Factors Associated With the Use of Meals-On-Wheels among Home Care Clients : The Nutormed Study

Irma Nykänen1,2*, Miia Tiihonen1, Prof Sirpa Hartikainen1 1Kuopio Research Centre of Geriatric Care, School of Pharmacy, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland 2Institute of Public Health and Clinical Nutrition, Unit of Public Health, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland Journal of Nutritional Health & Food Science Open Access Research Article


Introduction
Meals-on-Wheels (MOW) is an ancillary service that deliver meals to individuals at home who are unable to purchase or prepare their own meals.This is taking place in Finland and nowadays about 25% of Finns aged above 80 years use MOW [1].MOW helps home care clients maintain and improve The quality of MOW was assessed on a 3-point scale: 1 = good quality, 2 = acceptable quality, 3 = poor quality.Plasma albumin levels were measured according to standard protocols at the regional laboratory, ISLAB [11].Body Mass Index (BMI) was computed as the ratio of weight to the square of height (kg/m 2 ).
Performance in Activities of Daily Living (ADL) was assessed with the 10-item Barthel ADL Index [12] and performance in instrumental activity (IADL) [13], with the 8-item Lawton and Brody Scale.The scoring for ADL is 0−100 and for IADL, 0−8, with higher scores indicating better functioning.Depressive symptoms were evaluated on the 15-item Geriatric Depression Scale (GDS-15) [14].Comorbidity was computed using a modified version of the Functional Comorbidity Index (FCI) [15].Diagnosis of 13 diseases were collected from electronic medical records by a geriatrician.Each condition was given one point, and a higher FCI sum score represents greater comorbidity.Also dementia diagnosis was collected by a geriatrician and was based on electronic medical records of health care.A pharmacist interviewed the participants at the baseline and recorded each prescription and over-the-counter drug used regularly and as needed on the basis of the interview, medication lists and medication packages.
In statistical analyses the participants were categorized into users and non-users of MOW (Table 1).Statistical comparisons between the groups were done using a chi-square or t-test with ≤ 0.05 considered significant.Univariate and multivariate (stepwise, forward selection) regression analyses were performed to identify demographical, clinical and functional factors associated with using MOW (Table 2).The MOW users were categorized into good and weak of quality of MOW and statistical comparisons between the groups were done using a chi-square or t-test (Table 3).The analyses were done using SPSS version 21.0 (SPSS, Inc., Chicago, IL).
All the participants or their proxies gave written informed consent to participate in the study.The study protocol was approved by the Research Ethics Committee of the Northern Savo Hospital District, Kuopio, Finland.

Discussion
Home care clients receiving MOW were more frequently at risk of malnutrition or malnutrition, lived alone, had decline in activities of daily living and were demented.Also in an earlier cross-sectional study among MOW clients, the prevalence of malnutrition risk or malnutrition was higher than non-MOW clients [16].The reason for MOW client's poorer nutritional status is unclear according to our study because we did not have earlier information about them.However, in one Swedish study the participants who used MOW were more likely to be at risk of malnutrition [17].It is reasonable to assume that malnutrition leads to increased need for help from the community, including meal services.

Factors Associated With the Use of Meals-On-Wheels among Home Care Clients: The Nutormed Study
Copyright: © 2016 Nykänen, et al.
In accordance with previous studies, MOW clients are more likely to be aged 75 or older, female, living alone, less mobile and widowed than non-MOW clients [18][19][20][21].Older women living alone tended to simplify cooking and eating and had fewer cooked meals, whereas among older men, poor cooking skills were a barrier to maintaining healthy eating and a good appetite [22].It is reasonable to suggest that older people living alone eat more poorly, which affects their nutritional status [18], and this results in them using MOW.Many of the MOW clients were at a low level of economic resources, so meals were often split into two.Perhaps MOW clients split their delivered, midday meal between lunch and dinner because they had poor appetite or if portion size of meal was too big to eat all at once.We found that clients of MOW with dementia and declining performance in activities of daily living were unable to or had difficulty preparing meals on their own.This is in accordance with previous findings that persons with a cognitive and/or functional impairment are unable to prepare nutritionally adequate meals [22].In addition, at a later stage of dementia, persons have difficulty recognizing hunger and thirst and may forget to eat, or they are unable to recognize items of food [23].
In the present study, the clients of unsatisfied of MOW were at risk of malnutrition or malnourished and depressive more often than the clients of satisfied of MOW.Earlier studies have documented rates of depression among older adults currently receiving in-home services [24].Lack of appetite, loss of interest in self-care, apathy and physical weakness can be used early warning signals not only the risk of malnutrition or malnutrition, also depression [25].
Our study results are especially important now, when the number of home care clients is rapidly growing because of the decrease in residential care.In addition, the prevalence of malnutrition or risk of malnutrition is very high among this vulnerable population.The MOW service is based on the assumption that all of the food is actually consumed, which leads to an overly positive picture of the nutritional value of the meals.Looking to the future, it is essential that MOW is able to adapt to consumer needs and preferences and respond to challenges in MOW production and delivery.

Conclusion
Using MOW is common among home care clients and MOW clients were more likely to be at risk of malnutrition, living alone, have a decline in the performance of activities of daily living and diagnosed dementia.Unsatisfied with the quality of MOW were more likely to be at risk of malnutrition or malnourished and depressive.

Table 1 :
Characteristics of clients and non-clients of Meals on Wheels

Table 2 :
Univariate and multivariate associations between characteristics of home care clients and using of Meals on Wheels