The impact of Functionality on the Nutritional Status of Institutionalized and Non institutionalized elderly living in Nairobi County, Kenya

Physiological changes in the elderly, the type and quality of their diet as well as physical activity in the elderly are influenced by many factors among them psychological, demographic, socio- economic and cultural factors which are more pronounced in the developing countries (Solomons, 2002).

The functionality of the elderly was found to impact on the nutritional status of the elderly and therefore the proposed null hypothesis that functionality of the elderly does not impact on the nutritional status of the elderly was rejected.

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The risk of suffering from malnutrition increases with age and with it, the weakening in carrying out ADLs. On the other hand, immobility is a major risk factor for the development of malnutrition (Schmid et al, 2003). Majority of all the respondents (both from non-institution and institutions of the elderly) required minimal assistance in carrying out activities of daily living (64.5%) and were found to have a MUAC of 22 or greater. Only 0.4 % of those who had a MUAC of 21 to 22 cm were highly dependent on their care-givers in carrying out activities of Daily Living. The results showed that there was a significant association between functionality and being malnourished using the MUAC (χ2=43.7, df = 2, p=0.000) with those with severe dependency being more likely to be malnourished. The elderly people who are dependent on others in carrying out ADLs and in mobility are especially at high risk of malnutrition (Gerber et al., 2003).

Over 80% of all the elderly living in institutions had minimal dependency in carrying out activities of daily living (ADLs) and a MUAC of 22 or greater. It is only 23.8 % of the elderly who had a MUAC measure of less than 21cm who were severely dependent on their care-givers or independent colleagues in the institution. Good Functional Independence measure (FIM) in non-institution was found to be significantly associated to good nutritional status (χ2=43.4, df = 2, p=0.000). According to Schmid et al., 2003, the risk for malnutrition increases with age and with a weakening of functional capabilities. The elderly people who are dependent on care-givers help and who have impaired ADL skills and mobility are especially at high risk of malnutrition (Gerber et al., 2003).

Sarcopenia is a geriatric syndrome which affects the functional status and mobility of individuals. It is characterized by progressive generalized loss of skeletal mass, strength and

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muscle function (Visser et al., 2011). A majority of 83% of the elderly living in non-institutions had minimal dependency in carrying out ADLs and a MUAC of 22 or greater. Only 6.7% of the elderly who had minimal dependency in carrying out ADLs had a MUAC of less than 21 cm. This can be attributed to loss of muscle mass which is associated with weakness, loss of independence, disability, higher risk of falls and decrease in quality of life (Landi et al., 2012). Good Functional Independence measure (FIM) at institution was found to be significantly associated to positive nutritional status (χ2=9.4, df = 2, p=0.053)

Over 35% of those who had a normal BMI had minimal dependency in carrying out activities of daily living, compared to 2.2% who were of nomal BMI, but had severe dependency. About 1% of the elderly who had severe dependeny were overweight. Five point two percent of the elderly who had moderate dependency were at risk of becoming overweight. There was no significant difference between BMI and dependency level of the elderly (χ2=7.44, df = 3, p=0.281). According to Crocan and Pasvogel, 2003, malnutrition, low body mass index and unintentional weight loss have negative impacts on the functional status and psychosocial well-being of the elderly. There is however an increased risk of functional limitations among elderly women with very high BMI (> 35kg/m2). This is because obesity acts synergistically with Sarcopenia causing disability in the elderly people, partly because of the low muscle quality (Villareal et al, 2004). There are proposals that Sarcopenic obesity be considered a significant health problem among the elderly (Villareal et al, 2004).

Only 0.4% of the elderly living in institutions of the elderly were underweight and with severe dependency. Only 2.2% of all the elderly who reported severe dependency in carrying out ADLs were of normal BMI. There was no significant relationship between the BMI and dependency level among the elderly living in institutions (χ2=11.791, df = 3, p=0.067). A study by Saeidlou

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et al in 2011 contrasts these findings, since it was found that there was lower occurrence of malnutrition among non-institutionalized elderly. Malnutrition among the elderly is often associated with functional impairement, disability and impaired health. The progressive decline in the ability to perceive and recognize food taste may lead to decreased food intake (Brownie, 2006). Although ageing does not lead directly to malnutrition, physiological changes associated with ageing can increase the risk of malnutrition (Merell et al., 2012).

Calf circumference is considered to provide the most senstitive measure of muscle mass in the elderly, and is superior to arm circumference. It indicates the changes in fat –free mass that occur with ageing and with decreased activity. Direct measurements of body composition are not possible in a large number of the elderly. It is therefore important to have good anthropometric reference data such as CC, which is fundamental in assessing the nutritional status and functionality of the elderly (Bonnefoy et al., 2002). Eighty percent of the elderly people living in Non-institutions had Severe Dependency in performing ADLs but had a CC of 31 or more centimeters. Sixty five point one percent of the elderly however had a CC of 31 or more and had minimal dependence on their care-givers in non-institutions. There was a significant relationship between the CC in cm and the Level of Dependency among the elderly living in non-institutions (χ2=3.93, df = 2, p=0.014). The majority of the elderly who had a Calf Circumference of 31 or greater (77.3%) had minimal dependence on their care-givers in the Institutions of the elderly, compared to 22.7% of the elderly who had a Calf Circumference of 31 cm or less. There was no significant difference between Calf Circumference and the Level of Dependency (χ2=2.19, df = 2, p=0.334). Calf circumference is a pertinent marker of nutritional state (Bonnefoy et al., 2002). In a study carried out in 2002, Bonnefoy et al., found that there was a significant correlation between CC and other nutritional anthropometric markers (r = 0.706, p<0.0001) with

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body mass index (BMI) and r = 0.661, p<0.0001 with fat free mass. Multiple regression confirmed associations between CC and BMI (p<0.0001) for both men and women.

The majority of the elderly in Institutions (85.9%) had no pressure sores or skin ulcers and reported minimal assistance in carrying out activities of Daily Living compared to 44% of those who had pressure sores and reported severe dependency on their care-givers in carrying out ADLs. There was a significant relationship between FIM and the presence or absence of pressure sores and skin ulcers (χ2=9.97, df= 2, p=0.007). Pressure ulcers can decrease the quality of life, thereby increasing the need for intensive nursing and medical care, besides a rise in morbidity and mortality rates (De Laat, 2005). Various studies have identified a number of factors as risk factors for the development of pressure ulcers. Some of the elderly related factors are limited mobility and activity levels (Lindgren, 2004), medical conditions such as diabetes mellitus (Haleem, 2008) alzheimer disease (Zulkowski, 1998), cardiovascular problems (Capon, 2007), orthopedic problems (Haleem, 2008), medications such as sedatives, analgesics and anesthetics (Grey, 2006), malnutrition (Vangilder, 2009), skin moisture (Grey, 2006) and urinary fecal incontinence (Achterberg, 2008)

A majority of the elderly men and women living in non-institutions had minimal dependency (77.5%) and had no Pressure Sores or Skin Ulcers. Sixteen point seven percent of the elderly who had severe dependency on their care-givers in carrying out ADLs had either Pressure Sores or Skin Ulcers. There was no significant difference between Dependency level among the elderly and the presence of Pressure Sores or Skin Ulcers (χ2=1.000, df = 2, p=0.605). Nursing related interventions such as the application of repositioning and the performance of nutritional care are

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also linked to the development of pressure ulcers (Posthaver, 2006) Structural factors in non- institutions and in institutions such as staffing, staff training and the presence and use of pressure ulcer guidelines (Alexander, 2008) play a role in the development of pressure ulcers.

Among the elderly women, 53.2% reported to have mild dementia whereas 4.8% had severe or mild dementia compared to only 1.7% of the men who had Severe Depression or Dementia. There was a significant relationship between both genders (χ2 =9.884, df = 2, p=.007) with females reporting more neuropsychological stress than their male counterparts. Elderly women and men aged 80  7 years who have dementia have a BMI of less than 23and this is associated with an increased risk of 7 year mortality (Faxen-Irving et al., 2005).

Dementia and depression are mental disorders found in approximately 30% of elderly people. They are seen to increase with age (Skoog, 2004). Severe Depression or Dementia was highest in the institutions of the elderly (5.4%), compared to non-institution (1.6%). However, it is the institutions of the elderly that were housing the highest number of elderly people with no psychological problems. Over 58% of the elderly in non-institution had Mild Dementia. There was a significant relationship between Neuropsychological problems and the type of residence (χ2 = 19.546, df = 2, p<0.001). Cognitive reserve decline may result in a reduced capability in functions such as orientation, memory, abstract thought and perception (Cullum et al., 2000). This is because dementia involves reduction in brain capacity, resulting to limitations in understanding and interpretation of the sorroundings (Whalley et al., 2004).

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5.6. Institutional and Non-institutional Characteristics of care-givers that impact on