Associations Between Nutritional Status and Health-Related Quality of Life Among Long-Term Care Residents in Helsinki

The study was designed to obtain a comprehensive picture of nutritional status, nutritional care, and related factors of older residents in institutional settings. We collected cross-sectional data in all long-term care facilities (nursing homes and assisted living facilities) in Helsinki, Finland. Assisted living facilities in Finland provide 24-hour care with a registered nurse in charge of the unit. The residents are similar to those in nursing homes, but the environment is more home-like. Altogether 54 long-term facilities with 3767 eligible residents participated in the study. The inclusion criteria were: age ≥ 65 years, living in long-term care, and sufficient information availability on demographic factors, MNA, and HRQoL. Altogether 2545 (68%) residents provided informed consent. Of these, 2160 had data on both MNA and 15D available and were included. The dropouts were either refusals or residents with dementia having no proxy to give informed consent.

Data were collected by registered nurses in March 2017. In each ward, a thoroughly trained nurse assessed residents’ nutritional status by the MNA and retrieved demographic information, diagnoses, and use of medications from medical records. They assessed HRQoL according to the 15D instrument.

The MNA gives a maximum score of 30 points. Less than 17 points indicates malnutrition, 17–23.5 risk of malnutrition, and 24 or more good nutrition status (16, 17). The MNA is validated and widely used internationally (17). In addition, each resident was weighed and body mass index (BMI) calculated as weight divided by height squared (kg/m2).

The 15D instrument is a validated, generic measure for HRQoL (18). The dimensions of 15D are mobility, vision, hearing, breathing, sleeping, eating, speech, excretion, usual activities, mental function, discomfort and symptoms, depression, distress, vitality and sexual activity. 15D can be completed during an interview with the subject or completed by proxy. It combines the advantages of a profile and a preferencebased, single-index measure (18). Score 0 indicates the poorest HRQoL and 1 indicates perfect HRQoL. The 15D scores are reliable, sensitive and responsive to change (18). The nurse most familiar with resident was interviewed if the subject was cognitively impaired. The 15D score has been calculated from all dimensions of the instrument. In this study, all participants responded to the question concerning sexuality “My state of health makes sexual activity almost impossible”. Thus, this question was excluded from the partial correlation analysis.

Comorbidities were evaluated with the Charlson Comorbidity Index (CCI), which takes into account both the number and severity of a person’s medical conditions. High score indicates a greater burden from comorbidities (19).

Cognitive functioning and dependence in ADL were assessed with questions retrieved from the Clinical Dementia Rating Scale (CDR). The “memory” question was used to evaluate the resident’s stage of cognition (0=no memory problems, 0.5=possible memory problems, 1=mild problems, 2=moderate problems, or 3=severe problems) and was categorized into two groups: those with CDR <2 and those with CDR ≥2. The resident’s dependence in ADL functions was evaluated by CDR “personal care” question (1=totally independent; 2=needs prompting, 3=requires assistance in dressing, personal hygiene, and keeping of personal belongings, 4=requires much help with personal care; often incontinent). CDR “personal care” ≥ 2 was defined as dependence in ADLs.

The use of snacks was inquired as follows “Does the resident eat snacks between meals?” (yes/no). The amount of offered food eaten by the resident was evaluated with the question “How much does the residents on average eat from the main meal?” with the five options, “eats only a little, eats less than half, eats half their meal, eats most of their meal or eats all or nearly all of their meal”. The nurses were informed to use images of model portions to estimate this. The responses “eats only a little and eats less than half” were dichotomized as eats inadequately and the response “eats half their meal, eats most of their meal or eats all or nearly all of their meal” as eats adequately.

The local ethics committee of Helsinki University Hospital approved the study. An informed consent was acquired from all participants or in case of moderate-severe dementia from their closest proxies.

The descriptive statistics are presented as means with SDs or as counts with percentages. Statistical significances for the unadjusted hypothesis of linearity across categories of MNA (<23.5, 17.-23.5 and <17) were evaluated by using the Cochran-Armitage test for trend and analysis of variance with an appropriate contrast. In the case of violation of the assumptions (e.g. non-normality), a bootstrap-type test was used. The relationships of MNA and 15D-score was evaluated by use of quadratic model (curvilinear correlation). Adjusted correlation (partial) coefficients MNA and 15D dimensions were calculated by the Pearson method, using Sidak adjusted probabilities. The normality of the variables was tested by using the Shapiro–Wilk W-test. Stata 15.1 (StataCorp LP, College Station, TX, USA) was used for the analysis.