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Undernutrition in community dwelling elderly
e-SPEN Journal 8 (2013) e213ee215
Contents lists available at SciVerse ScienceDirect
e-SPEN Journal journal homepage: http://www.elsevier.com/locate/clnu
Short report
Undernutrition in community dwelling elderlyq Marianna Arvanitakis a, *, Maurice Vandewoude b, Stany Perkisas b, André Van Gossum a a b
Nutrition Team, Erasme University Hospital ULB, Brussels, Belgium Universitair Centrum Geriatrie, Universiteit Antwerpen, ZNA, Ziekenhuisnetwerk Antwerpen, Belgium
a r t i c l e i n f o
a b s t r a c t
Article history: Received 18 December 2012 Accepted 28 June 2013
Background and aim: The aim of the present study was to assess the risk and the prevalence of undernutrition as well as associated factors among community dwelling elderly adults (home dwelling as well as nursing home residents). Methods: During one week a questionnaire was completed in 70 general practices and in 70 nursing homes. The questionnaire was based on items from validated screening instruments such as the MNA (Mini Nutritional Assessment; short form), the SNAQ (Short Nutritional Assessment Questionnaire) and some additional parameters (mobility, independence, social isolation and co-morbidities). Results: The study sample consisted of 5334 elderly of which 975 lived at home (Mean age: 83 years). Sixteen percent was older than 90. The overall risk for undernutrition (MNA 11) was 57%, and was significantly higher in nursing home residents, women and in the older age groups. Undernutrition was already present in 15.9% (BMI < 20 kg/m2), 17.1% (SNAQ) and 17.6% (clinical evaluation). Decreased mobility was associated with older age and undernutrition. Conclusions: The overall risk of and the prevalence of undernutrition are common in older people. The prevalence is highest among the oldest, in women and in nursing home residents. Undernutrition and worsening mobility are interrelated. Ó 2013 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.
Keywords: Community dwelling elderly Nutritional status Nutritional screening
1. Introduction An optimal nutritional status is an important co-factor of overall health, functional autonomy and quality of life in elderly.1 Furthermore, in case of a hospital admission, a previously affected nutritional status can prolong length of stay and increase overall health care costs.2 On the other hand, hospital caregivers are also concerned by undernutrition in community-dwelling seniors. Indeed, as the length of hospital stay becomes shorter, the need to improve the interaction between hospitals and home care settings in order to assure an optimal nutrition plan acquires a growing importance.3 Studies in developed countries found that up to 28% of community-dwelling elderly, and up to 65% of nursing home residents suffer from undernutrition.3 However, evaluation of the nutritional risk amongst this population is not performed
Abbreviations: MNAsf, Mini Nutritional Assessment-short form; SNAQ, Short Nutritional Assessment Questionnaire; BMI, body mass index. q This work was presented as a poster during the ESPEN Congress in Nice, 2010. * Corresponding author. Department of Gastroenterology, Erasme University Hospital ULB, Route de Lennik 808, 1070 Brussels, Belgium. Tel.: þ32 2 5553712; fax: þ32 2 5554697. E-mail address: [email protected] (M. Arvanitakis).
systematically as in the hospital setting; therefore large scale data, although increasing, still remains scarce. The aim of the present study is to assess the prevalence of undernutrition as well as the associated factors in persons who are older than 70 years, living either at home or in nursing homes. This evaluation was also performed as a campaign, in order to increase awareness, information and implementation of undernutrition screening amongst the elderly population. 2. Material and methods A questionnaire has been designed by various scientific societies for persons older than 65 years living either at home or in specialized nursing homes in different areas of Belgium. Assessment was done by nurses or general practitioners, who had previously received a specific training, during one week in November 2008. Seventy general practices and 70 nursing homes participated. There were no inclusion criteria for participating nursing homes; participation was at the discretion of the center. The evaluation included: the Mini Nutritional Assessmentshort form (MNAsf-a 6-question score assessing food intake, previous weight loss, mobility, recent acute disease, neuropsychological problems such as depression or dementia, and body
2212-8263/$36.00 Ó 2013 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.clnme.2013.06.005
e214
M. Arvanitakis et al. / e-SPEN Journal 8 (2013) e213ee215
3.2. Prevalence of undernutrition
Table 1 Demographic data for the study population (n ¼ 5334).
Number Gender (M/F) Age (mean SD) Age group (n,%) <70 y 70e75 y 76e80 y 81e85 y 86e90 y >90 y
Community dwelling
Nursing homes
Total
975 323/647 79.5 7.19
4359 1012/3322 84.0 7.81
5334 1335/3969 83.2 7.9
30 (3.1%) 265 (27.2%) 262 (26.9%) 218 (22.4%) 145 (14.9%) 55 (5.6%)
181 (4.2%) 338 (7.8%) 624 (14.3%) 1228 (28.2%) 1204 (27.6%) 784 (18%)
211 (4.0%) 603 (11.3%) 886 (16.6%) 1446 (27.1%) 1349 (25.3%) 839 (15.7%)
M: male, F: female, SD: standard deviation.
Table 2 Distribution of co-morbidities according to gender and setting for the study population (n ¼ 5334). Co-morbidities
Total population
Males
Females
Community dwelling
Nursing homes
Diabetes Previous stroke Cancer Swallowing difficulties Pressure ulcers
19% 11.4% 7.1% 12.4%
18.7% 14.9% 10.6% 14.2%
19.1% 10.2% 5.8% 11.7%
20.6% 8.9% 10% 8.3%
18.7% 12% 6.4% 13.3%
6.6%
5.3%
7%
5.1%
7%
mass index (BMI)); the total score of the MNAsf distinguished between nutritional risk (MNA-sf score between 8 and 11) and undernutrition (MNA-sf score < 8),4 the Short Nutritional Assessment Questionnaire (SNAQ-a 3 question subjective appetite assessment score; a score 2 indicates moderate malnutrition whereas 3 indicates severe malnutrition),5 previous weight loss, mobility and autonomy assessment (on a scale of 3: >50% of the time bed-ridden, decreased mobility or complete autonomy) social isolation and the presence of underlying diseases (diabetes mellitus, active cancer, swallowing disorders, pressure ulcers). Continuous variables were expressed as mean standard deviation. Differences between groups were analyzed using the Student t-test for continuous variables. The chi-square test was used for categorical variables. Statistical significance was considered for p values 0.05. 3. Results
A BMI of less than 20 was detected in 849 individuals (15.9%). A risk of undernutrition according to the MNA-sf (score 11) was identified in 3045 (57.1%). The SNAQ was 3 in 912 participants (17.1%), indicating also severe undernutrition. Previous weight loss had been observed in 1265 participants (23.7%) and 347 (6.5%) had lost more than 3 kg during the last 6 months. Similarly, one fourth of the population (25.3%, n ¼ 1349) had experienced previous loss of appetite. The presence of a low BMI (<20 kg/m2) was significantly more frequent in women (16.9% vs 12.5%, p<0.01). Furthermore, the fact of being a nursing-home resident was significantly associated with a higher prevalence of a BMI <20 kg/m2, compared to homedwelling individuals (16.6% vs 12.8%, p < 0.01). A BMI <20 was more frequently encountered in participants over 90 years compared to the rest of the study group (21.9% vs 14.2%, p < 0.05). Similarly, a MNA-sf score of 11 was significantly associated with an age >90 years (66.4% vs 54.1%) (p < 0.05). Finally, this age group also showed a higher rate of previous appetite loss (30.1% vs 24.4%, p < 0.05). 3.3. Associated factors (mobility, co-morbidity) Concerning co-morbidities, diabetes and previous stroke were encountered in respectively 19% and 11.4% of the population. Difficulties in swallowing were observed in 12.4% of individuals, and were more frequent in nursing home residents (13.3% vs 8.3%, p < 0.05) (Table 2). An important decrease of mobility resulting in more than 50% of the time being bedridden was recorded in 32.8% of the participants (n ¼ 1749). Nursing-home residents suffered more frequently than home-dwellers (37.4% vs 12.3%, p<0.001). Loss of mobility appeared to be related to increased age, with individuals >90 years having significantly more mobility problems compared to the rest of the study group (42.8% vs 29.2%, p < 0.001). Autonomy could be evaluated in 5273 patients. Interestingly, there was significant association between autonomy levels and undernutrition: BMI 20 kg/m2 and MNA >11 were more frequently encountered in individuals who were considered to have complete autonomy (Tables 3 and 4). Neuropsychological co-morbidities such as dementia or depression were encountered in 56% of the population. Nursinghome residents seemed to be at an increased risk (60.3% vs 36.7%, p < 0.001). On the other hand, social isolation was observed more frequently in home dwellers (24.8% vs 15%, p < 0.05).
3.1. Participants 4. Discussion A total of 5334 citizens were assessed, 975 (18.3%) were homedwellers and 4359 (81.7%) were nursing home residents. The majority of the population was females (74.4%, n ¼ 3969). Mean age was 83.2 7.9 years. More than half (52.4%) was between 80 and 90 years old. Nonagenarians consisted 15.7% (n ¼ 839) of the population. Setting and age distribution are represented in Table 1.
To our knowledge, this is one of the largest epidemiological cross-sectional studies regarding nutritional and global health assessment in the community-dwelling elderly. It is focused on individuals over 70-year-old and also contains an important subgroup of nonagenarians, who have not been evaluated in depth up
Table 3 Relation between BMI and autonomy in the study population (n ¼ 5273). Autonomy
BMI < 20 (N, %)
BMI 20 (N, %)
Total (N,%)
p Value
OR
Lower CI
Upper CI
>50% bedridden Decreased mobility Complete autonomy
396 (23.1%) 220 (15.6%) 221 (10.3%)
1319 (76.9%) 1189 (84.4%) 1928 (89.7%)
1715 (100%) 1409 (100%) 2140 (100%)
<0.0001 <0.0001
0.62 0.38
0.51 0.32
0.74 0.46
OR: odds ratio; CI: confidence interval.
M. Arvanitakis et al. / e-SPEN Journal 8 (2013) e213ee215
e215
Table 4 Relation between MNA and autonomy in the study population (n ¼ 5180).a Autonomy
MNA 11 (N, %)
MNA 12 (N, %)
Total (N,%)
p Value
OR
Lower CI
Upper CI
>50% bedridden Decreased mobility Complete autonomy
1510 (88.8%) 892 (63.8%) 588 (27.5%)
190 (11.2%) 507 (36.2%) 1553 (72.5%)
1700 (100%) 1339 (100%) 2141 (100%)
<0.0001 <0.0001
0.22 0.05
0.18 0.04
0.27 0.06
MNA: Mini Nutritional Assessment; OR: odds ratio; CI: confidence interval. a 5180 of the 5334 subjects underwent autonomy assessment and MNA.
to now concerning risk and prevalence of undernutrition. A risk of undernutrition according to the MNA-sf (score 11) was identified in more than half (57.1%). A recent Spanish epidemiological study including 22,007 community dwelling elderly that were assessed only by the MNA and the MNAsf revealed that 4.3 % of the subjects were classified as undernourished (MNA score <17) and 25.4 % were at risk of undernutrition (MNA score 17 to 23.5).6 These rates are considerably lower that those reported in our study. However, the population of the Spanish was younger (>65 years old) and did not include nursing home residents, therefore possibly explaining this discrepancy. Furthermore, the evaluation did not encompass other variables such as BMI, co-morbidities, and mobility issues, which were reported in our assessment. Concerning elderly over 85 years old, there are few studies dealing with nutritional assessment. In the present study, 839 nonagenarians were included and revealed high undernutrition rates, with 21.9% having a BMI <20 and 66.4% having a MNAsf score 11. Furthermore, this subgroup was shown to have higher risk of appetite loss. A previous published series focusing on 85-year-old community dwelling subjects included nutritional evaluation with the MNA, along with additional quality of life and autonomy scores, showed that successful aging was associated with higher MNA scores, underlying the importance of nutritional evaluation in this group.7 Risk factors identified as being associated with undernutrition were female gender, older age and living in a nursing home. Female gender has also been identified as a risk factor in other studies.8,9 A recent, longitudinal, population-based study in community dwelling residents identified female gender as a risk factor for development of undernutrition (based on a BMI < 20 kg/m2 or weight loss 5% in the previous 6 months) during follow-up.8 Moreover, physical performance and undernutrition have been known to be interrelated.10,11 A previous observational study regarding elderly patients undergoing ambulatory rehabilitation who had a nutritional assessment revealed a correlation between the risk of undernutrition and variables such as muscle mass measured by bioimpedance, triceps skinfold thickness, handgrip strength and gait speed.10 Indeed, the major age-related physiological change in older people is a decline in skeletal muscle mass, which results in muscle strength and performance, known as sarcopenia.11 On the other hand, sarcopenia with muscle wasting is a major consequence of undernutrition, leading to respiratory failure and decreased capacity for daily activities. Consequently, these individuals are physically dependent and experience an important loss of autonomy, which leads to depression and progressive withdrawal. A vicious cycle is installed, resulting in social isolation and aggravation of the nutritional state.10,11 There are some limitations in this study. First of all, there is no biochemical evaluation focusing on albumin, transthyretin, vitamin and trace element assessment. Nevertheless, undernutrition in the elderly can be associated with various deficiencies with clinical implications. Furthermore, the study consisted of a single evaluation, and there is no follow-up period to determine outcome according to the risk and degree of undernutrition. Finally, due to the large sample size, it was difficult to collect
information concerning the impact of an eventual nutritional intervention. In conclusion, the overall risk of and the prevalence of undernutrition are common in older people living in the community, either at home or in nursing homes. The prevalence is highest among the oldest, in women and in nursing home residents. Undernutrition and worsening mobility are interrelated. Therefore, the role of screening conducted by general practitioners or dieticians is of importance. Large-scale studies in elderly, community dwelling, individuals with screening, nutritional intervention and outcome measures could be useful in improving global health care. Acknowledgments Statement of authorship: MA carried out the data analysis and drafted the manuscript. MV and SP participated in the design, contributed to the coordination of the study and carried out data analysis. AV participated in the design and helped to draft the manuscript. All authors read and approved the final manuscript. Sources of funding: Nutricia, Belgium, who coordinated data collection and contributed to data analysis, supported this study. However, there was no participation in manuscript drafting and submission. Conflict of interest: There is no conflict of interest to declare. References 1. Kvamme JM, Olsen JA, Florholmen J, Jacobsen BK. Risk of malnutrition and health-related quality of life in community-living elderly men and women: the Tromsø study. Qual Life Res 2011;20:575e82. 2. Darmon P, Lochs H, Pichard C. Economic impact and quality of life as endpoints of nutritional therapy. Curr Opin Clin Nutr Metab Care 2008;11:452e8. 3. Arvanitakis M, Coppens P, Doughan L, Van Gossum A. Nutrition in care homes and home care: recommendations e a summary based on the report approved by the Council of Europe. Clin Nutr 2009;28:492e6. 4. Rubenstein LZ, Harker JO, Salvà A, Guigoz Y, Vellas B. Screening for undernutrition in geriatric practice: developing the short-form mini-nutritional assessment (MNA-SF). J Gerontol A Biol Sci Med Sci 2001;56:M366e72. 5. Kruizenga HM, Seidell JC, de Vet HC, Wierdsma NJ, van Bokhorst-de van der Schueren MA. Development and validation of a hospital screening tool for malnutrition: the short nutritional assessment questionnaire (SNAQ). Clin Nutr 2005;24:75e82. 6. Cuervo M, García A, Ansorena D, Sánchez-Villegas A, Martínez-González M, Astiasarán I, et al. Nutritional assessment interpretation on 22,007 Spanish community-dwelling elders through the Mini Nutritional Assessment test. Public Health Nutr 2009;12:82e90. 7. Formiga F, Ferrer A, Megido MJ, Chivite D, Badia T, Pujol R. Low co-morbidity, low levels of malnutrition, and low risk of falls in a community-dwelling sample of 85-year-olds are associated with successful aging: the Octabaix study. Rejuvenation Res 2011;14:309e14. 8. Schilp J, Wijnhoven HA, Deeg DJ, Visser M. Early determinants for the development of undernutrition in an older general population: Longitudinal Aging Study Amsterdam. Br J Nutr 2011;106:708e17. 9. Tamura BK, Bell CL, Masaki KH, Amella EJ. Factors associated with weight loss, low BMI, and malnutrition among nursing home patients: a systematic review of the literature. J Am Med Dir Assoc 2013 Apr 29. http://dx.doi.org/10.1016/ j.jamda.2013.02.022. pii: S1525-8610(13)00113-8. [Epub ahead of print]. 10. Chevalier S, Saoud F, Gray-Donald K, Morais JA. The physical functional capacity of frail elderly persons undergoing ambulatory rehabilitation is related to their nutritional status. J Nutr Health Aging 2008;12:721e6. 11. Cruz-Jentoft AJ, Baeyens JP, Bauer JM, Boirie Y, Cederholm T, Landi F, et al., European Working Group on Sarcopenia in Older People. Sarcopenia: European consensus on definition and diagnosis: report of the European Working Group on Sarcopenia in older people. Age Ageing 2010;39:412e23.
Contents lists available at SciVerse ScienceDirect
e-SPEN Journal journal homepage: http://www.elsevier.com/locate/clnu
Short report
Undernutrition in community dwelling elderlyq Marianna Arvanitakis a, *, Maurice Vandewoude b, Stany Perkisas b, André Van Gossum a a b
Nutrition Team, Erasme University Hospital ULB, Brussels, Belgium Universitair Centrum Geriatrie, Universiteit Antwerpen, ZNA, Ziekenhuisnetwerk Antwerpen, Belgium
a r t i c l e i n f o
a b s t r a c t
Article history: Received 18 December 2012 Accepted 28 June 2013
Background and aim: The aim of the present study was to assess the risk and the prevalence of undernutrition as well as associated factors among community dwelling elderly adults (home dwelling as well as nursing home residents). Methods: During one week a questionnaire was completed in 70 general practices and in 70 nursing homes. The questionnaire was based on items from validated screening instruments such as the MNA (Mini Nutritional Assessment; short form), the SNAQ (Short Nutritional Assessment Questionnaire) and some additional parameters (mobility, independence, social isolation and co-morbidities). Results: The study sample consisted of 5334 elderly of which 975 lived at home (Mean age: 83 years). Sixteen percent was older than 90. The overall risk for undernutrition (MNA 11) was 57%, and was significantly higher in nursing home residents, women and in the older age groups. Undernutrition was already present in 15.9% (BMI < 20 kg/m2), 17.1% (SNAQ) and 17.6% (clinical evaluation). Decreased mobility was associated with older age and undernutrition. Conclusions: The overall risk of and the prevalence of undernutrition are common in older people. The prevalence is highest among the oldest, in women and in nursing home residents. Undernutrition and worsening mobility are interrelated. Ó 2013 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.
Keywords: Community dwelling elderly Nutritional status Nutritional screening
1. Introduction An optimal nutritional status is an important co-factor of overall health, functional autonomy and quality of life in elderly.1 Furthermore, in case of a hospital admission, a previously affected nutritional status can prolong length of stay and increase overall health care costs.2 On the other hand, hospital caregivers are also concerned by undernutrition in community-dwelling seniors. Indeed, as the length of hospital stay becomes shorter, the need to improve the interaction between hospitals and home care settings in order to assure an optimal nutrition plan acquires a growing importance.3 Studies in developed countries found that up to 28% of community-dwelling elderly, and up to 65% of nursing home residents suffer from undernutrition.3 However, evaluation of the nutritional risk amongst this population is not performed
Abbreviations: MNAsf, Mini Nutritional Assessment-short form; SNAQ, Short Nutritional Assessment Questionnaire; BMI, body mass index. q This work was presented as a poster during the ESPEN Congress in Nice, 2010. * Corresponding author. Department of Gastroenterology, Erasme University Hospital ULB, Route de Lennik 808, 1070 Brussels, Belgium. Tel.: þ32 2 5553712; fax: þ32 2 5554697. E-mail address: [email protected] (M. Arvanitakis).
systematically as in the hospital setting; therefore large scale data, although increasing, still remains scarce. The aim of the present study is to assess the prevalence of undernutrition as well as the associated factors in persons who are older than 70 years, living either at home or in nursing homes. This evaluation was also performed as a campaign, in order to increase awareness, information and implementation of undernutrition screening amongst the elderly population. 2. Material and methods A questionnaire has been designed by various scientific societies for persons older than 65 years living either at home or in specialized nursing homes in different areas of Belgium. Assessment was done by nurses or general practitioners, who had previously received a specific training, during one week in November 2008. Seventy general practices and 70 nursing homes participated. There were no inclusion criteria for participating nursing homes; participation was at the discretion of the center. The evaluation included: the Mini Nutritional Assessmentshort form (MNAsf-a 6-question score assessing food intake, previous weight loss, mobility, recent acute disease, neuropsychological problems such as depression or dementia, and body
2212-8263/$36.00 Ó 2013 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.clnme.2013.06.005
e214
M. Arvanitakis et al. / e-SPEN Journal 8 (2013) e213ee215
3.2. Prevalence of undernutrition
Table 1 Demographic data for the study population (n ¼ 5334).
Number Gender (M/F) Age (mean SD) Age group (n,%) <70 y 70e75 y 76e80 y 81e85 y 86e90 y >90 y
Community dwelling
Nursing homes
Total
975 323/647 79.5 7.19
4359 1012/3322 84.0 7.81
5334 1335/3969 83.2 7.9
30 (3.1%) 265 (27.2%) 262 (26.9%) 218 (22.4%) 145 (14.9%) 55 (5.6%)
181 (4.2%) 338 (7.8%) 624 (14.3%) 1228 (28.2%) 1204 (27.6%) 784 (18%)
211 (4.0%) 603 (11.3%) 886 (16.6%) 1446 (27.1%) 1349 (25.3%) 839 (15.7%)
M: male, F: female, SD: standard deviation.
Table 2 Distribution of co-morbidities according to gender and setting for the study population (n ¼ 5334). Co-morbidities
Total population
Males
Females
Community dwelling
Nursing homes
Diabetes Previous stroke Cancer Swallowing difficulties Pressure ulcers
19% 11.4% 7.1% 12.4%
18.7% 14.9% 10.6% 14.2%
19.1% 10.2% 5.8% 11.7%
20.6% 8.9% 10% 8.3%
18.7% 12% 6.4% 13.3%
6.6%
5.3%
7%
5.1%
7%
mass index (BMI)); the total score of the MNAsf distinguished between nutritional risk (MNA-sf score between 8 and 11) and undernutrition (MNA-sf score < 8),4 the Short Nutritional Assessment Questionnaire (SNAQ-a 3 question subjective appetite assessment score; a score 2 indicates moderate malnutrition whereas 3 indicates severe malnutrition),5 previous weight loss, mobility and autonomy assessment (on a scale of 3: >50% of the time bed-ridden, decreased mobility or complete autonomy) social isolation and the presence of underlying diseases (diabetes mellitus, active cancer, swallowing disorders, pressure ulcers). Continuous variables were expressed as mean standard deviation. Differences between groups were analyzed using the Student t-test for continuous variables. The chi-square test was used for categorical variables. Statistical significance was considered for p values 0.05. 3. Results
A BMI of less than 20 was detected in 849 individuals (15.9%). A risk of undernutrition according to the MNA-sf (score 11) was identified in 3045 (57.1%). The SNAQ was 3 in 912 participants (17.1%), indicating also severe undernutrition. Previous weight loss had been observed in 1265 participants (23.7%) and 347 (6.5%) had lost more than 3 kg during the last 6 months. Similarly, one fourth of the population (25.3%, n ¼ 1349) had experienced previous loss of appetite. The presence of a low BMI (<20 kg/m2) was significantly more frequent in women (16.9% vs 12.5%, p<0.01). Furthermore, the fact of being a nursing-home resident was significantly associated with a higher prevalence of a BMI <20 kg/m2, compared to homedwelling individuals (16.6% vs 12.8%, p < 0.01). A BMI <20 was more frequently encountered in participants over 90 years compared to the rest of the study group (21.9% vs 14.2%, p < 0.05). Similarly, a MNA-sf score of 11 was significantly associated with an age >90 years (66.4% vs 54.1%) (p < 0.05). Finally, this age group also showed a higher rate of previous appetite loss (30.1% vs 24.4%, p < 0.05). 3.3. Associated factors (mobility, co-morbidity) Concerning co-morbidities, diabetes and previous stroke were encountered in respectively 19% and 11.4% of the population. Difficulties in swallowing were observed in 12.4% of individuals, and were more frequent in nursing home residents (13.3% vs 8.3%, p < 0.05) (Table 2). An important decrease of mobility resulting in more than 50% of the time being bedridden was recorded in 32.8% of the participants (n ¼ 1749). Nursing-home residents suffered more frequently than home-dwellers (37.4% vs 12.3%, p<0.001). Loss of mobility appeared to be related to increased age, with individuals >90 years having significantly more mobility problems compared to the rest of the study group (42.8% vs 29.2%, p < 0.001). Autonomy could be evaluated in 5273 patients. Interestingly, there was significant association between autonomy levels and undernutrition: BMI 20 kg/m2 and MNA >11 were more frequently encountered in individuals who were considered to have complete autonomy (Tables 3 and 4). Neuropsychological co-morbidities such as dementia or depression were encountered in 56% of the population. Nursinghome residents seemed to be at an increased risk (60.3% vs 36.7%, p < 0.001). On the other hand, social isolation was observed more frequently in home dwellers (24.8% vs 15%, p < 0.05).
3.1. Participants 4. Discussion A total of 5334 citizens were assessed, 975 (18.3%) were homedwellers and 4359 (81.7%) were nursing home residents. The majority of the population was females (74.4%, n ¼ 3969). Mean age was 83.2 7.9 years. More than half (52.4%) was between 80 and 90 years old. Nonagenarians consisted 15.7% (n ¼ 839) of the population. Setting and age distribution are represented in Table 1.
To our knowledge, this is one of the largest epidemiological cross-sectional studies regarding nutritional and global health assessment in the community-dwelling elderly. It is focused on individuals over 70-year-old and also contains an important subgroup of nonagenarians, who have not been evaluated in depth up
Table 3 Relation between BMI and autonomy in the study population (n ¼ 5273). Autonomy
BMI < 20 (N, %)
BMI 20 (N, %)
Total (N,%)
p Value
OR
Lower CI
Upper CI
>50% bedridden Decreased mobility Complete autonomy
396 (23.1%) 220 (15.6%) 221 (10.3%)
1319 (76.9%) 1189 (84.4%) 1928 (89.7%)
1715 (100%) 1409 (100%) 2140 (100%)
<0.0001 <0.0001
0.62 0.38
0.51 0.32
0.74 0.46
OR: odds ratio; CI: confidence interval.
M. Arvanitakis et al. / e-SPEN Journal 8 (2013) e213ee215
e215
Table 4 Relation between MNA and autonomy in the study population (n ¼ 5180).a Autonomy
MNA 11 (N, %)
MNA 12 (N, %)
Total (N,%)
p Value
OR
Lower CI
Upper CI
>50% bedridden Decreased mobility Complete autonomy
1510 (88.8%) 892 (63.8%) 588 (27.5%)
190 (11.2%) 507 (36.2%) 1553 (72.5%)
1700 (100%) 1339 (100%) 2141 (100%)
<0.0001 <0.0001
0.22 0.05
0.18 0.04
0.27 0.06
MNA: Mini Nutritional Assessment; OR: odds ratio; CI: confidence interval. a 5180 of the 5334 subjects underwent autonomy assessment and MNA.
to now concerning risk and prevalence of undernutrition. A risk of undernutrition according to the MNA-sf (score 11) was identified in more than half (57.1%). A recent Spanish epidemiological study including 22,007 community dwelling elderly that were assessed only by the MNA and the MNAsf revealed that 4.3 % of the subjects were classified as undernourished (MNA score <17) and 25.4 % were at risk of undernutrition (MNA score 17 to 23.5).6 These rates are considerably lower that those reported in our study. However, the population of the Spanish was younger (>65 years old) and did not include nursing home residents, therefore possibly explaining this discrepancy. Furthermore, the evaluation did not encompass other variables such as BMI, co-morbidities, and mobility issues, which were reported in our assessment. Concerning elderly over 85 years old, there are few studies dealing with nutritional assessment. In the present study, 839 nonagenarians were included and revealed high undernutrition rates, with 21.9% having a BMI <20 and 66.4% having a MNAsf score 11. Furthermore, this subgroup was shown to have higher risk of appetite loss. A previous published series focusing on 85-year-old community dwelling subjects included nutritional evaluation with the MNA, along with additional quality of life and autonomy scores, showed that successful aging was associated with higher MNA scores, underlying the importance of nutritional evaluation in this group.7 Risk factors identified as being associated with undernutrition were female gender, older age and living in a nursing home. Female gender has also been identified as a risk factor in other studies.8,9 A recent, longitudinal, population-based study in community dwelling residents identified female gender as a risk factor for development of undernutrition (based on a BMI < 20 kg/m2 or weight loss 5% in the previous 6 months) during follow-up.8 Moreover, physical performance and undernutrition have been known to be interrelated.10,11 A previous observational study regarding elderly patients undergoing ambulatory rehabilitation who had a nutritional assessment revealed a correlation between the risk of undernutrition and variables such as muscle mass measured by bioimpedance, triceps skinfold thickness, handgrip strength and gait speed.10 Indeed, the major age-related physiological change in older people is a decline in skeletal muscle mass, which results in muscle strength and performance, known as sarcopenia.11 On the other hand, sarcopenia with muscle wasting is a major consequence of undernutrition, leading to respiratory failure and decreased capacity for daily activities. Consequently, these individuals are physically dependent and experience an important loss of autonomy, which leads to depression and progressive withdrawal. A vicious cycle is installed, resulting in social isolation and aggravation of the nutritional state.10,11 There are some limitations in this study. First of all, there is no biochemical evaluation focusing on albumin, transthyretin, vitamin and trace element assessment. Nevertheless, undernutrition in the elderly can be associated with various deficiencies with clinical implications. Furthermore, the study consisted of a single evaluation, and there is no follow-up period to determine outcome according to the risk and degree of undernutrition. Finally, due to the large sample size, it was difficult to collect
information concerning the impact of an eventual nutritional intervention. In conclusion, the overall risk of and the prevalence of undernutrition are common in older people living in the community, either at home or in nursing homes. The prevalence is highest among the oldest, in women and in nursing home residents. Undernutrition and worsening mobility are interrelated. Therefore, the role of screening conducted by general practitioners or dieticians is of importance. Large-scale studies in elderly, community dwelling, individuals with screening, nutritional intervention and outcome measures could be useful in improving global health care. Acknowledgments Statement of authorship: MA carried out the data analysis and drafted the manuscript. MV and SP participated in the design, contributed to the coordination of the study and carried out data analysis. AV participated in the design and helped to draft the manuscript. All authors read and approved the final manuscript. Sources of funding: Nutricia, Belgium, who coordinated data collection and contributed to data analysis, supported this study. However, there was no participation in manuscript drafting and submission. Conflict of interest: There is no conflict of interest to declare. References 1. Kvamme JM, Olsen JA, Florholmen J, Jacobsen BK. Risk of malnutrition and health-related quality of life in community-living elderly men and women: the Tromsø study. Qual Life Res 2011;20:575e82. 2. Darmon P, Lochs H, Pichard C. Economic impact and quality of life as endpoints of nutritional therapy. Curr Opin Clin Nutr Metab Care 2008;11:452e8. 3. Arvanitakis M, Coppens P, Doughan L, Van Gossum A. Nutrition in care homes and home care: recommendations e a summary based on the report approved by the Council of Europe. Clin Nutr 2009;28:492e6. 4. Rubenstein LZ, Harker JO, Salvà A, Guigoz Y, Vellas B. Screening for undernutrition in geriatric practice: developing the short-form mini-nutritional assessment (MNA-SF). J Gerontol A Biol Sci Med Sci 2001;56:M366e72. 5. Kruizenga HM, Seidell JC, de Vet HC, Wierdsma NJ, van Bokhorst-de van der Schueren MA. Development and validation of a hospital screening tool for malnutrition: the short nutritional assessment questionnaire (SNAQ). Clin Nutr 2005;24:75e82. 6. Cuervo M, García A, Ansorena D, Sánchez-Villegas A, Martínez-González M, Astiasarán I, et al. Nutritional assessment interpretation on 22,007 Spanish community-dwelling elders through the Mini Nutritional Assessment test. Public Health Nutr 2009;12:82e90. 7. Formiga F, Ferrer A, Megido MJ, Chivite D, Badia T, Pujol R. Low co-morbidity, low levels of malnutrition, and low risk of falls in a community-dwelling sample of 85-year-olds are associated with successful aging: the Octabaix study. Rejuvenation Res 2011;14:309e14. 8. Schilp J, Wijnhoven HA, Deeg DJ, Visser M. Early determinants for the development of undernutrition in an older general population: Longitudinal Aging Study Amsterdam. Br J Nutr 2011;106:708e17. 9. Tamura BK, Bell CL, Masaki KH, Amella EJ. Factors associated with weight loss, low BMI, and malnutrition among nursing home patients: a systematic review of the literature. J Am Med Dir Assoc 2013 Apr 29. http://dx.doi.org/10.1016/ j.jamda.2013.02.022. pii: S1525-8610(13)00113-8. [Epub ahead of print]. 10. Chevalier S, Saoud F, Gray-Donald K, Morais JA. The physical functional capacity of frail elderly persons undergoing ambulatory rehabilitation is related to their nutritional status. J Nutr Health Aging 2008;12:721e6. 11. Cruz-Jentoft AJ, Baeyens JP, Bauer JM, Boirie Y, Cederholm T, Landi F, et al., European Working Group on Sarcopenia in Older People. Sarcopenia: European consensus on definition and diagnosis: report of the European Working Group on Sarcopenia in older people. Age Ageing 2010;39:412e23.