Sima. Ghasemi; Farshad. Sharifi, MD; Shahrbano Maghsoodnia, MD;
Fariba Teimoori, MD; Asghar Dadkhah, PhD
University of social welfare and Rehabilitation Sciences
Iranian Research Center on Aging, Tehran

Correspondence
Dr. Asghar Dadkhah,
University of welfare and Rehabilitation,
Evin, Kudakyar Ave., Tehran 19834, Iran.
E-mail: asgaredu@uswr.ac.ir

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INTRODUCTION

The elderly are a vulnerable group of society all around the world and are taken into particular consideration. During recent years, due to reduced mortality, improved hygiene and increased life expectancy, the number of elderly is higher than any time in history and of each ten people in the world; one is more than 65 years old⁽¹⁾.
Also in Iran increased general population has led to increased number of elderly and according to the most recent data, 7/8% of population is 65 years old and older. Regarding the increase in population, it is predicted that this will reach 16% in next decades^(2,3). However, the elderly population distribution in the world and particularly in developing countries shows the importance of the increasing elderly population on future planning and since they are considered as a vulnerable group and the main health care consumers, it seems necessary to provide and perform proper health programs for them.
Age is accompanied by cognitive, metabolic and mood changes as a natural progressive and irreversible phenomenon occurring in each person's life. These changes are followed by changes in health and nutritional status. Nutrition as one of the most important parts of health can greatly influence healthy aging, disease prevention, and shortening of convalescence periods in the elderly. Data shows 30 to 60% of institutionalized elderly suffer from malnutrition^(4.5).
As it is always confirmed, the improvement and repair of nutrition quality starts with health education.
By means of proper education, we can prevent many nutritional problems and improve the nutritional health status of the elderly. So, we assessed the effect of the nutritional education program for Kahrizak foundation staff on increasing the nutritional health status of their inhabitants and proper intervention to improve the nutritional quality for the elderly.

Background
The nutritional status of the elderly can be affected by many factors including inadequate nutrient absorption, acute or chronic medical problems, drug therapy, physical or mental shortcomings, low income and social isolation.
Many of these factors compromise nutritional health status. Recent research concerning the nutritional status of the elderly, shows the high incidence of protein-calorie nutrient malnutrition in this group. For instance, the Rodman study showed that in 30 to 50% of institutionalized elderly, the bodyweight, arm circumference and serum albumin levels are below the normal standards⁽⁷⁾. Other studies show that weight loss and cachexia of the elderly are accompanied by increased mortality and health status disorders⁽⁷⁾.
Malnutrition can cause significant disability and abnormal functions^(8.9). The results of other studies in the elderly show a firm relationship between the nutritional status of elderly and their functional capacity⁽¹⁰⁾. Some of the malnutrition indices are strongly related to reduced functional capacity of the elderly and their inability to complete daily activities (ADLs), and this is regardless of their age and gender^(11,12,13). In another study, the effect of reduction in some nutritional indices such as body mass cells, Albumin, transferin, total cholesterol, hemoglobin, skin wrinkle thickness and body mass index (BMI), on worsening of function and daily activities was highlighted^(14-16). Other studies on home resident elderly show that in this group, in spite of living in their own homes, still 3 to 13% suffer from malnutrition^(17,18). According to the study on 92 elderly, 65 years old or more, in two governmental foundations in Tehran, in 25% of samples, the received energy was less than the recommended dose, and this was more prominent in men⁽¹⁹⁾. In another study in three private sanatoriums among 100 elderly 65 years old and more, 49/2% of women and 43/2% of men received less energy than the recommended dose. This study showed that 54% of low-weight women and 46% of low-weight men were suffering from malnutrition⁽²⁰⁾.
In another study on 170 65 year old elderly in Tehran, the following results were found : poor nutrition was seen in 52/9% of them and energy intake and all nutrients except vitamins B1 and B12 were more in elderly man than women. These elderly had a deficiency in most nutrients particularly vitamins B6 and B2 and from the viewpoint of energy intake 51% and protein intake 42%, were deficient. Anorexia, dental problems, singleness and/or living alone were effective factors in receiving nutrients, respectively⁽²¹⁾.
Proper nutrition is important in prevention of many ailments including degenerative diseases. According to one estimate one half to one third of health problems in the elderly are due to insufficient nutrient intake. Therefore improper nutrient intake in old age not only causes nutritional deficiency, but also facilitates many disorders of this period, indicating the need for intensive health care services. Then it is morally, economically and socially so important to take care of nutritional problems in the elderly (20). On the other hand, improving the nutritional status of the elderly is of the most important and basic parts of elderly health. Health education is an important issue in primary prevention and many studies have identified the role of health education in health improvement⁽²²⁾. So, we evaluated the effect of health education programs in improving the nutritional status of the elderly.

METHODS

This is a semi experimental interventional and prospective study. The main purpose is to determine the effect of health education programs for the staff on improving the nutritional status of the elderly living in Kahrizak foundation in Tehran.
Sampling and number of samples:
The qualified cases were randomly selected among 1100 institutionalized elderly of Kahrizak foundation. Regarding the previous studies, the prevalence of malnutrition was considered P=0/3 and based on the formula:
N= t2 p9 (t = 1/96, d = 0/06), the number of samples was calculated as 200.

Samples Criteria
In this study the elderly were 60 years old and more, and at least institutionalized for the last 2 months.
They did not have dialysis dependent renal failure or progressed liver failure. They did not undergo surgery 4 weeks prior to study and those with Nasogastric tubes or jejunostomy were not included.

Instruments and Methods
Data collection was via questionnaires designed into several parts. The first part included demographic data (age, gender), the second part contained questions concerning nutritional status, the third part was a Mini Nutritional assessment (MNA), the fourth part Activities of Daily Living (ADL) and the fifth part, the laboratory indices (Albumin, HB, HCT, LDL, HDL, CRP and FBS), the sixth part was about assessment of bed sore risk (Norton), the seventh part about brief cognitive state (Folstein) and the last part about the evaluation of drugs influencing the nutritional status of the elderly. These questionnaires were completed by 3 nutritionists, already trained in this field, prior to study and 4 months after it.

Validity and Reliability
We used content validity method, so that after using foreign and internal sources to design the questions, health and nutritional science specialists confirmed the scientific validity. In order to determine the scientific reliability of data collection instruments, we used repeated questionnaire evaluation method. So 10 qualified randomly chosen elderly completed the questionnaires twice within a 10 day interval. The results were analyzed by Pierson relationship method and no meaningful difference was found. Kapla ratio also showed no meaningful difference about inquires.

Educational program (Intervention)
In this research, the intervention was to perform an educational program (3 day workshop) for all medical, nursing, nutritional and administrative staff of Kahrizak foundation, parallel with problem solving and case studies. It was carried on in 2 levels regarding the educational level of staff for medical, nursing and nutritional staff, and others.

Analytical Method
After data collection, and before and after the educational program, data was encoded and computerized. Descriptive statistics including mean, standard deviation and frequency distribution were found by means of SPSS software and charts were drawn. Parametric and non-parametric paired tests and some other statistical tests were used to analyze the data.

Findings
Among 200 qualified samples, 192 were completely assessed (8 elderly did not cooperate). This included 142 women (74%) and 50 men (26%). The mean age was 77 years old with 8/9 SD. Women were mostly in 75-84 years age group (32/8%) and men mostly in the 66-74 years age group (12/5%). 94% of male elderly were single in a way, and only 3 were married. 73/2% of female elderly were widowed and only 7 (4/9%) were married. 59/9% of elderly women and 40% of men had children. The mean residency period in the institute was calculated as 40 months (3 years and 4 months).

Laboratory indices assessment prior to education
The mean serum Albumin level was 3/98 gr with 0/44 SD minimum 2/1 and maximum 5/3 gr/dL. The mean serum Albumin in women and men was 4 with 0/45 SD and 3/9 with 0/41 SD, respectively. 16/4 % women had Albumin equal to or less than 3/5 and 22% men had Albumin equal to or less than 3/5 gr/dL.
The mean Hemogolobin level of all samples was 12/68 mg/dL with 2/78 SD.
The mean hemoglobin in women and men was 12/56 with 2/91 SD and 13/03 with 2/39 SD, respectively. 51/5% of all samples had hemoglobin less than 12/5 and 32% of men had hemoglobin equal to or less than 13 mg/dL.
The mean hematocrit was 37/86 % with 5/3 SD, and 37/24% with 5/1 SD and 39/64 with 5/43 SD in women and men, respectively, 36/62% of women had HCT equal to or less than 36% and 28% of men had HCT equal to or less than 39.
The mean low density serum lipoprotein was 135/13 mg/dL with 44 SD.
The mean LDL in men was 124/4 with 42/2 SD and in women 138/87 with 44 SD. 31/6% of all samples had LDL less than 110, 32/8 % more than 150 and 35/6% had LDL 110-150. 40% of men had LDL less than 110 and 22/2% more than 150 and 37/2% had LDL 110-150. 23/7% of women had LDL less than 110 and 36/4% more than 150 and 34/9 % had LDL 110-150.
The mean HDL high density lipoprotein of all samples was 43/89 mg/dL with 11/5 SD, the mean HDL in women was 44/46 with 12/53 SD. 14% of women and 27/3% of men had HDL less than 35.
17/3% of all samples had HDL less than 35.
The mean fasting blood sugar was 81/42 mg/dL with 19/9 SD, and this was 82/59 with 20/75 SD in women and 80/02 with 17/23 SD in men. 21/7% of all samples had blood sugar less than 70 and 7/2 %, more than 110. 71/1% of all samples had blood sugar 70 - 110. 20/3% of women and 25/5% of men had blood sugar less than 70 and 8/3% of women and 4/3% of men had blood sugar more than 110. 71/4% of women and 70/1% of men had fasting blood sugar 70-110 mg/dL.

Assessment of questions concerning nutrition prior to education
Only 3 elderly were on special diets. Most of them (56/8%) had no problem with their sleep condition. 69/8% had good appetite and 52/1% were satisfied with their lives. 57/3 were not worried or anxious and 4/7% had recreational activities. 69/8% were not happy most of the times. 88% did not achieved ADL score in eating and only 12% (23 people) did.
72/4% had Norton score equal to or more than 14 and 27/1% of elderly had Norton score less than 14. 5/7% had MNA score less than 11 and 30/2%, 11-17 and 60/9% 17-23/5, and only 1/6% (3 people) had a score more than 23/5. 84/9% had no mouth disorder and 19/3% had swallowing problems. 29/2% (56 people) were taking one or two drugs affecting their nutritional state. Regarding the cognitive state of elderly 16/5 % had a score 5-7 and 83/5% a score more than 8. 27/1% of elderly had a CRP situation + 2 and + 3 and 7/8% + 1, and 58/9% had negative CRP.

Laboratory indices assessment after intervention
Mean albumin level of all samples was 4/11 gr/dL with 0/39 SD minimum 2/1 and maximum 5/2. Mean albumin in men and women was 4/16 with 0/31 SD and 4/1 with 0/42 SD, respectively. 5/1% of all samples had albumin equal to or less than 3/5 gr/dL. 7% of women had albumin equal to or less than 3/5 and all men had albumin more than 3/5.
Mean hemoglobin of all samples was 13/03 mg /dL with 1/88 SD. Mean hemoglobin in women and men was 12/67 with 1/75 SD and 14/04 with 1/86 SD, respectively. After intervention, 41% of women had a hemoglobin equal to or less than 12/5 mg/dL and 20% of men had a hemoglobin equal to or less than 13 mg/dL.
Mean hematocrit in all samples was 38/8% with 5/82 SD. Mean hematocrit in women and men was 38/6% with 4/69 SD and 40/79% with 7/83 SD, respectively. 31/7% of women had a hematocrit equal to or less than 36 and 26% of men had a hematocrit equal to or less than 39. Mean LDL of all samples was 146/25 mg/dL with 51 SD. Mean LDL in women and men was 147/58 with 52/5 SD and 141/7 with 46/07 SD, respectively.
25/5% had LDL less than normal and 41/4% had LDL more than normal range. 25/6% of women had LDL less than normal and 45/3% had LDL more than 150 mg/dL, 25% of men had LDL less than normal and 30% had LDL more than 150 gr/dL. After intervention, mean HDL was 42/85 mg/dL with 11/92 SD and 24/1% of all samples had HDL less than 35 mg/dL. Mean HDL in women was 44/9 mg/dL with 12/40 SD and 16/9% had HDL less than 35 mg/dL. Mean HDL in men was 36/77 mg/dL with 7/8 SD and 45% of men had HDL less than 35 mg/dL. Mean fasting blood sugar of all samples was 95/8 mg/dL with 29 SD. 6/2% of all samples had FBS less than 70 mg/dL and 16/7% more than 110 mg/dL. Mean FBS in women and men was 99/42 mg/dL with 31/5 SD and 85/47 mg/dL with 13/47 SD, respectively. 4/8 % of men and 20/8 % of women had FBS more than 110 mg/dL and 11/9 % of men had FBS less than 70 mg/dL. The comparison of mean blood indices for all samples and also according to sex prior to and after intervention is illustrated in Table 1.

Ethical considerations
Approval of the research as well as the national ethical committee was gained. Informed consent was signed by participants after explanation of purpose of the study, the direct and indirect benefits and risks, as well as confidentiality of collected data with their right to withdraw at any stage of the study.

Table 1. Laboratory indices according to sex prior and after intervention

Assessment of questions concerning the nutritional state after intervention:
81/3% of elderly had a Norton score 14 or more and 16/1% less than 14. 1/6% had MNA score less than 11, 16/7%, 11-17, 60/5%, 23/5 - 17 and 2/6% more than 23/5. Table 2 shows the comparison of MNA score prior to and after intervention.

Table 2. Assessment of nutritional state of elderly by means of MNA tool prior and after intervention

84% of all samples had no mouth disorder and 80% had no swallowing problem. 23/8% had a cognitive status score 8-7 and 76/2% had a score more than 8. The CRP status was +2 and +3 in 26% < +1 in 4/7% and negative in 62% of elderly.

DISCUSSION

Comparing the blood indices prior to and after education in both males and females using paired test with a certainty level of 95% the following results were found:

• There was a meaningful difference between serum albumin level in all samples prior to and after education (3/98 VS 4/11, p< 0/002 and T = 3/2).
• There was a meaningful difference between serum albumin level in males prior to and after intervention (3/9 VS 4/2 gr/dL, p< 0/003 and T = 3/2).
• There was no meaningful difference between mean serum albumin level in women prior to and after intervention (4 VS 4/1, p< 0/051 and T = 1/97).
• Overall 5% of samples had serum albumin less than 3/5 gr/dL and this was only in the female group.
• There was a meaningful difference between mean hemoglobin level prior to and after intervention (12/7 VS 13/03 mg/dL, p< 0/000 and T = 5/2), women had a mean hemoglobin level less than men.
• There was a meaningful difference between mean hemoglobin prior to and after education in men and women (women p< 0/001 and T = 3/53) and (men p< 0/000 and T= 4/07).
• There was a meaningful difference between mean hemoglobin levels prior to and after education (37/86 VS 38/8), (7=3/36 and p< 0/001). Also there was a meaningful difference between mean HCT levels in both women (37/24 VS 38/6 with p< 0/021 and T=2/4) and men (39/64 VS 40/8 with P< 0/027 and T= 2/3).
• There was a meaningful difference between mean LDL prior to and after intervention (135/13 VS 146/25 mg/dL), (T= 2/1 and P< 0/39).
  Overall prior to education 32/8% of samples had LDL more than 150, increasing to 41/4% following education. 31/6% of all samples had LDL less than normal, reducing to 25/5% following education.
• There was no meaningful difference between mean HDL prior to and after intervention (43/84 VS 42/85 mg/dL) (T= 0/19 and P< 0/89).
  Overall 25% of samples had HDL less than 35 mg/dL.
• HDL had a meaningful rise from 29/07 to 38/96 mg/dL (P<0/001).
• There was a meaningful difference between Fasting blood sugar prior to and after intervention from 81/92 to 95/8 mg/dL (P<0/000 and T= - 6/72). After intervention 10% of all samples had FBS more than 110 mg/dL.
• There was no meaningful difference in Norton score prior to and after intervention. 16/1% of all samples were at risk of bed sore and 81/3% were not. There was no meaningful difference about mouth disorders and swallowing problems prior to and after intervention.
  
• Those elderly with a good cognitive state increased from 16/5% to 23/8% and those with a worse cognitive state decreased from 83/5% to 76/2%. This was statistically meaningful (P<0/01).
  
• There was no meaningful difference in CRP situation prior to and after education.
  

5/7% of elderly had a MNA score less than 11 (profound malnutrition), decreasing to 1/6% (3 people) after education.
30/2 % had 11 to 17 score (severe malnutrition), 60/9 % had 17-23/5 score (threatened malnutrition), 1/6% had a score more than 23/5 (at no risk for malnutrition) all increasing to 16/7%, 60/5% and 2/6%, respectively.
Overall, MNA score difference using non parametric test prior to and after intervention, was meaningful (P<0/05).
Generally it was concluded that education was effective in improving blood indices such as albumin, hemoglobin and hematocrit, but it did not affect LDL, HDL and FBS.

Assessment of relationship between some variables and the nutritional state
Nutritional state was meaningfully related to Norton score (p<0/000), in other words, the higher the Norton score, the better the nutritional state. Nutritional state also had a meaningful relationship with mouth disorders (P<0/002), and swallowing problems, (P<0/05) and drugs (P<0/01). Also, the more severe the malnutrition, the higher the age of samples (P<0/013 ). There was no sex predilection.
Those with worse cognitive state, had worse malnutrition (P<0/01).
Those who were dependent regarding eating (ADL score) had a worse nutritional state (P<0/001). Also those who were dependent for their daily activities, had a worse nutritional state.

RESULTS

Overall, according to our research and MNA questionnaires, prior to education 35/9% of elderly had profound and severe malnutrition and 60/9% were at risk for malnutrition. The Rodman study in a group of institutionalized elderly showed 30-50% were below standard levels for body weight, arm circumference and albumin concentration⁽⁷⁾. Another study in Australia showed 35/4 - 43/1% of institutionalized elderly had moderate to severe malnutrition according to MNA score⁽²³⁾. Of course only 5% of samples had serum albumin less than 3/5 gr/dL; this may be due to abundant meat consumption of the elderly (because of people oblations) that serum albumin level is within normal limits. But other indices are less than normal.
The elderly are at risk for bed sore because of factors such as urinary incontinence, limited activity, kind of activity, cognitive state and nutritional insufficiency. This was assessed with Norton device. 27/1% of elderly were at risk for bed sore. The relationship between nutritional state with Norton score prior to and after education was meaningful. In another study in Florida, 38/4% of institutionalized elderly had bed sores. Another study also showed that malnutrition is more common in institutionalized elderly⁽²⁴⁾.
ADL score shows most elderly can independently perform their private activities except eating. This is concordant with studies in other countries⁽¹³⁾. Our research revealed that 88% of samples could not eat independently and need help.
Regarding the limited number of staff, this may jeopardize the nutritional state of the elderly. There was also a meaningful relationship between nutritional state and ADL score prior to and after education. Other studies show that the nutritional state of institutionalized elderly has a strong relationship with their functional state⁽⁸⁾. And some of the malnutrition indices have a very strong and independent relationship with their functional capacity regardless of age and gender (8 and 9).
Assessment of albumin level before and after education showed an increase in mean serum albumin of samples. Also mean hemoglobin, hematocrit, LDL, HDL, and FBS all increased after intervention.
After intervention 40/8% of women and 20% of mean had a hemoglobin level less than normal. This was concordant with the studies in other countries⁽⁵⁾. Men had a better nutritional state. These were also in concordance with other studies^(24,23,4,7).
Poly pharmacy is one of the risk factors for malnutrition and can lead to side effects such as increased or decreased appetite changes in test, constipation, weakness, drowsiness, diarrhea, nausea and so on. In our study, 29/2% of elderly were taking one or more drugs that could have an important role in their malnutrition.
Overall, we can conclude that:
Education is effective in improving albumin, hemoglobin and hematocrit, also in increasing MNA score and reducing those with moderate to severe malnutrition. LDL and FBS had also a meaningful difference prior to and after education, but HDL had a relative reduction which was not meaningful.

Suggestions
MNA scale showed 35/9% and 18/3% of elderly had severe and profound malnutrition respectively. So, the elderly were at risk for some nutritional indices and the following suggestions can improve their nutritional quality:

1. 1) Education is a basic factor in prevention and improving health in every society. So t job training for the staff seems necessary.
   
2. Since continuous education and its evaluation has an important role in maintaining results, we should keep on evaluating the education and its results to perform proper changes, if indicated.
   
3. Nutritional education is effective only when it is continuous and accompanied by a wide socio-economic development and improving the health of the general society particularly in vulnerable groups like the elderly.
   
4. Since most medical and health staff including physicians, technicians, nurses, cooks and others, they need proper nutritional information. We suggest that nutritional educational programs should be considered to improve the health state.
   
5. Continuous research and evaluation of nutritional state of institutionalized elderly should be done intermittently, so that we can recognize their nutritional deficiencies and treat them immediately.
   
6. Educational texts concerning different occupational responsibilities of staff should be provided. And all staff should be trained.
   
7. Education is also necessary for managers and laboratory staff, to facilitate management performance in improving the health state.

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