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To examine the health and needs of extremely obese women aged over 65 years receiving home care in Europe. A cross-sectional assessment study based on the Aged in Home Care (AdHOC) project recruited 2974 women aged 65 or over who were receiving home care at 11 sites in European countries. Extreme obesity was defined as 'Obesity of such a degree as to interfere with normal activities, including respiration'. Resident Assessment Instrument for Home Care (RAI-HC version 2.0); Activity of Daily Living Scale; Instrumental Activity of Daily Living Scale; the Minimum Data Set Cognitive Performance Scale; and a health profile. One hundred and twenty women (4.0%) were extremely obese. They were younger than their thinner counterparts, with a median age of 78.3 versus 83.3 years, and they more often had multiple health complaints and needed more help with mobility outside the home. The extremely obese had received home care longer than the non-extremely obese (median 28.7 versus 36.6 months). Extremely obese women also needed more help with personal care than the other group and, due to lower age, they were less cognitively impaired. Extreme obesity is a problem that increasingly affects home care of elderly women.
84 Menopause International Vol. 13 No. 2 June 2007
Original article
Home care needs of extremely obese
elderly European women
L W Sørbye,* M Schroll,
H Finne-Soveri,
P V Jónnson,
G Ljunggren,**
E Topinkova
and R Bernabei
for the AdHOC Project Research Group
* Diakonhjemmet University College, Oslo, Norway;
Bispebjerg Hospital, København, Denmark;
STAKES/CHESS, Helsinki, Finland;
Landspitali University Hospital, Reykjavík, Iceland; ** Department of
Social and Clinical Pharmacy, Faculty of Pharmacy, Hradec Králové, Czech Republic;
Forum/Centrum fõr
Vårdutveckling, Stockholm, Sweden;
Centro Medicina Invecchiamento, Università Cattolica del Sacro Cuore,
Rome, Italy
Correspondence: Liv Wergeland Sørbye, RN MA, Diakonhjemmet University College, Postboks 184, 0319 Oslo, Norway.
Objective. To examine the health and needs of extremely obese women aged over 65 years receiving home
care in Europe.
Study design. A cross-sectional assessment study based on the Aged in Home Care (AdHOC) project
recruited 2974 women aged 65 or over who were receiving home care at 11 sites in European countries.
Extreme obesity was defined as ‘Obesity of such a degree as to interfere with normal activities, including
Main outcome measures: Resident Assessment Instrument for Home Care (RAI-HC version 2.0); Activity
of Daily Living Scale; Instrumental Activity of Daily Living Scale; the Minimum Data Set Cognitive
Performance Scale; and a health profile.
Results: One hundred and twenty women (4.0%) were extremely obese. They were younger than their
thinner counterparts, with a median age of 78.3 versus 83.3 years, and they more often had multiple
health complaints and needed more help with mobility outside the home. The extremely obese had
received home care longer than the non-extremely obese (median 28.7 versus 36.6 months). Extremely
obese women also needed more help with personal care than the other group and, due to lower age, they
were less cognitively impaired.
Conclusions: Extreme obesity is a problem that increasingly affects home care of elderly women.
Keywords: Ageing, extreme obesity, female health, home care, Resident Assessment Instrument
Menopause International 2007; 13: 84–87
Average life span has increased continuously in the
industrialized world.
Over the last few decades, there
has been an unprecedented increase in the prevalence of
obesity, especially in economically developed countries.
Of 93,290 female US veterans aged 18 and over, 37.4%
were classified as obese,
defined as a body mass index
(BMI) of 30 kg/m
or more. Obesity is associated with
an increased risk of health problems such as diabetes,
hypertension, dyslipidaemia, breathlessness, sleep
apnoea, gall bladder disease, coronary heart disease
or heart failure and osteoarthritis.
It is becoming an
increasingly recognized health issue in the elderly and is
associated with more requirements for care.
The aim of this study was to examine the health and
needs of extremely obese women aged over 65 years
receiving home care in 11 European countries.
A cross-sectional study was undertaken using the
population recruited for the European Aged in Home
Care (AdHOC) project (all aged 65 years and over). The
participants lived in urban settings and were already
receiving home care services at the start of the study:
1036 men and 2974 women from 11 European countries
were involved (Figure 1). The total refusal rate was 13%.
Participants were assessed using the Resident Assess-
ment Instrument for Home Care (RAI-HC), version
The assessors observed and talked with the
clients; additional information was gathered from
written documentation, other team members or next
of kin. ‘Extreme obesity’ was defined as ‘Obesity of
such a degree as to interfere with normal activities,
including respiration’.
This corresponds to the
World Health Organization’s classes 2 (BMI 35–39.9 )
Menopause International Vol. 13 No. 2 June 2007 85
L W Sørbye et al. Extremely obese elderly women
and 3 (BMI q 40).
Physical and cognitive function
were assessed using the Activity of Daily Living (ADL)
and the Instrumental Activity of Daily Living (IADL)
and the Minimum Data Set (MDS) Cognitive
Performance Scale.
Associations between extreme obesity and the follow-
ing conditions were analysed: hypertension, congestive
heart failure, diabetes, chronic obstructive pulmonary
disease (COPD), Alzheimer’s disease and other
dementias, oedema, urinary incontinence, renal failure,
falls (at least one fall during the last 90 days) and pain.
Medication use was also examined.
Local legislation for ethical approval and data col-
lection in each country was followed and informed
consent was obtained.
Statistical analysis
Descriptive statistics were retrieved from the database
from July 2004. Analyses were performed using SPSS
software, version 13. The factors associated with the
extreme obesity were analysed. Conditions significantly
associated with extreme obesity (P<0.05) were entered
into a forward logistic regression model, with grade of
obesity (extreme versus non-extreme) as the dependent
variable. Results from both the cross-tabulations and the
regression model are reported as odds ratios (ORs) with
95% confidence intervals (CIs).
One hundred and twenty women (4.0%) and 22 men
(2.1%) were extremely obese (further analysis was
confined to women). Extremely obese women receiving
home care were younger than the non-extremely obese:
median age 78.3 (range 64.3–94.9) years versus 83.3
(range 64.4–104.5) years and had received home care for
longer (Table 1). Extremely obese women needed more
help with personal care than the other group but they
were less cognitively impaired.
Table 2 presents the frequency of clinical condi-
tions. The OR indicates the risk for each. The extremely
obese group had significantly more shortness of breath
and oedema, urinary incontinence and required more
specialist skin care. Due to diabetes they needed more
dietary consultations; five of them were treated with
insulin injections (data not shown). They required
more help when moving outside the house. They also
reported multiple heath complaints.
All the conditions listed in Table 2 were entered
into a logistic regression. In the final model, extreme
obesity was significantly associated at the 5% level with:
increased need of care related to diabetes (OR 1.81,
95% CI 1.20–2.72), shortness of breath (OR 2.26, 95%
CI 1.52–3.37), oedema (OR 1.56, 95% CI 1.04–2.32),
multiple health complaints (OR 1.73, 95% CI 1.05–2.84)
and urinary incontinence (OR 2.16, 95% CI 1.45–3.22).
The extremely obese were also more likely to need assist-
ance for locomotion outside the home (use of frame
outside home, OR 1.73, 95% CI 1.10–2.71; help for
moving outside the home, OR 1.56, 95% CI 1.03–2.37).
This study examined the characteristics and special
needs of extremely obese elderly European women and
the challenges they pose for home care services. As far as
we know, this is the first cross-national study of extreme
obesity in older European women receiving home care.
Extreme obesity here is a clinical term without any
specific linkage to BMI, making this study difficult to
compare with other studies. Another limitation is the
relatively small number of EO clients in the sample; the
analysis may therefore have been hampered by lack of
statistical power.
We found that 4.0% of women were extremely obese;
they were five years younger than non-obese women
receiving home care, more often had multiple health
Table 1 Sociodemographic, functional and clinical
(n = 2854)
(n = 120)
Median age
(range): years 83.3
Number (%) living alone 1945 (68%) 70 (58%)
Median duration
of home care
at assessment (range): months
Median ADL score (range) 1.0 (0–8) 2.0 (0–8)
Median IADL score (range) 5.0 (0–7) 4.0 (0–7)
Median CPS score (range) 0.0 (0–6) 0.0 (0–6)
Median number of medications
6.0 (0–9) 6.0 (0–9)
One extremely obese and four non-obese women were 64 years old.
n =2588 and 113.
ADL, Activities of Daily Living (range 0–8); IADL, Instrumental Activity
of Daily Living (0–7); CPS, Cognitive Performance Scale (range 0–6); for
all three scales a higher number indicates greater impairment.
Figure 1 European Aged in Home Care project (AdHOC)
sites in 11 European countries. The present study examined
women aged 65 years or more who met the criterion for
extreme obesity. The n values are for sample sizes for the
larger project. The EO values are the sample prevalence
rates for extreme obesity.
n = 259
EO = 2.7%
n = 338
EO = 0.3%
n = 152
EO = 9.9%
n = 274
EO = 6.6%
n = 371
EO = 5.1%
n = 215
EO = 3.3%
n = 153
EO = 10.5%
n = 301
EO = 2.3%
n = 278
EO = 0.7%
n = 179
EO = 1.1%
n = 454
EO = 5.7%
86 Menopause International Vol. 13 No. 2 June 2007
L W Sørbye et al. Extremely obese elderly women
complaints and needed more help with mobility outside
the home. As this is a cross-sectional study, we cannot
comment on any cause and effect relationships. For
example, it is not clear whether the multiple health
complaints were the cause or a consequence of obesity
in this group.
The prevalence of extreme obesity in our population,
and that it was more common in women, concurs with
the findings of other studies. For example, Friedmann et
al. found in a US sample of people with a mean (SD) age
of 71.7 (5.7) years that the prevalence of extreme obesity
was 4% in women and 1.4% in men.
Scores for Activity of Daily Living were approximately
the same in both extremely obese and non-extremely
obese subjects. These results could correspond to the
U-shaped BMI–mortality curve reported by Waaler
for older people: a high BMI was associated with lower
relative mortality risk than in younger people. Elia
has given different explanations for this U-curve; one
possibility is that individuals who had been prone to the
complications of obesity may have already died, while
those who remain are more resistant to the effects of
obesity. Zamboni et al.
have documented this ‘survival
effect’. Must et al.
found that the disease burden associ-
ated with extreme obesity was lower for people aged 55
years or more than for those aged 25–54 years.
That extremely obese women are younger and have
been receiving home care for longer than their thin-
ner counterparts has economic implications. This is of
special concern as populations are ageing and obesity
may not necessarily be associated with increased mortal-
ity, as found in a US cohort.
Extreme obesity in elderly women is a problem of the
21st century that governments will have to address until
the obesity epidemic has been halted and reversed.
Table 2 Clinical characteristics of the 120 extremely obese women and 2854 non-extremely obese elderly women receiving
home care
Clinical characteristics Non-extremely
obese: n (%)
obese: n (%)
Odds ratio (95% CI)
65–85 years versus 85 years or more 1218 (42.7) 17 (14.2) 4.51 (2.69–7.57) 0.001
Conditions and clinical symptoms
Not demented versus demented 2486 (87.0) 113 (94.0) 2.42 (1.12–5.23) 0.001
Diabetes versus no diabetes 476 (16.7) 42 (35.0) 2.69 (1.82–3.96) 0.01
Congestive heart failure versus no heart failure 664 (23.3) 41 (34.2) 1.71 (1.16–2.52) 0.001
Shortness of breath versus no shortness of breath 576 (20.2) 51 (42.5) 2.92 (2.01–4.25) 0.001
Oedema versus no oedema 695 (24.4) 50 (41.7) 2.21 (1.53–3.22) 0.01
Pain interrupting daily activity versus no pain 1095 (38.6) 60 (50.4) 1.62 (1.12–2.34) 0.001
Urinary incontinence
q1/week versus continent
1328 (46.5) 79 (65.8) 2.21 (1.51–3.25) 0.000
Use of pads versus no use of pads 1223 (42.9) 69 (57.5) 1.80 (1.25–2.61) 0.002
Skin problems versus no skin problems 752 (26.3) 47 (39.2) 1.80 (1.24–2.62) 0.002
Mental, cognitive and social functioning
Any psychiatric diagnosis versus no such diagnosis 246 (8.6) 17 (14.2) 1.75 (1.03–2.97) 0.04
Multiple health complaints versus no complaints 270 (9.5) 23 (19.2) 2.27 (1.42–3.64) 0.001
Physical functioning
Use of frame outside home versus no use 438 (15.3) 29 (24.2) 1.75 (1.14–2.70) 0.009
Help for moving out of house versus no use of help 583 (20.4) 37 (30.8) 1.74 (1.17–2.58) 0.006
Skin care versus no skin care 327 (11.5) 22 (18.39 1.74 (1.07–2.79) 0.02
Special diet versus no special diet 145 (5.1) 15 (12.5) 2.67 (1.52–4.70) 0.001
Includes use of different types of catheter.
Acknowledgements: We are grateful to interRAI, a collabora-
tive network of researchers in over 20 countries committed
to improving health care for people who are elderly, frail, or
disabled. For statistical advice we are grateful to the following
members of the AdHOC group: Iain Carpenter, UK; Dinnus
Frijters, The Netherlands; Jean Claude Henrard, France; Vjenka
Garms-Homolová, Germany; and Sigrunn Holbek Sørbye,
Norway. We are grateful for funding from the European
Commission Fifth Framework Program, contract number
Competing interests: None declared.
1 US Census Bureau. Global Population at a Glance: 2002 and
Beyond. Washington, DC: US Census Bureau, 2004. Available at (last accessed 30 April 2007)
2 Das SR, Kinsinger LS, Yancy WS Jr, et al. Obesity prevalence
among veterans at Veterans Affairs medical facilities. Am J Prev
Med 2005;28:291–4
3 Haslam D, Sattar N, Lean M. ABC of obesity. Obesity time to
wake up. BMJ 2006;333:640–2
4 Horani MH, Mooradian AD. Management of obesity in the
elderly: special considerations. Treat Endocrinol 2002;1:387–98
5 Trakas K, Lawrence K, Shear NH. Utilization of health care
resources by obese Canadians. CMAJ 1999;160:1457–62
6 Reidpath DD, Crawford D, Tilgner L, Gibbons C. Relationship
between body mass index and the use of healthcare services in
Australia. Obes Res 2002;10:526–31
7 León-Muoz LM, Guallar-Castillon P, Lopez Garcia E, et al.
Relationship of BMI, waist circumference, and weight change
with use of health services by older adults. Obes Res 2005;13:
8 Carpenter I, Gambassi G, Topinkova E, et al. Community care
in Europe. The Aged in Home Care project (AdHOC). Aging Clin
Exp Res 2000;16:259–69
9 Morris JN, Fries BE, Steel K, et al. Comprehensive clinical
Menopause International Vol. 13 No. 2 June 2007 87
L W Sørbye et al. Extremely obese elderly women
assessment in community setting applicability of the MDS–
HC. J Am Geriatr Soc 1997;45:1017–24
10 Landi F, Tua E, Onder G, et al. Minimum data set for home
care: a valid instrument to assess frail older people living in the
community. Med Care 2000;38:1184–90
11 Morris J, Fries B, Bernabei R, et al. RAI – Home Care (RAI-HC)
8. Assessment Manual for Version 2.0. Marblehead, MA: Opus
Communications, 2000
12 World Health Organization. Obesity: Prevention and Managing the
Global Epidemic. Report of a WHO Consultation. Technical Report
Series No. 894. Geneva: World Health Organization, 2004
13 Morris JN, Fries BE, Morris SA. Scaling ADL’s within the MDS. J
Gerontol 1999;4:M546–53
14 Morris JN, Fries BE, Mehr DR, et al. The MDS Cognitive
Performance Scale. J Gerontol 1994;49:174–82
15 Friedmann JM, Elasy T, Jensen GL. The relationship between body
mass index and self-reported functional limitation among older
adults: a gender difference. J Am Geriatr Soc 2001;49:398–403
16 Waaler HT. Hazard of obesity the Norwegian experience. Acta
Med Scand Suppl 1988;723:17–21
17 Elia M. Obesity in the elderly. Obes Res 2001;9 (suppl. 4):244–8
18 Zamboni M, Mazzali G, Zoico E, et al. Health consequences of
obesity in the elderly: a review of four unresolved questions. Int
J Obes Relat Metab Disord 2005;29:1011–29
19 Must A, Spadano J, Coakley EH, Field AE, Colditz G, Dietz WH.
The disease burden associated with overweight and obesity.
JAMA 1999;282:1523–9
20 Grabowski DC, Ellis JE. High body mass index does not predict
mortality in older people: analysis of the Longitudinal Study of
Aging. J Am Geriatr Soc 2001;49:968–79
... Several ADHOC publications report on the status of the study population and highlight the differences among the different European urban areas [4][5][6][7][8][9][10][11]. The main topics were nutrition, elimination, depression and pain. ...
... Within the oldest group, i.e. among clients who were 85+ years old, there was a significant association between UWL and decline in Instrumental Activities of Daily Living (IADL) and Activities of Daily Living ADL functions (p < 0.001 and p < 0.05 respectively). Extreme obesity was present in 4.0% of women, who were on average 5 years younger and needed 7 months more of home care provision than women who were not obese [5]. Table 1 Summary of scientific publications from the ADHOC study. ...
... Reduced social activity and hospitalization were important indicators for the risk of malnutrition. Sørbye et al. (2007): EO was studied. The physical, social, and psychological characteristics of female home care clients were analyzed, as were their health profiles and service utilization. ...
During the 1990s, use of home care sector has increased substantially in Europe. However, research on home care continues to be underreported. This article summarizes the findings from the "Aged in Home Care" (ADHOC) study - carried out from 2001 to 2004 in Europe - and women's situation in European Home Care. The review is based on 4 book chapters as well as on 23 articles listed in PubMed and published from August 2004 to October 2008. ADHOC used a standardized data set collected with the Resident Assessment Instrument for Home Care (RAI-HC 2.0); this instrument was used to assess 4010 home care clients at 11 European sites. The included articles analyzed the sociodemographic and clinical characteristics, basic physical needs, provision of selected preventive measures, and medication data from the ADHOC sample. In addition home service provision, quality indicators, and selected outcomes of home care intervention during the course of 1 year were assessed. The mean subject age was 82.3 years; women were on average 2 years older than men and more frequently lived alone, 74% were women. Women suffered more frequently from pain, depression, and extreme obesity. There were marked regional differences in both the functional status of the clients and the characteristics and use of home care services. The implementation of a common assessment instrument for HC clients may help contribute the necessary wealth of data for (re)shaping home care in Europe. Policy makers and service providers may learn about best practices in the European context.
... A longitudinal study on the elderly (aged 60 years and above) by Nizalova et al. [18] found that obese older adults are 25% more likely to be the recipients of long-term care support, particularly informal care, or privately paid care, than their normal-weight counterparts. A cross-sectional study by Sørbye et al. [19] evaluated that extremely obese older women (aged 65 years and above) require more help with their personal care than their normal weight counterparts. Tompson et al. [20] found that 63% of older adults aged 65 years and over received community-based social care. ...
Full-text available
Objectives. The study aims to determine the social care need among overweight and obese older adults by identifying the number of social care support receipts from different sources. Methods. A sample of 5640 participants (aged 50 years and over) taken from the English Longitudinal Study of Ageing Wave 8 dataset. Multivariate logistic regression analysis was performed to explore the relationship between the study variables. Results. The statistical analyses demonstrated that overweight and obese older adults are the recipients of increasing amounts of informal social care. Moderate and morbidly obese participants are the recipients of increasing amounts of formal care compared to their normal-weight counterparts, with morbid obesity being a strong predictor for receipt of formal care. Conclusions. The present study’s findings demonstrate that for older adults aged 50 years presence of morbid obesity is a strongest predictor for receipt of formal care, and their well-being is not associated with formal or informal care receipt. The findings on how wider lifestyle factors influence the number of social care receipts, from different sources, may help policymakers and healthcare providers to allocate limited resources for adult social care services and promote healthy ageing rather than just focusing on weight loss alone.
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The prevalence of obesity in Canada has been increasing in recent years. Using data from the National Population Health Survey (NPHS), the authors determined the prevalence of obesity among Canadians, the associated comorbidities and the patterns of resource utilization by obese people. The NPHS, a cross-sectional survey conducted in 1994, was administered to 17,626 Canadians 12 years of age or older who were not long-term residents of hospitals or long-term care facilities and were not residing on First Nations reserves or Canadian Armed Forces bases, or in the Yukon and Northwest Territories. For the authors' analysis, the study population consisted of 12,318 Canadians aged 20-64 years who were not pregnant and for whom the body mass index (BMI) had been calculated. The prevalence of comorbidities, health status index scores, self-esteem, self-rated health, restriction of activity, health care resource utilization (physician visits, disability days, admissions to hospital and medication use) were determined for obese people (BMI of 27 or greater) and nonobese people. The NPHS data revealed that 35.2% of men and 25.8% of women in Canada were obese in 1994. Obese respondents were more likely than nonobese respondents to suffer from stress (adjusted odds ratio [OR] 1.20, 95% confidence interval [CI] 1.11-1.31), activity restrictions (adjusted OR 1.39, 95% CI 1.26-1.54) and a number of chronic comorbidities. Obese respondents were also more likely to consult with physicians (adjusted OR 1.32, 95% CI 1.22-1.43), be prescribed a number of medications and to require excess disability days (adjusted OR 1.22, 95% CI 1.08-1.36). Obesity represents a substantial burden on the health of Canadians and on Canada's health care resources.
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Overweight and obesity are increasing dramatically in the United States and most likely contribute substantially to the burden of chronic health conditions. To describe the relationship between weight status and prevalence of health conditions by severity of overweight and obesity in the US population. Nationally representative cross-sectional survey using data from the Third National Health and Nutrition Examination Survey (NHANES III), which was conducted in 2 phases from 1988 to 1994. A total of 16884 adults, 25 years and older, classified as overweight and obese (body mass index [BMI] > or =25 kg/m2) based on National Institutes of Health recommended guidelines. Prevalence of type 2 diabetes mellitus, gallbladder disease, coronary heart disease, high blood cholesterol level, high blood pressure, or osteoarthritis. Sixty-three percent of men and 55% of women had a body mass index of 25 kg/m2 or greater. A graded increase in the prevalence ratio (PR) was observed with increasing severity of overweight and obesity for all of the health outcomes except for coronary heart disease in men and high blood cholesterol level in both men and women. With normal-weight individuals as the reference, for individuals with BMIs of at least 40 kg/m2 and who were younger than 55 years, PRs were highest for type 2 diabetes for men (PR, 18.1; 95% confidence interval [CI], 6.7-46.8) and women (PR, 12.9; 95% CI, 5.7-28.1) and gallbladder disease for men (PR, 21.1; 95% CI, 4.1-84.2) and women (PR, 5.2; 95% CI, 2.9-8.9). Prevalence ratios generally were greater in younger than in older adults. The prevalence of having 2 or more health conditions increased with weight status category across all racial and ethnic subgroups. Based on these results, more than half of all US adults are considered overweight or obese. The prevalence of obesity-related comorbidities emphasizes the need for concerted efforts to prevent and treat obesity rather than just its associated comorbidities.
Dependency in activities of daily living (ADLs) is a reality within nursing homes, and we describe ADL measurement strategies based on items in the Minimum Data Set (MDS) and the creation and distributional properties of three ADL self-performance scales and their relationship to other measures. Information drawn from four data sets for a multistep analysis was guided by four study objectives: (1) to identify the subcomponents of ADLs that are present in the MDS battery; (2) to demonstrate how these items could be aggregated within hierarchical and additive ADL summary scales; (3) to describe the baseline and longitudinal distributional properties of these scales in a large, seven-state MDS database; and (4) to evaluate how these scales relate to two external criteria. Prevalence and factor structure findings for seven MDS ADL self-performance variables suggest that these items can be placed into early, middle, and late loss ADL components. Two types of summary ADL self-performance measures were created: additive and hierarchical. Distributional properties of these scales are described, as is their relationship to two external ADL criteria that have been reported in prior studies: first as an independent variable predicting staff time involved in resident care; second as a dependent variable in a study of the efficacy of two programs to improve resident functioning. The new ADL summary scales, based on readily available MDS data, should prove useful to clinicians, program auditors, and researchers who use the MDS functional self-performance items to determine a resident's ADL status.
OBJECTIVES: To determine whether there is a gender difference in how body mass index (BMI) relates to self-reported functional limitation. Also, to evaluate whether the method of categorizing BMI changes the observed results. DESIGN: Cross-sectional cohort study. SETTING: Rural Pennsylvania. PARTICIPANTS: A total of 7,120 male (n = 3,312) and female (n = 3,808) community-dwelling older adults enrolled in a Medicare managed-risk contract. MEASUREMENTS: All subjects completed a modified Level II Nutrition Risk Screen upon enrollment in the health plan. Height and weight were obtained by nursing personnel during an enrollment clinic visit. Subjects who reported 10 or more pounds weight loss in the previous 6 months were excluded. Logistic regression was used to evaluate the relationship between BMI and self-reported functional limitation separately for each sex, adjusting for age, depression, and polypharmacy. Two schemes were used to categorize BMI: equally distributed sex-specific quintiles and arbitrary division based on National Institutes of Health (NIH) Obesity Guidelines. RESULTS: How BMI relates to functional limitation depends upon both sex and method of categorizing BMI. When BMI was considered in gender-specific quintiles, women in the highest quintile of BMI had increased risk of functional impairment; there was no relationship between BMI and functional limitation for men. When BMI was categorized by the NIH obesity guidelines, both men and women with BMI> 40 had significantly increased risk of functional limitation. CONCLUSIONS: The mechanisms behind gender discrepancy in self-reported functional limitation remain unclear. Studies may need to consider men and women separately, because how BMI relates to function depends on gender. Further research is needed to evaluate how changes in weight and body composition during middle and old age affect functional status.
Objective: To determine the excess mortality associated with obesity (defined by body mass index (BMI)) in older people, with and without adjustment for other risk factors associated with mortality and for demographic factors. Design: Retrospective cohort analysis of the Longitudinal Study of Aging (LSOA). Setting: Nationally representative sample of community-dwelling older people. Participants: Seven thousand five hundred and twenty-seven participants age 70 and older in 1984. Measurements: We used Cox regression to calculate proportional hazards ratios for mortality over 96 months. We tested the hypothesis that increased BMI (top 15%) increased mortality rates in older people. Results: Death occurred in 38% of the cohort: 54% of the thin (lowest 10% of the population, BMI <19.4 kg/m(2)), 33% of the obese (highest 15%, BMI> 28.5 kg/m(2)), and 37% of the remaining participants (normal) died. Adjustment for demographic factors, health services utilization, and functional status still demonstrated reduced mortality in obese older people (hazard ratio 0.86, 95% confidence interval (CI) = 0.77-0.97) compared with normal. After adjustment, thin older people remained more likely to die (hazard ratio 1.46, 95% CI = 1.30-1.64) than normal older people. Sensitivity analyses for income, mortality during the first two years of follow-up, and medical comorbidities did not substantively alter the conclusions. Conclusion: Obesity may be protective compared with thinness or normal weight in older community-dwelling Americans.
Ten years' follow-up of mortality of 1.7 million persons aged 15 years or more with measured body weight and height demonstrates a consistent correlation between body mass index and mortality. The risk function is an asymmetrical U-function. This shape makes the determination of an optimum very uncertain. The two tails in the distribution of the body mass index show marked differences as to the causes of death: the lower tail is characterized by tuberculosis, lung cancer, obstructive lung diseases, and the upper tail by cerebrovascular and cardiovascular diseases, diabetes and (for males) colon cancer.
Chronic cognitive impairment is a major problem in U.S. nursing homes, yet traditional assessment systems in most facilities included only limited information on cognitive status. Following the Congressional mandate in the Omnibus Reconciliation Act of 1987 (OBRA '87), U.S. nursing homes now complete the Minimum Data Set (MDS), a standardized, comprehensive assessment of each resident's functional, medical, psychosocial, and cognitive status. We designed a Cognitive Performance Scale (CPS) that uses MDS data to assign residents into easily understood cognitive performance categories. Information was drawn from three data sets, including two multistate data sets constructed for the Health Care Financing Administration. The prevalence and reliability of the MDS cognitive performance variables were established when assessed by trained nursing personnel. Five selected MDS items were combined to create the single, functionally meaningful seven-category hierarchical Cognitive Performance Scale. The CPS scale corresponded closely with scores generated by the Mini-Mental State Examination and the Test for Severe Impairment, nursing judgments of disorientation, and neurological diagnoses of Alzheimer's disease and other dementias. The new CPS provides a functional view of cognitive performance, using readily available MDS data. It should prove useful to clinicians and investigators using the MDS to determine a resident's cognitive assets.
To describe the results of an international trial of the home care version of the MDS assessment and problem identification system (the MDS-HC), including reliability estimates, a comparison of MDS-HC reliabilities with reliabilities of the same items in the MDS 2.0 nursing home assessment instrument, and an examination of the types of problems found in home care clients using the MDS-HC. Independent, dual assessment of clients of home-care agencies by trained clinicians using a draft of the MDS-HC, with additional descriptive data regarding problem profiles for home care clients. Reliability data from dual assessments of 241 randomly selected clients of home care agencies in five countries, all of whom volunteered to test the MDS-HC. Also included are an expanded sample of 780 home care assessments from these countries and 187 dually assessed residents from 21 nursing homes in the United States. The array of MDS-HC assessment items included measures in the following areas: personal items, cognitive patterns, communication/hearing, vision, mood and behavior, social functioning, informal support services, physical functioning, continence, disease diagnoses health conditions and preventive health measures, nutrition/hydration, dental status, skin condition, environmental assessment, service utilization, and medications. Forty-seven percent of the functional, health status, social environment, and service items in the MDS-HC were taken from the MDS 2.0 for nursing homes. For this item set, it is estimated that the average weighted Kappa is .74 for the MDS-HC and .75 for the MDS 2.0. Similarly, high reliability values were found for items newly introduced in the MDS-HC (weighted Kappa = .70). Descriptive findings also characterize the problems of home care clients, with subanalyses within cognitive performance levels. Findings indicate that the core set of items in the MDS 2.0 work equally well in community and nursing home settings. New items are highly reliable. In tandem, these instruments can be used within the international community, assisting and planning care for older adults within a broad spectrum of service settings, including nursing homes and home care programs. With this community-based, second-generation problem and care plan-driven assessment instrument, disability assessment can be performed consistently across the world.
Optimal care for frail elderly patients depends on comprehensive assessment. This is especially true in the complex setting of interdisciplinary home care programs. To facilitate comprehensive assessment, as well as to generate a useful, policy-relevant patient database, standardized, multidimensional, and validated instruments are very helpful. The aim of the present study was to demonstrate that the Minimum Data Set assessment instrument for Home Care (MDS-HC) can be used to detect functional and cognitive impairment as defined by analogous research instruments. This was a cross-sectional correlation study. We studied 95 patients admitted to home care services of the Health Care Agency of Bergamo (Italy). The MDS-HC form was completed for all patients by well-trained nurses, independently of and with nurses blinded to the results from the research rating scales. The Barthel Activities of Daily Living (ADL) Index, the Instrumental Activities of Daily Living of Lawton (IADL), and the Mini Mental State Examination (MMSE) were considered the gold standard. Agreement between the MDS-HC scales and the research rating scales was assessed with Pearson's correlation coefficient. This coefficient was 0.74 for MDS-ADL versus Barthel Index, 0.81 for MDS-IADL versus Lawton Index, and 0.81 for Cognitive Performance Scale versus MMSE, indicating an excellent agreement. The MDS-HC scales, when performed by trained nurses using recommended protocols, provide a valid measure of function and cognitive status in frail home care patients. These findings point out the overall validity of the functional and clinical data contained in the MDS-HC assessment. Use of the MDS-HC gives the unique opportunity of setting up a database, a prerequisite for all epidemiological evidence-based medicine studies.
In developed countries, there is a general increase in body weight and body mass index (BMI) with age, until approximately 60 years of age, when body weight and BMI begin to decline. The proportion of intra-abdominal fat, which is related to increased morbidity and mortality, progressively increases with age. There is also a progressive decline in energy intake and daily total energy expenditure (165 kcal/decade in men and 103 kcal/decade in women in developed countries), which is primarily due to a decrease in physical activity, and to a lesser extent, a decrease in basal metabolic rate. The decrease in physical activity is more pronounced in those with chronic disabilities and diseases. The BMI-mortality curves have been reported to move upward (greater overall mortality), become flatter (less effect of BMI on mortality), and in some cases shift to the right (minimum mortality occurs at a higher BMI), for a variety of possible reasons. Weight loss in the elderly has been reported to increase, decrease, or not alter mortality, but the studies are confounded by numerous methodological problems. It has been argued that there may be little benefit in encouraging weight loss in extreme old age (short life expectancy), especially when there are no obesity-related complications or biochemical risk factors and when strong resistance and distress arise from changes in lifelong habits of eating and exercise. In contrast, weight loss in the elderly can reduce morbidity from arthritis, diabetes and other conditions, reduce cardiovascular risk factors, and improve well-being. BMI also predicts morbidity in those without disease. Furthermore, increased physical activity in the elderly, which is an important component of weight management, can produce beneficial effects on muscle strength, endurance, and well-being.