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DEVELOPMENT OF A NEW DEVICE FOR IDENTIFICATION OF NUTRITIONAL NEEDS OF DYSPHAGIC INPATIENTS

 

F. Bortolazzi1,2, A. Calabrò2, M. Pesce2, U. Tortorolo1, T.F. Piccinno3, M. Masini3, C. Chiorri3,4

 

1. Korian srl, Italy; 2. Gruppo Insieme srl, Italy; 3. VIE srl, spin off of the Università degli Studi di Genova, Italy; 4. Università degli Studi di Genova, Italy. Corresponding author: T.F. Piccinno, VIE srl, spin off of the Università degli Studi di Genova, Italy, piccinno@vie-srl.com

Jour Nursing Home Res 2019;5:27-32
Published online June 12, 2019, http://dx.doi.org/10.14283/jnhrs.2019.6

 


Abstract

Objectives: Dysphagia in elderly patients can cause serious health problems. The aim of this study was to investigate the effects of a new method for the identification of the elderly dysphagic patient. We hypothesized that a simple identification device could reduce errors in providing food and therefore reduce negative outcomes. Design: Two group of participants were enrolled (experimental and control). Each patient received a diagnosis of the severity of his/her own dysphagia disorder on a scale ranging from 1 (no swallowing problem) to 5 (unable to swallow). Inpatients of the experimental group only worn a bracelet with a specific color code for each level of the dysphagia disorder. Operators were trained to check the bracelet color and provide the corresponding diet to the patients. Participants were tested three times over a two months period. Setting: The participants were hospitalized in three nursing homes of the same institute. The colored bracelet method was adopted in two of these nursing homes. Participants: Fifty-five participants were enrolled for the study (44 in the experimental group, 78% female, mean age = 88.9±6.6 years). Forty-two operators (86% female, 64% of age between 36 and 55)) filled in an evaluation questionnaire. Measurements: Several measures of nutrition, hydration, and clinical condition were collected. Results: The method significantly improved hydration (p = .002) and BMI (p = .010) and reduced the risk of bedsore (p < .001) of the patients. Conclusion: The colored bracelet method is an effective instrument for managing the diet of elderly dysphagic inpatients.

Key words: Dysphagia, malnutrition, nutritional intervention, aged, nursing homes.


 

 

Background and objective

Dysphagia is an alteration in the swallowing process due to degeneration and ageing of involved organs.
The number of dysphagic inpatients in rehabilitation centres and residential structures is going to increase with the extension of life expectancy. Dysphagia occurs in 15% to 23% of older persons living in the general non-patient population and it is prevalent in hospitalized patients (1).
Dysphagia may lead to serious health and life-threatening complications such as malnutrition and aspiration pneumonia (2). Malnutrition from dysphagia is considered a risk factor for pressure ulcers in elderly people (3). Errors in providing the correct type of nutrition to the patients could have serious consequences such as suffocation, aspiration pneumonia, denutrition, dehydration and, eventually, death. A recent study (4) showed that patients who suffered from dysphagia or malnutrition had poor outcome with regard to mortality, and that patients suffering from both dysphagia and malnutrition had the poorest outcome.
Guidelines of the International Dysphagia Diet Standardisation Initiative (IDDSI) and of the Italian Society of Artificial Nutrition and Metabolism (SINPE) for the management of dysphagic patients recommended that all patients with dysphagia should be assessed by a specialist (speech therapist) and should be referred to a dietitian to develop individual nutrition care plans.
Functional severity of dysphagia makes recommendations for nutritional therapy. The primary aim of nutritional therapy is to meet nutritional requirements of individuals and prevent adverse events such as aspiration pneumonia.
A simple and fast method to identify the severity of dysphagia in elderly patients could reduce the probability of feeding errors and, consequently, increase the health quality of patients.

Aim of the study

In this study, we aimed at investigating the effects on patients and operators of a device for the identification of severity of inpatients’ dysphagia using colored bracelets.
We hypothesized that the introduction of this method could improve the health of the inpatients, and could reduce the number of adverse events, such as feeding errors and consequently aspiration pneumonia. Specifically, we are interested in measuring the effects of the colored bracelets method on:
a)    nutrition of the inpatients
b)    hydration of the inpatients
c)    risk of bedsore of the patients

Furthermore, we were interested in evaluating the operators’ perception of the usefulness and ease of use of the device.

 

Methods

Design of the study

At the beginning of the study each patient received an evaluation of the severity his/her own dysphagia disorder by a speech therapist using Bedside Swallowing Assessment and the Smithard’s Three-oz Water Swallow Test (5). Patients with the most severe clinical conditions took also an instrumental phoniatric examination with Fiberoptic Endoscopic Examination of Swallowing (FEES). The evaluation of the severity of the dysphagia disorder ranged from 1 (no swallowing problem) to 5 (unable to swallow),  it  was identified by a different color-code (1 = green, 2 = blue, 3 = yellow, 4 = orange, 5 = red) and was associated to a specific diet. Three nursing homes were involved in the study: the participants of the experimental group were enrolled from two of them, while the control group was sampled from the third nursing home. The three clinics had similar procedures, patients had similar health and personal characteristics, and staff were equally trained and experienced. A colored bracelet indicating the severity of dysphagia was always worn by the patient of the experimental group. A speech therapist trained the operators every six month in the physiopathology of the dysphagia disorder and in the management of the diet of dysphagic inpatients. During this course, the operators of the experimental group were also trained to check the bracelet color and provide the corresponding diet to the patients. Participants of both groups were tested at the beginning of the study, i.e., before the introduction of the bracelet method (T0), after one month from the beginning of the study (T1), and after two months (T2).

Sample

Fifty-five participants were enrolled in the study (78% female, mean age = 88.9±6.6 years). Three participants died before the end of the study, therefore there were only 52 observations in T2. The experimental group included 44 inpatients, while the control group comprised 11 inpatients. Furthermore, 42 operators (86% female, 64% of age between 36 and 55, 71% with secondary school degree or higher) working in the nursing homes of the experimental group were asked to fill in a questionnaire to evaluate their perception of the of the usefulness and ease of use of the device for the identification of the dysphagia severity.

Measures

Several measures were collected to evaluate the nutritional status of the patients: Body Mass Index (BMI), Mini Nutritional Assessment (MNA) (6), and calorie intake through food.
BMI was calculated with the classical formula W/H2 (W = weight [kilograms]; H = height [metres]).
The MNA test comprises simple measurements and brief questions that can be completed in about 10’-15’. The full MNA includes 18 items grouped in 4 rubrics: a) anthropometric assessment; b) general assessment; c) short dietary assessment; and d) subjective assessment. It provides a single, rapid assessment of nutritional status in elderly patients. The MNA score distinguishes between elderly patients with adequate nutritional status (MNA ≥ 24 up to 30), patients at risk of malnutrition (MNA between 17 and 23.5) and patients with protein-calorie malnutrition (MNA < 17).
Calorie intake was estimated from the patient’s diet. The diet was prescribed according to the nutritional needs of elderly population indicated by the Italian Human Nutrition Society (SINU) (7). Each diet of the inpatients was determined accordingly considering age, sex and clinical status. Therefore, the calorie intake is an esteem of the nutritional needs.
Hydration was evaluated using three measures collected by a physician: blood pressure, tongue moisture, and skin turgor (the degree of elasticity of skin). Furthermore, a subjective hydration score (ranging from 0 = very low hydration to 5 = good hydration) was provided by the physician after a physical examination of the patient. Given the high correlation of these indices, a general hydration index (GHI) was calculated performing a principal component analysis (PCA) on these measures.
The risk of bedsore of the patient was measured with the Braden Scale for Predicting Pressure Sore Risk (BS) (8). It comprises six subscales representing the most common risk factors for pressure ulcers. It ranges from 6 to 23, with higher scores indicating lower risk of developing sores. A cutoff score of 18 is generally used to designate increased risk of pressure ulcer development. It has been shown that this measure has adequate levels of validity and reliability (9, 10).
Several other variables were collected from the medical records to obtain a more detailed assessment of the health of the patients and to be used as control variables in the statistical analyses. Alzheimer dementia, Parkinson’s disease, and stroke data were collected. Furthermore, comorbidity was measured with the Cumulative Illness Rating Scale (CIRS) (11). CIRS provides two scores (a) severity of the illness; and (b) comorbidity.
Two items were administered to the operators to investigate their perception of the usefulness and ease of use of the bracelet method. Both item responses were collected on a Likert scale ranging from 1 = “not at all” to 5 = “a lot”. We considered mean ratings of no less than 4 on either characteristic as a satisfactory result (12).

 

Results

Linear mixed models (LMMs) (13) were used to assess the effect of the use of bracelet on the measures of nutrition (BMI and MNA), hydration, and risk of bedsore while controlling for background and clinical characteristics.
Four LMMs were specified, one for each dependent variable (i.e., BMI, MNA score, GHI score, BS score). Predictors of the model were a) treatment (experimental or control), b) time of the observation (T0, T1, T2), c) daily calorie intake, d) severity of dysphagia, e) Alzheimer dementia diagnosis, f) Parkinson’s disease diagnosis, g) past stroke diagnosis, h) diabetes diagnosis, i) comorbidity (CIRS S and CIRS C scores), j) artificial nutrition with nasogastric intubation, k) sex, and l) age.. While the focus variables were treatment, and time, the rest of the predictors were included in order to reduce the bias in the estimate of the effect of the treatment due to the impossibility to randomly assign patients to treatment levels.
Results are reported in Figure 1 and in Tables 1. As for BMI, participants in the experimental group had a higher  BMI than controls (p = .035) and  an overall decrease of BMI over time (p = .031) was observed; also the group-by-time interaction was statistically significant (p = .014), due to  a decrease of BMI in the control group and a lack of substantial change  in the experimental group (Table 1 and Figure 1a).

Table 1
Results of the four linear mixed models performed (only fixed effects are shown)

Significance Codes: < 0.001 ‘***’; < 0.01 ‘**’; < 0.05 ‘*’; < 0.1 ‘.’

Figure 1
Group-time interaction effects for each dependent variable. Each dashed line represents a participant. Thick solid lines represent group means. Error bars represent 95% confidence intervals of the mean scores.

 

The LMM for MNA revealed a significant fixed-effect of diabetes on MNA (p = .018, inpatients with diabetes diagnosis had higher scores), but the group-by-time interaction was only marginally significant (p = .081). However, the mean score of the experimental group tended to increase from T0 to T2, while the mean score of the control group remained substantially stable (Table 1 and Figure 1b).

A significant fixed-effect of the amount of daily calorie intake (p < .001) on the GHI score was found, where higher amounts of daily calorie intake was associated to higher hydration scores. The group-by-time interaction was statistically significant (p = .002), showing an increase of the hydration level in the experimental group and a decrease in the control group form T0 to T2 (Table 1 and Figure 1c).
Finally, a significant fixed-effect of the group (p = .004) was found on the BS score: inpatients of the experimental group had lower scores on the BS and therefore higher risk of pressure sores; also the group-by-time interaction was statistically significant  (p < .001) due to a reduction of the sore risk in the experimental group from T0 to T2, while no change was observed in the control group (Table 1 and Figure 1d).
One-sample t-tests were used to test whether the operators’ ratings of usefulness and ease of the use of the device differed from the expected result (score 4). Both t-test revealed that the target rating was achieved since there were not a statically significant differences (Usefulness: M = 3.80±1.27; t(39) = -0.98, p = .331, d = 0.16; Ease of use: M = 3.75±1.31; t(39) = -1.19, , p = .241, d  = 0.19).

 

Conclusion

The aim of this study was to test the efficacy of a new method for the identification of elderly dysphagic patients in improving their health outcomes. The method uses a color code on a bracelet worn by the inpatients that indicates to the operator the severity of the dysphagia. Results supported the efficacy of the method as they showed an overall improvement of the health condition of the inpatients of the experimental group with respect to those of the control group. The average BMI of the patients in the experimental group was stable across time, while it decreased in the control group. Hydration level significantly increased in patients identified with bracelets, while it decreased in the other patients. Finally, participants of the experimental group had lower pressure sore risk over time. The method was also considered adequately useful and easy to use by operators. Taken together, these findings suggest that the colored bracelet method is an effective method to manage the diet of elderly inpatients and it has a positive impact on their nutritional status and health condition.
Some limitations of this study have to be acknowledged. It was not possible to randomly assign the participants in the experimental and control group. Then the sample resulted unbalanced, although its size is not small. In this study differences of the two groups were statistically controlled, but a different sampling with more participants could solve this issue in the future. Furthermore, the study last for only two months. Next studies should enrol a higher number of and they should be conducted for longer period. These changes in the design of the study should allow to evaluate the impact of the colored bracelet method on aspiration pneumonia and related death incidence in elderly dysphagic inpatients.

 

Conflict of interest: Dr. Bortolazzi (francesca.bortolazzi@email.it) reports personal fees from NOEMA CONGRESSI during the conduct of the study; to have other relationships with nursing homes in Genoa; and to be consultant of KORIAN group and GRUPPO INSIEME. Dr. Calabrò (alessiocalabro83@gmail.com) reports personal fees from NOEMA CONGRESSI during the conduct of the study; and to have other relationships with nursing homes in Genoa; and to be manager of GRUPPO INSIEME. Dr. Pesce (pesce.matteo1@gmail.com) reports to be consulent for SERENITA S.R.L. and CITTADELLA S.R.L. (GRUPPO INSIEME); Dr. Tortorolo (umberto.tortorolo@pcdo.it) reports to have other relationships with nursing homes in Genoa and to be health director in KORIAN group. Dr. Piccinno (piccinno@vie-srl.com) reports grants from Noema S.r.L. Unipersonale during the conduct of the study. Dr. Masini (masini@vie-srl.com) has nothing to disclose. Dr. Chiorri (carlo.chiorri@unige.it) has nothing to disclose.»

Ethical standard: All procedures performed in the study were in accordance with the ethical standards of the institutional and/or national research committee, and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

 

References

1.    Payne M, & Morley JE; Dysphagia, Dementia and Frailty. J Nutr Health Aging, 2018, https://doi.org/10.1007/s12603-018-1033-5
2.    Eglseer D, Halfens RJG, Schols JMGA et al. Dysphagia in hospitalized older patients:associated factors and nutritional interventions. J Nutr Health Aging, 2018, https://doi.org/10.1007/s12603-017-0928-x
3.    Neloska L, Damevska K, Nikolchev A, Pavleska L, Petreska-Zovic B & Kostov M. The association between malnutrition and pressure ulcers in elderly in long-term care facility. Open access Macedonian journal of medical sciences, 2016;4(3), 423 10.3889/oamjms.2016.094
4.    Huppertz VA, Halfens RJ, van Helvoort A, de Groot LCPGM, Baijens LWJ, & Schols JMGA.  Association Between Oropharyngeal Dysphagia and Malnutrition in Dutch Nursing Home Residents: Results of the National Prevalence Measurement of Quality of Care. J Nutr Health Aging, 2018;1-7 https://doi.org/10.1007/s12603-018-1103-8
5.    Smithard DG. Dysphagia management and stroke units. Current physical medicine and rehabilitation reports, 2016;4(4), 287-294.
6.    Vellas, BJ, Garry PJ, & Guigoz Y (Eds.). Mini Nutritional Assessment (MNA): research and practice in the elderly (Vol. 1). Karger Medical and Scientific Publishers, 1999
7.    Società Italiana di Nutrizione Umana SINU. LARN Livelli di Assunzione di Riferimento di Nutrienti ed Energia per la Popolazione Italiana–IV Revisione. SIdN Umana, Rome, 2014.
8.    Bergstrom N, Braden BJ, Laguzza A, Holman V . The Braden Scale for Predicting Pressure Sore Risk. Nurs Res; 1987;36: 205–10.
9.    Bergstrom N, Braden B, Kemp M, Champagne M, & Ruby E.  Predicting pressure ulcer risk: a multisite study of the predictive validity of the Braden Scale. Nurs Res, 1998;47(5), 261-269
10.    Braden BJ, Bergstrom N. Predictive validity of the Braden Scale for pressure sore risk in a nursing home population. Res Nurs Health, 1994;17(6), 459-470
11.    Linn BS, Linn, MW, & Gurel LEE. Cumulative illness rating scale. Jour Americ Geriat Soc, 1968;16(5), 622-626.
12.    Rosson MB, Carroll JM. Usability engineering. Scenario-based development of human-computer interaction. Morgan Kaufmann Publishers, San Francisco, 2001.
13.    Henderson CR. Applications of linear models in animal breeding (Vol. 462). University of Guelph, Guelph 1984.

IS MALNUTRITION A RISK FACTOR FOR INCIDENT URINARY TRACT INFECTION AMONG OLDER PEOPLE IN RESIDENTIAL CARE FACILITIES?

 

M. Burman1, C. Hörnsten1, M. Carlsson1, E. Rosendahl2, P. Nordström1, B. Olofsson3, Y. Gustafson1

 

1. Department of Community Medicine and Rehabilitation, Geriatric Medicine, Umeå University, Umeå, Sweden; 2. Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden; 3. Department of Nursing, Umeå University, Umeå, Sweden.  Corresponding author: M. Burman, Department of Community Medicine and Rehabilitation, Geriatric Medicine, Umeå University, Umeå, Sweden, SE-90187, maria.burman@umu.se.
Jour Nursing Home Res 2018;4:49-55
Published online November 19, 2018, http://dx.doi.org/10.14283/jnhrs.2018.10

 


Abstract

Background: Malnutrition and urinary tract infections (UTI) are common among older people living in residential care facilities. Objectives: To determine whether malnutrition is a risk factor for incident urinary tract infection in people aged ≥65 years living in residential care facilities. Design, Setting, and Participants: A prospective cohort study of people living in residential care facilities in northern Sweden (N=373). Data from the Frail Older People-Activity and Nutrition and Umeå Dementia and Exercise studies were used. Measurements: Malnutrition was assessed using the Mini Nutritional Assessment (MNA). Risk factors for UTI were explored using univariate and multivariate Cox proportional hazard regression analyses. Maximum follow-up time was 9 months. Results: The incidence of UTI was 460/1000 person-years; 85/276=30.8% of women and 16/97=16.5% of men contracted UTIs. History of UTI (hazard ratio [HR] 2.804, 95% confidence interval [CI] 1.824–4.311), heart failure (HR 2.101, 95% CI 1.368–3.225), hypertension (HR 1.656, 95% CI 1.095–2.504), and low Mini-Mental State Examination (MMSE) score (HR 0.937, 95% CI 0.892–0.985) were associated independently with higher risk of incident UTI in multivariate analyses. Malnutrition was not associated with UTI in the whole sample or in women; MNA score was associated with UTI in men in univariate analysis (HR 0.841, 95% CI 0.750–0.944). Conclusion: The incidence of UTI was high in residential care facilities and individuals with histories of UTI, heart failure, hypertension, or cognitive impairment were more likely to be affected. Malnutrition was not a risk factor for UTI in the whole sample or in women, but may constitute a risk for UTI among men.

Key words: Malnutrition, urinary tract infection, residential care, older people.


 

Introduction

Malnutrition is very common in older people (1, 2), especially among people in residential care facilities (3–5). It negatively affects physical and cognitive function, muscle mass, and cardiac output, and increases the risks of pressure ulcers, falls, institutionalization, and mortality (6, 7). Furthermore, malnutrition reduces the immune response, leading to an increased risk of infection (4, 6, 8–10). Malnutrition has been suggested to be among the most important risk factors for infection among older people (4), who generally have higher rates of infection due to physiological changes associated with aging (11–13). Older people in residential care facilities are especially susceptible to infection due to factors such as chronic disease, certain medications, cognitive decline, functional impairment, and the use of invasive devices, including urinary catheters, which may predispose them to infection (14).
Urinary tract infection (UTI) is the most common infection in residential care facilities (5, 11, 13, 15). In a Swedish study of older people living in such facilities, the annual incidence of UTI was 45% (3). More women than men are affected by UTIs (16), but the incidence of UTI in men increases with age and with the level of functional impairment (17), and for older men living in residential care facilities the difference in prevalence between men and women is less pronounced (18, 19). UTI in older people is associated with worse functional status and a higher morbidity rate (4, 15, 20); it is also a source of sepsis and death (21).
A previous study of older people identified unintentional loss of faeces, history of UTI, functional decline, level of education, and severe cognitive impairment as predictors of UTI in univariate analysis of people living in long-term care facilities (22). Diabetes mellitus has also been found to be a risk factor for UTI among older people (23, 24). It has previously been reported a cross-sectional association between a history of UTI in the previous year and a lower Mini Nutritional Assessment (MNA) score in a sample of older people that included many individuals living in residential care facilities (3, 25). To our knowledge, the most recent study to investigate whether malnutrition increases the risk of UTI among older people living in residential care facilities is a study from 1988 that included 97 participants (26). The aim of this study was to investigate whether malnutrition is a risk factor for incident UTI in a population of older people living in residential care facilities.

 

Methods

This prospective cohort study included data from the Frail Older People-Activity and Nutrition (FOPANU) (27) and Umeå Dementia and Exercise (UMDEX) (28) randomized controlled trials, which have been described in detail elsewhere. These studies involved 3- and 4-month social and physical activity interventions, respectively. In the FOPANU study, participants were also randomized to receive a protein-enriched supplement or placebo beverage. In both studies, people living in residential care facilities in Umeå, northern Sweden (N=1351), were screened for participation. Those aged ≥65 years with Mini-Mental State Examination (MMSE) scores ≥10 (29) who were dependent in personal activities of daily living (P-ADL), according to the Katz index (30), could stand up from a chair with armrests with help from no more than one person, and had physician approval to participate were included. In addition, participants in the UMDEX study were diagnosed with dementia, able to hear speech in a usual speaking voice from a distance of 1 m, and understood instructions in Swedish. Participants provided informed oral consent; when cognitive impairment was suspected or confirmed (including all UMDEX study participants), next-of kin were also asked to provide consent. The FOPANU and UMDEX studies were approved by the Ethics Committee of the Medical Faculty of Umeå University (§391/01) and the Regional Ethics Review Board of Umeå (2011-205-31M), respectively. Participants with documented MNA scores were selected for the present study. The final sample comprised 373 participants. During the maximum follow-up period of 9 months, 44 participants died and 15 participants withdrew from the study for other reasons. Figure 1 illustrates the sample selection process. No individual participated in both studies.
Malnutrition was assessed using the MNA, a validated and widely used tool for nutritional screening in older people. It comprises 18 questions; scores were classified as indicating malnutrition (<17), risk of malnutrition (17–23.5), and good nutritional status (24–30) (1, 31). Body mass index (BMI)was calculated as weight (in kilograms) divided by height (in meters) squared (32). The level of dependence in P-ADL was assessed using the Barthel index; the maximum score of 20 indicates independence in P-ADL (33, 34). The Berg Balance Scale (BBS) was used to assess balance, with scores ranging from 0 to 56 and lower scores indicating poorer balance (35). The MMSE was used to assess cognitive function, with scores ≤17 indicating severe cognitive impairment (29). The 15-item Geriatric Depression Scale was used to assess depressive symptoms. Scores of 5–9 were considered to indicate mild depression and scores of 10–15 were considered to indicate moderate or severe depression (36).
At baseline assessment, measurements, diagnoses, and medication use were registered. After the interventions, the incidence of UTI was ascertained systematically. Nurses working at the residential care facilities collected data on diagnoses, clinical characteristics, and prescribed drugs from participants’ medical records in the FOPANU study; in the UMDEX study, physicians reviewed medical records. In both studies, an experienced geriatrician evaluated diagnoses, drug treatments, and assessment scores to make final diagnoses. Depressive disorder and dementia were diagnosed according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders IV, Text Revision (37). The measure of incident UTI was based on clinical UTI diagnoses made by treating physicians. The physicians based the diagnoses on clinical symptoms, and used laboratory tests, urinary dipstick tests and/or bacterial cultures as diagnostic tool. In examining the occurrence of UTI in the previous year, we included participants with UTI at baseline, as a large proportion (26/33) of these individuals also had documented UTI in the previous year.

Statistical Analysis

SPSS software (version 22.0; IBM, Armonk, NY, USA) was used for statistical analysis. P values

 

Results

The mean age of study participants was 84.9±6.8 years and 276 (74%) participants were women. The mean MNA score did not differ between women and men (20.8±3.2 vs. 20.8±3.4, p=0.899). Eleven percent of participants were malnourished and 72% were at risk of malnourishment, according to MNA scores (Table 1).

Table 1
Characteristics of the sample with and without urinary tract infection (UTI) during the 9- month follow-up period

Values are presented as n (%) or as mean±SD. BMI= body mass index; GDS= Geriatric Depression Scale; MMSE= Mini-Mental State Examination; BBS= Berg Balance Scale; P-ADL=personal activities of daily living; MNA= Mini Nutritional Assessment; ASA= acetyl-salicylic acid. SSRI = selective serotonin reuptake inhibitor. * According to item in Barthel index.

 

Out of the 373 participants, 101 persons overall (27.1%), 85 of women (85/276=30.8%) and 16 of men (16/97=16.5%)contracted at least one UTI during the 9-month follow-up period. The incidence rate of UTI was 460 UTIs per 1000 person-years. Fifteen of 33 (45.5%) participants with baseline UTI had at least one UTI during follow up, compared with 86 of 340 (25.3%) persons with no UTI at baseline (p=0.013). Significantly more women than men had a UTI diagnosed in the previous year (43.8% vs. 30.9%, p=0.026).
The mean MNA score did not differ between participants with and without incident UTI (20.4±3.4 vs. 20.9±3.2, p=0.208; Table 1). However, MNA scores were significantly lower among those with a history of UTI in the previous year than among those with no such history (20.0±3.4 vs. 21.3±3.1, p<0.001). Additionally, during the 9-month follow-up period, 17.7% of participants with MNA scores ≥24 and 28.9% of those with MNA scores In univariate Cox proportional hazard regression analyses, female sex, low MMSE score, dependence in P-ADL, urinary incontinence, number of prescribed drugs, heart failure, hypertension, pneumonia in the previous year, and UTI in the previous year were risk factors for incident UTI during follow up (Table 2). History of UTI in the previous year, heart failure, hypertension, and low MMSE score were associated independently with higher risk of incident UTI in multivariate Cox proportional hazard regression analyses (Table 3). Exclusion of participants with baseline UTI (n=33) and adjustment for intervention activity type and protein supplement consumption did not alter the results (data not shown).

Table 2
Risk factors for urinary tract infection (UTI) in univariate analyses

Cox proportional hazard regression analyses of potential risk factors for UTI. Variables associated with UTI (p-value <0.15) in chi-squared or independent-samples t-tests were added to the analyses. The dependent variable was UTI during the 9-month follow-up period. HR= hazard ratio; CI= confidence interval; MMSE= Mini-Mental State Examination; P-ADL= personal activities of daily living. MNA= Mini Nutritional Assessment. * According to item in Barthel index.

 

Table 3
Risk factors for urinary tract infection (UTI) in multivariate analysis of the whole sample

Cox proportional hazard regression analysis. Variables significantly associated (p<0.05) with UTI in univariate Cox proportional hazard regression analyses were added to the multivariate analysis. Urinary incontinence was correlated with P-ADL and was excluded. The dependent variable was UTI during the 9-month follow-up period. HR= hazard ratio; CI= confidence interval; P-ADL= personal activities of daily living; MMSE= Mini-Mental State Examination.

 

In separate analyses of women, low MMSE score, dependence in P-ADL, urinary incontinence, arthritis, heart failure, pneumonia in the previous year, and UTI in the previous year were associated significantly with incident UTI (Table 2). For men, the number of prescribed drugs, heart failure, hypertension, urinary catheter use, pneumonia in the previous year, UTI in the previous year, and urinary retention were associated significantly with incident UTI. Also, a higher MNA score was associated with a lower risk of incident UTI for men, but not for women (Table 2).

Figure 1
Flow chart of the study population

 

Discussion

This study revealed a high incidence of UTI among older people living in residential care facilities. Malnutrition was not a risk factor for UTI in the whole sample or in women, but it seemed to be associated with UTI development in men in univariate analyses. History of UTI in the previous year, heart failure, hypertension, and low MMSE score were associated independently with incident UTI during the 9-month follow-up period. Although UTI was more common among women than among men, sex was not an independent risk factor for UTI.
The high incidence of UTI in the present study (460/1000 person-years or 1.3/1000 person-days) is in agreement with previous studies of older people living in residential care facilities (3, 38).
Malnutrition was not associated with the incidence of UTI in the present study, similar to the results of a study published in 1988. The study in question also investigated residential care facilities, however, malnutrition was assessed by blood albumin level, their sample only included 97 participants, and the age of participants ranged widely from 21 to 94 years (26). Malnutrition has been suggested to be an important risk factor for pneumonia and skin and soft-tissue infection, two other extremely common infections in older people (39–41). Furthermore, other authors have suggested that malnutrition is a risk factor for nosocomial infection (8, 42) and that malnutrition among people living in residential care facilities is associated with serious infection and/or death (43). However, for older people in residential care facilities, malnutrition does not appear to be a risk factor for UTI generally. However, in men, a low MNA score seemed to be associated with an increased risk of UTI in univariate analyses. Both malnutrition and the ageing process itself reduce the immune function and additionally older people tend to have fewer symptoms of infection (4). This might make it more difficult to diagnose symptomatic UTI in older people, as in the present study. However, despite this, a small but non-significant difference in MNA-scores was found between those who contracted an UTI and those who did not. Therefore, larger studies are needed to explore this possible association.
This study showed an association between history of UTI and low MNA score, as reported previously among people living in residential care facilities and very old community-dwelling women (3, 25). A possible explanation for this finding is that infection increases the risk that a person will become malnourished because of greater metabolic demand (4, 10). History of UTI was also a strong risk factor for UTI contraction, and individuals with UTI at baseline contracted another UTI more often than did those with no baseline UTI. These results are also in line with those published previously (22, 44).
Heart failure and hypertension were associated independently with incident UTI. Heart failure has previously been found to be a risk factor for UTI in older trauma patients (45). In addition, people with heart failure often have multiple non-cardiac (46) and cardiac (47) comorbidities (including hypertension). This factor may partly explain the associations of UTI with heart failure and hypertension in our sample. The number of prescribed drugs was also associated with incident UTI in univariate analyses; this number increases with age and disease burden (48). Several medications are also associated with adverse effects that increase the risk of infection (5, 14). Furthermore, polypharmacy is associated with an increased risk of urinary incontinence (49, 50), which in turn is associated with UTI (51, 52).
Low MMSE score was associated with incident UTI in the present study. A previous study found that low MMSE score was a risk factor for UTI contraction among older people (22). Cognitive impairment may increase the risk of infection by affecting a person’s ability to maintain personal hygiene (53). This factor may also explain our finding that dependence in P-ADL was associated with UTI. Individuals with cognitive decline can have difficulty communicating symptoms (11), and urinary sample collection can be problematic (53), which may render UTI diagnosis in these individuals difficult (54). The authors of a previous study suggested that the difficulty in communicating symptoms could lead to the underestimation of UTI in older people with dementia (38).
Surprisingly, female sex was not an independent risk factor for UTI. Although a large proportion of women in our sample contracted UTIs other factors than sex appear to contribute to UTI susceptibility. Furthermore, UTI risk factors differed partially between women and men, perhaps due to sex-based differences in the pathophysiology of this infection. Prostatic hypertrophy has been suggested to be among the most important factors predisposing men to UTI (18), which may explain the observed association of related variables – urinary retention and urinary catheter use – with UTI in men, but not in women. Urinary incontinence was associated with UTI in women, but not in men, in univariate analyses. The variable was excluded from the multivariate analysis of the whole sample because of correlation with the P-ADL variable. Urinary incontinence affects many older women in nursing homes (55) and has been associated with UTI previously (25, 52).

Study strengths and limitations

This study involved a large and well-defined sample of older people living in residential care facilities in Sweden, a large proportion of whom had dementia. All participants were assessed comprehensively and the sample was well defined regarding P-ADL and cognition. The inclusion of people with cognitive decline and/or dementia requires careful consideration, and next-of-kin were asked to give consent when cognitive impairment was suspected or confirmed in both studies.
Given that this was part of larger randomized controlled trials the exercise and nutritional interventions may have affected participants’ nutritional status. However, adjustment for intervention type and protein-enriched supplement receipt during the intervention did not change the results. Only 11% of participants were malnourished, although the sample comprised only people living in residential care facilities, the majority of whom were diagnosed with dementia. Furthermore, only 16 of 97 men contracted UTIs. These factors limited our ability to analyze malnutrition as a risk factor for infection.
The incidence of UTI has been reported to decrease with administration of intravaginal estriol to postmenopausal women with recurrent UTIs (56). Unfortunately, available information about estrogen supplementation in this sample did not specify whether administration was oral or vaginal; this variable was thus not analyzed in the present study.

 

Conclusion

The incidence of UTI was high among older people living in residential care facilities and individuals with histories of UTI, heart failure, hypertension, or cognitive impairment were more likely to be affected. Those with histories of UTI the previous year had a lower mean MNA score but malnutrition was not an independent risk factor for incident UTI in the whole sample or in women, but may constitute a risk for UTI among men. Identifying risk factors may contribute to the prevention of UTI and this is greatly needed, especially as UTI negatively affects social life and physical and psychological health (57).

 

Funding: This research was funded by The Swedish Research Council (K2009-69P-21298-01-4, K2009-69X-21299-01-1, K2002-27VP-14165-02B, K2002-27VX-14172-02B, K2005-27VX-15357-01A, K2014-99X-22610-01-6), The Swedish Dementia Foundation, The King Gustav V and Queen Victoria Foundation of Freemasons, The Faculty of Medicine at Umeå University, The Bothnia Atlantica Program, The County Council of Västerbotten, The Umeå University Foundation for Medical Research, The Ragnhild and Einar Lundström’s Memorial Foundation, Erik and Anne-Marie Detlof’s Foundation, The Vårdal Foundation, The Magnus Bergvalls Foundation, The Äldrecentrum Västerbotten, The Gun and Bertil Stohne Foundation, The Loo and Hans Ostermans Foundation, The Borgerskapet in Umeå Research Foundation, Forte – Swedish Research Council for Health, Working Life and Welfare (formerly FAS – Swedish Council for Working Life and Social Research; grant number 2012-0775), Norrmejerier, The Strategic Research Program in Care Sciences, Sweden, The Swedish Society of Medicine, and The Swedish Alzheimer Foundation.

Ethical standards: The FOPANU study was approved by the Ethics Committee of the Medical Faculty of Umeå University (§391/01) and the UMDEX study was approved by the Regional Ethics Review Board of Umeå (2011-205-31M).

Conflict of interest: The authors declare no conflict of interest.

 

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