Obesity, Disability, and Nursing Home Admission

The U.S. long-term care (LTC) system is faced with potentially greater demand for services as the population ages. Current projections indicate that by 2030, 20% of the U.S. population will be over age 65 years, compared to only 12% of the population in 2000.¹ There are mixed opinions as to whether this growing population of older adults will increase demand for LTC services.^2-3 However, the emergence of the U.S. obesity epidemic,⁴ which could reverse recent declining trends in disability rates among the elderly,⁵ may present new, unforeseen demands on and challenges for the LTC system. This article reviews the literature on the association between obesity and disability, and on obesity and nursing home admissions. In addition, it reviews the few articles that exist in the literature that discuss the known and potential impacts of obesity among the elderly on the delivery of care within nursing homes.

Prevalence of Obesity in the United States

Currently, more than two-thirds of all U.S. adults are overweight or obese (body mass index [BMI] ≥ 25).⁶ The prevalence of overweight (BMI = 25-29.9) and obesity (BMI ≥ 30) among older adults in the United States is also high and has seen modest increases in recent years. The Figure shows the percentage of older adults age 65-74 years and age 75 years and older who are overweight or obese using data from selected years of the National Health And Nutrition Examination Survey (NHANES). Between the time periods of 1988-1994 and 2001-2004, the percentage of adults age 65-74 years and the percentage of adults age 75 years and older who are obese has increased 9.6 percentage points and 5 percentage points, respectively. During the same time period, the percentage of adults age 65-74 years who are overweight remained at approximately 38%, while the percentage of adults age 75 years and older who are overweight increased 6 percentage points.⁷

One growing concern is that those in the “pre-elderly” age group, those age 50-64 years, will continue to be overweight and/or obese as they age, increasing the proportion of elderly individuals who are obese. In fact, current analysis indicates this will be the case: Arterburn and colleagues⁸ have projected that between 34% and 40% of Americans age 60 years and older will be obese by 2010. This concern is magnified when considering the aforementioned demographic changes in the U.S. elderly population, with the aging of the Baby Boom generation. The coupling of the increasing numbers of elderly individuals with the higher rates of obesity in this subpopulation will most likely present significant problems for the LTC system in the near future.

The Burden of Obesity

The rising rates of obesity raises a number of public concerns due to the individual and societal impacts associated with obesity, including increased prevalence of a number of chronic conditions,⁹ and increased service utilization and cost.^10-11 As these impacts have been reviewed in other publications,^9-11 they will not be covered here. Less discussed is the association of obesity with increased cognitive and functional decline, and with increased nursing home admission. As these impacts are of particular concern for the long-term care system, they are the focus of this review.

Obesity has been shown to be independently related to cognitive decline, due to its association with known risk factors for vascular disease (eg, hypertension, coronary heart disease). A study using health insurance wellness screening and claims data found that overweight and obesity at midlife was associated with a 35% and a 75%, respectively, increase in the risk of dementia later in life, after controlling for sociodemographic characteristics and chronic conditions.¹² Similar results were discussed by Kivipelto and colleagues,¹³ who found that persons who were obese at middle age were two times more likely to develop dementia and Alzheimer’s disease (odds ratio [OR] = 2.1, 95% confidence interval [CI] = 1.0-4.6), even after controlling for sociodemographic characteristics, blood pressure, cholesterol level, and smoking status, as compared to non-obese persons at middle age (although the association became insignificant when apolipoprotein E genotype and history of vascular disorders were added to the model (OR = 1.9, 95% CI = 0.8-4.6). Finally, in their systematic review of published findings from longitudinal population-based studies, Gorospe and Dave14 concluded that there is an independent increase in the risk of dementia with increased weight.

Obesity is also associated with physical disability and functional decline. An analysis of two waves of the Asset and HEAlth Dynamics among the Oldest Old (AHEAD) survey found that obesity was significantly associated with strength loss, lower-body mobility impairment, and limitations in activities of daily living, even after controlling for sociodemographic characteristics, health behaviors, and health conditions.¹⁵ Another study also found an association between obesity and limitations in activities of daily living (ADLs). Strum et al5 found that the probability of having limitations in ADLs increased 50% for moderately obese (BMI = 30-34.9) men and increased 100% for moderately obese women; it increased 300% for severely obese (BMI ≥ 35) men and 400% for severely obese women. A recent study analyzing NHANES data from 1999 to 2004 found that women and men in the fourth quartile BMI (BMI ≥ 31.4 for women, BMI ≥ 30.1 for men) had significantly greater odds of having difficulty performing ADLs, leisure and social activities, lower-extremity mobility, and general physical activities as compared to women and men in the first BMI quartile (BMI < 24.3 for women and BMI < 24.7 for men), after controlling for age, gender, ethnicity, education, smoking status, alcohol use, and level of physical activity. In a second analysis, women in the fourth quartile BMI continued to have higher odds of difficulty in performing ADLs, leisure and social activities, lower-extremity mobility, and general physical activities as compared to women in the first BMI quartile, after controlling for presence of chronic diseases in addition to sociodemographic and health behavior characteristics. Men in the fourth BMI quartile, however, only had a higher odds of having difficulty in leisure and social activities, lower-extremity mobility, and general physical activities, as compared to men in the first BMI quartile, after control for presence of chronic disease, sociodemographic status, and health behaviors.¹⁶

Both cognitive impairment and limitations in ADLs have been shown to be strong predictors of NH admission. 17 Obesity has also been found to predict nursing home admission. This may be due, in part, to obesity’s association with cognitive impairment and limitations in ADLs; however, those factors have not been included in models examining the association of obesity and NH admission, which have been reported in the literature. The studies that have examined the association between obesity and NH admission found that persons who were obese at midlife had odds 30% higher of entering a nursing home later in life, even after controlling for comorbid conditions and health behaviors as compared to those who were of normal weight at midlife.¹⁸ Obesity in older persons has also been found to be a significant risk factor for NH admission, after controlling for age, race, gender, and major diagnoses.¹⁹

Although evidence of the obesity epidemic abounds, and studies have identified obesity as a risk factor for NH admission, few studies have been found in the literature that document the prevalence of obesity among newly admitted NH residents in the United States, or that examine the impact of providing care for obese elderly persons in nursing homes. Of those that exist, one study found that 14.5% of elderly residents newly admitted to nursing homes in Arkansas between 1999 and 2004 were obese²⁰; another found that 25% of all newly admitted NH residents in Kansas, Maine, Mississippi, New York, and South Dakota in 2002 were obese, up from only 15% of all the newly admitted residents in these states in 1992.²¹ Furthermore, newly admitted elderly residents who were obese were found to be significantly younger than newly admitted elderly residents who were not obese (78.5 vs 82.5 yr, respectively; P < 0.0001).²⁰

Even less is known about providing care for obese elderly NH residents. Case studies have reported obese elderly residents typically require two or more persons to assist them with performing activities of ADLs.²² However, this was only recently confirmed with an analysis of admission assessments of nearly 48,000 elderly persons (≥ 65 years) entering nursing homes in Arkansas from 1999 through 2004. In this recent study, obese (BMI ≥ 30) older persons had significantly higher odds (OR = range, 1.18 - 1.70; P < 0.01) of needing two or more persons to assist them in performing ten selected ADLs as compared to non-obese (BMI = 16-29) elderly persons, after controlling for age, gender, race, year of admission, and health conditions.²⁰

Lapane and Resnick²³ also outlined a number of issues that nursing homes may face in trying to care for obese residents. For example, they suggest that nursing homes may not have the specialized supplies (eg, blood pressure cuffs to accommodate residents with larger arms) and equipment (eg, beds and wheelchairs to accommodate persons weighing more than 300 pounds) or adequate space (eg, larger rooms with wider doorways to accommodate larger equipment and wider wheelchairs) to provide care for obese elderly residents. They further suggest that the lack of such supplies, equipment, and space in nursing homes may result in obese elderly individuals facing LTC access issues. In addition, Lapane and Resnick²³ note that obese nursing home residents may increase the risk for workplace injuries among nursing home staff, who already face high workplace injuries rates. However, they acknowledge that studies are needed to examine these issues within the NH industry.

Discussion

Although little is known about the impact of obesity among elderly persons and delivery of care in U.S. nursing homes, increasing numbers of the elderly population, combined with increasing rates of obesity among elderly persons, are likely to create new challenges for the U.S. LTC system in the near future.

Current projections estimate that annual expenditures for NH care will reach $108.5 billion by 2010.²⁴ These projections were made without factoring in the costs associated with caring for obese elderly individuals, such as the increased staffing needed to provide extensive assistance with the performance of ADLs. Furthermore, recent research indicates that obese elderly persons entering nursing homes are significantly younger than their non-obese counterparts.²⁰ There is conflicting evidence on the association of mortality with obesity. Some studies have shown an inverse relationship between obesity and mortality, so that as BMI increases, risk of mortality decreases.²⁵ This so-called “obesity paradox” may be partially explained by the greater protection that obesity provides from wasting due to severe health conditions.²⁶ However, some researchers suggest that there is only a modest increase in mortality risk associated with moderate obesity in elderly individuals.²⁷ But, even with a moderate mortality risk among this group, there is a potential for longer NH stays given their lower age of entry²⁰ and, thus, increased NH care expenditures. Finally, as Lapane and Resnick²³ point out, LTC expenditures may increase due to the need for nursing homes to purchase specialized equipment and supplies to adequately care for obese residents, as well as increased workplace injuries from assisting obese residents with ADLs.

Conclusion

This review highlights several new challenges that the LTC system may face due to the increasing prevalence of obesity in older Americans. In order to prepare for these challenges, nursing homes should begin considering the impact of obesity on the delivery of quality care in their facilities. This may entail the monitoring of obesity rates among newly admitted residents, assessing the availability of equipment and supplies needed to care for obese elderly individuals, and documenting the specific care needs of obese elderly residents. Furthermore, nursing homes should consider providing in-service training for staff in specific aspects of caring for obese elderly residents, such as proper body mechanics for assisting with transfers of these residents.

Researchers should also heighten their focus on investigating the impact of obesity in elderly individuals on the cost and delivery of quality LTC services. Using administrative data sets, such as Medicare and Medicaid claims files and the nursing home Minimum Data Set, researchers may be able to document and understand differential service utilization and costs for caring for obese versus non-obese elderly residents in NH facilities.

The author reports no relevant financial relationships.