promote healthy aging. Health care professionals should encourage older adults with obesity to implement healthy lifestyle behaviors including exercise and diet routine. Treating obesity in older adults mitigates the significant public health crisis, and reduces health care utilization and risk of long-term adverse events.

Organizational and Geographic Nursing Home Characteristics Associated With Increasing Prevalence of Resident Obesity in the United States

Nursing home resident obesity increases the complexity of nursing care, and nursing homes report avoiding residents with obesity when choosing which prospective residents to accept. The objective of this study was to examine the associations between nursing home obesity prevalence rate and nursing home organizational, staffing, resident, and geographic factors within a profit maximization framework. The study cohort included U.S. Centers for Medicare and Medicaid Services data from U.S. nursing homes in 2013. Study findings supported hypothesized associations between obesity prevalence rate and higher occupancy, higher bed capacity, and multi-facility affiliation, but findings did not support a relationship between obesity prevalence rate and for-profit status.

Relationship between mobility and cognitive impairment in patients with Alzheimer's disease

OBJECTIVE

Alzheimer's disease (AD) is usually accompanied by impairments to mobility, performance of the basic activities of daily life (ADL), and progressive cognitive decline. We analyzed the relationship between cognitive performance and related cognitive subdomains and mobility.

PATIENTS AND METHODS

All AD patients of the recruited individuals were living in nursing homes; they underwent a blood analysis, cognitive examination by using the Mini-Mental State Examination, functional evaluation of independence in the ADLs with Barthel score and Katz index, and mobility assessment with the elderly mobility scale.

RESULTS

The mean sample age was 84 years and majority were women; more than 60% of the participants had severe cognitive impairment. Statistically significant relationships were found between the severity of cognitive impairment and functional capacity (p <  0.01) and their degree of mobility (p <  0.05). Among the different domains, memory impairment was not associated with impaired mobility or ability to perform the ADLs. Women had lower scores in the ADL and mobility assessments (p <  0.05) and an increased ratio of severe cognitive impairment (OR = 3.03 95% CI: [1.30, -7.05]) compared to men. Being overweight or obese and high blood levels of HDL cholesterol were directly (p <  0.05) and inversely (p <  0.01) associated with poor cognitive performance in individuals with mild to moderate cognitive dysfunction, respectively.

CONCLUSIONS

This study shows that better functional capacity and mobility are generally, but not exclusively, correlated with better cognitive function, depending on the severity of cognitive impairment. In contrast, lipid profile alterations might play a role in cognitive deficits in individuals with mild to moderate cognitive impairment who are overweight. Further longitudinal studies will be required to explore this possibility.

Obesity and intensive staffing needs of nursing home residents

The objective of this study is to examine how increasing body mass index (BMI) among nursing home residents affects the amount of staffing assistance needed for activities of daily living (ADL). We analyzed 1,627,141 US nursing home residents reported in the 2013 Minimum Data Set in seven BMI categories, from underweight (BMI < 18.5 kg/m²) to obesity Class IIIB (≥50 kg/m²). Logistic regression models estimated the odds of nursing home-reported need for extensive (≥2 staff member) assistance needed for ADLs. The adjusted odds increased from 1.07 (95% Confidence Interval (95%CI) 1.06-1.08) for Class I, 1.16 (95%CI 1.14-1.17) for Class II, 1.33 (95%CI 1.31-1.35) for Class IIIA, and 1.90 (95%CI 1.86-1.95) for Class IIIB obesity residents compared to residents of normal weight. As a nursing home resident's BMI increases, especially for BMI ≥40 kg/m², the need for extensive staffing assistance with ADLs also increases substantially.