In the long-term care facility where I work, we often see newly admitted residents being diagnosed with malnutrition. Malnutrition refers to deficiencies, excesses or imbalances in a person’s intake of energy and/or nutrients (World Health Organization, 2020). A report by Ramage-Morin, Gilmour & Rotermann (2017), for Statistics Canada shows that poor nutrition is putting many Canadian seniors at risk. Results from the 2008-2009 Canadian Community Health Survey – Healthy Aging indicates that close to 1 million Canadian seniors are at nutritional risk. Seniors at nutritional risk who participated in the survey were 60% more likely to die during the survey’s follow-up period and 20% more likely to be admitted to hospital than seniors not at risk (Ramage-Morin et. al., 2017). The report also showed that women are at greater risk than men, with 37% of female seniors affected versus 29% of male seniors. Seniors aged 75 years or older are more likely to be at nutritional risk than those 65–74 years of age (Ramage-Morin et. al., 2017). The authors state “a paradox of aging is that caloric needs decrease, but the need for a nutritious diet does not. It is important to identify the people most likely to be at risk of nutritional depletion, who, without intervention, may become malnourished, frail, and susceptible to negative health outcomes including functional limitations, poor quality of life, longer hospital stays and readmissions, and earlier death” (Ramage-Morin et al., 2017).
Social Ecological Model – Senior’s Health and Well-being
Individual Level
At the individual level, seniors may not have good knowledge of nutrition and healthy eating. They make have limited knowledge of their disease conditions and about what types of foods are best for their unique circumstances and how to prepare them. They may be unable to access education resources on nutrition information due to limited access to specific health care services, or poor technology skills. They may have long held, unhealthy attitudes toward food that can result in disordered eating or malnutrition, especially as they age.
Many other factors can contribute to malnutrition in the older population. Seniors may have chronic health conditions or be taking medications that interfere with appetite, reduce their enjoyment of food related to loss of taste or smell, and reduce the capacity to absorb nutrients. Medications taken incorrectly, at the wrong time of day, or with the wrong foods can result in serious side effects. Seniors may also have limited mobility or impaired dexterity which can hamper their ability to prepare meals. They may have poor oral health and/or wear dentures which can reduce the variety of foods they are able to eat. They may have cognitive issues where they forget to eat meals or combine or eliminate foods resulting in depleted and insufficient nutrients. Seniors often suffer from mental health issues such as depression due to stress, major life changes, medications or disease conditions (Canadian Mental Health Association, n.d.). This can impact the quality and quantity of foods consumed.
Substance use and abuse can interfere with food consumption and have detrimental effects on an individual’s physical and mental health. According to the Canadian Coalition for Seniors’ Mental Health (n.d.), substance misuse and dependency among older adults is a growing but neglected issue. Many older adults are often taking complicated regimens of multiple prescribed medications each day. Because of physiological changes, older adults are much more vulnerable to the negative effects of substance use and misuse. Alcohol, cannabis and medications commonly given to older adults to manage pain, anxiety, sleeplessness and depression can have a negative effect on the cognition, emotions and physical health of older adults (Canadian Coalition for Seniors’ Mental Health, n.d.). These factors can also affect dietary intake and nutrition.
Seniors are also impacted by social determinants of health such as socio-economic status. Many seniors, particularly women aged 65 and older, are more likely to live in low-income households than their male counterparts (Fox & Moyser, 2018). Even for women who participated in the workforce, their employment earnings were lower than men's. Women were more likely to retain a disproportionate share of housework, childcare and eldercare, which contributed to their heightened vulnerability to financial insecurity, particularly in the event of separation, divorce, or widowhood) and during old age (Fox & Moyser, 2018). Low income, food insecurity and malnutrition often go hand in hand and are of major concern for seniors. Seniors with less disposable income are less able to afford nutrition foods.
The impact of chronic diseases can have a dramatic effect on seniors’ health and well-being. According to the Public Health Agency of Canada, women aged 65 years and older are more likely than senior men to be newly diagnosed with a chronic disease. The most common of these are osteoarthritis, osteoporosis, dementia, asthma, and rheumatoid arthritis. While age plays a role in disease development, other factors also have an influence. These include biological and physical differences between women and men, lifestyle behaviours such as physical inactivity, unhealthy food choices, smoking and alcohol use. Socio-economic factors such as education and income affect the likelihood of developing a chronic disease. An individual with one chronic disease is more at risk of developing multiple co-morbidities. Conservative estimates from the 2017–2018 Canadian Community Health Survey indicated that about 37% of seniors report have at least two of the ten most common chronic diseases, with almost half of those aged 85+ reporting multiple co-morbidities. Women younger than 75 years old were more likely to report multiple co-morbidities than men the same age (Government of Canada, 2021).
Interpersonal Level
At this stage of life, seniors often experience significant loss such as death of a spouse, family members and close friends. This can have a negative effect on their nutritional health as well as their mental health. Seniors who eat alone are more likely to reduce the quality and quantity of foods consumed resulting in an imbalance of nutrient intake (Chae, W., Ju, Y., Shun, J., Jang, S. & Park, E., 2018). Many seniors who live alone have poor social supports and social networks. According to the Public Health Agency of Canada (2018), female seniors were almost twice as likely to live alone (35.7% vs. 19.1%) and 1.5-fold less likely to live with a partner (48.9% vs. 71.3%) compared to senior males. Among both sexes, the prevalence of living alone was highest for participants who were older, lower income, divorced or separated, living in a population centre, renters, and less educated (Public Health Agency of Canada, 2018). These factors put this population at higher risk for negative health outcomes in older age. Recent international studies have shown that living arrangements of seniors are an important determinant of healthy aging, as they predict social support and interactions. Seniors living with a spouse or partner were more likely to have lower incidence rates of dementia, and experience better mental health.
They reported fewer limitations from multiple co-morbidities in all aspects of life (including social life, housework and leisure-time activities). Those living with family demonstrated lower rates of chronic and acute disease, and those living with others reported better mental health, social support and engagement in more physical activities, compared to those living alone (Public Health Agency of Canada, 2018).
Seniors are also at higher risk of being victimized or abused. Senior abuse can take different forms and can be perpetrated by various people. The three major areas of vulnerability for seniors are financial crime by strangers (telemarketers, scammers), crime and abuse by relatives and caregivers, and crime and abuse in institutional settings (Government of Canada, 2021). Each year, about 10 percent of Canadian seniors are victims of crime, the vast majority of these are property crimes. Up to one percent of Canadian seniors experience violent crimes or physical abuse. About 45 percent of seniors’ report experiencing some form of abuse from the age of 65 on. Financial abuse/exploitation and emotional abuse appear to be the most prevalent forms of abuse (Government of Canada, 2021). The actual numbers are difficult to capture as these types of abuses often go unreported.
Organizational Level
At the organizational level access to health care services can be challenging for seniors. They may face difficulty getting to doctor’s appointments. Taking a bus can be especially challenging in winter. Using taxi or other paid modes of transportation can be cost prohibitive for some seniors. Seniors living in rural, remote or northern communities may face the biggest barriers to accessing timely medical care.
Community Level
Seniors may have limited availability to reliable transportation which can reduce access to grocery stores. This may also restrict the quantity of food they are able to purchase and carry home. Some seniors live in areas where there is limited access to a supermarket. For example, in Winnipeg’s core area, there are very few large grocery stores. This has been an ongoing issue for residents living in this area for many years. Often, they are forced to access food at local convenience stores which stocks foods items of less nutritional value at higher cost. Seniors may use the services of a meal delivery company, however, this can be cost prohibitive for many seniors.
Seniors may want to be more active in their communities such as attending community centres and senior’s clubs and going for walks and outings. However, the physical environment can hold significant barriers to many leisure activities, especially in Manitoba, with adverse weather conditions and slippery streets and sidewalks. Lack of physical activity and social connections can affect their mental, physical, and nutritional health.
Public Policy Level
The Manitoba Government’s Seniors and Healthy Aging Department has many programs and services for seniors living in the province. These include:
· Pharmacare, a drug benefit program for Manitobans whose income is seriously affected by high prescription drug costs.
· Eligibility information on health care coverage for medical, hospital, ambulance and long-term care services.
· List of available health care services in various regions of the province.
· Information on seniors’ benefits such as OAS and CPP.
· Rent assist programming for low-income renters.
· 55 Plus program which provides income supplementation for low-income Manitobans 55 years and older.
The Age-Friendly Manitoba Initiative provides a Seniors Abuse Support Line for information, referral, counselling and follow-up support as well as the Prevent Elder Abuse Manitoba program that aims to increase awareness, and support communities in preventing the abuse of older Manitobans.
Community supports and resources for seniors include:
· Senior centres to support programs and activities that enhance dignity, independence and encourage participation in the community.
· Seniors community resource councils that offer congregate meal programs, transportation programs and health and wellness programs.
The Seniors and Healthy Aging Website offers information and resources on healthy aging, social connectedness, fall prevention, smoking cessation and housing options for older Manitobans (Government of Manitoba, n.d.).
The Winnipeg Regional Health Authority provides many support services to seniors to promote health and well-being through community-led programs as those shown in the Support Services to Seniors Framework.
Support Services to Seniors Framework: Winnipeg Regional Health Authority
For food and nutrition information, Dial-A-Dietitian is a free service provided to all Manitobans who are looking for answers to questions on healthy eating (College of Dietitians of Manitoba, n.d.).
Bias and Discrimination Toward Vulnerable, Older Adults
There are many cases of bias and discrimination toward vulnerable, older adults. I, personally, have not witnessed this type of bias or discrimination in my workplace. However, older adults are very vulnerable in many situations. One incident that came to the attention of staff and management was a situation that occurred in our long-term care facility. It involved a son visiting his mother. The son came regularly to visit, and always at lunch time. On those days the mother requested that the meal be brought to her room so she could visit with her son while eating lunch. Being in a smaller community, some staff were aware of the son’s character which was less than stellar, although everyone agreed it was so wonderful that he cared very much for his elderly mother and visited frequently. Many of the residents did not have family or friends visit often and, when they did, it was usually for special occasions such as birthdays and holidays. At one point, a health care aide was checking on the resident to see how she was doing and if she had finished her meal. The health care aide discovered the son was eating his mother’s meal. When the manager asked the resident about the situation, she admitted that her son was eating her food, and she was letting him because she felt he needed it more than she did.
Improving Health Outcomes for Older Adults
Seniors are living longer than ever. Seniors also want to age well and be as healthy as possible to enjoy their later years. The Public Health Agency of Canada (2018), in its report of living arrangements and health status of seniors, recommends that health policy makers promote the development of community programs that increase social participation and inclusion of older adults, especially those living alone, for the purpose of increasing their sense of community and belonging. Seniors need to have reliable transportation and access to community programming specifically geared toward their needs. In this environment, seniors can participate in meal programs, exercise programs, and activities of interest. It provides an opportunity to social with peers and make personal connections and friendships. Community programs can also provide access to reliable information that can help them in their daily living. Resources can be provided on relevant topics such as healthy eating, falls prevention, disease management and prevention and mental health services and more. The key to promoting longevity and good health among older adults lies in providing educational resources and encouraging social connections.
Conclusion
There are many vulnerable populations in our society. Older adults can definitely be counted among this group. When considering the health issues affecting these groups and the impact of the social determinants of health as well as the levels of influence in a framework such as the Social Ecological Model, it becomes clear that these factors are intertwined and function in a reciprocal manner. While this may appear to proceed only in a negative direction, it can also be viewed from a positive approach to address health issues among vulnerable groups through targeted interventions.
References:
Canadian Coalition for Seniors’ Mental Health. (n.d.).
Canadian Mental Health Association. (n.d.). Depression in Older Adults.
Chae, W., Ju, Y., Shun, J., Jang, S. & Park, E. (2018). Association between eating behaviour and diet quality: eating alone vs. eating with others. Nutrition Journal, 17(117).
College of Dietitians of Manitoba. (n.d.). Dial-A-Dietitian.
Fox, D. & Moyser, M. (2018). Women in Canada: A Gender-based Statistical Report, The Economic Well-Being of Women in Canada. Statistics Canada.
Government of Canada. (2021). Aging and chronic diseases: A profile of Canadian seniors.
Government of Canada. (2021). Crime and Abuse Against Seniors: A Review of the Research Literature with Special Reference to the Canadian Situation.
Government of Manitoba. (n.d.). Seniors and Healthy Aging.
Public Health Agency of Canada. (2018). At-a-glance – Living arrangements and health status of seniors in the 2018 Canadian Community Health Survey.
Ranage-Morin, P., Gilmour, H. & Rotermann, M. (2017). Nutritional risk, hospitalization and mortality among community-dwelling Canadians aged 65 or older. Statistics Canada.
Winnipeg Regional Health Authority. (2022). Support Services to Seniors.
World Health Organization. (2022). Malnutrition.
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