Biomedical Research 2011; 22 (1): 120-126

Comparative study of nutritional status of elderly population living in the

home for aged vs those living in the community
M Kirtana Pai

Department of Physiology, Kasturba Medical College, Manipal, India

Abstract

The higher incidence of malnutrition in elderly is well documented. Elderly nursing home
residents seem to have a higher risk of malnutrition with respect to the community dwell-
ing elderly population. A comparative study was therefore performed to evaluate the nutri-
tional status of elderly living at old age homes and in community, in the city of Mangalore.
Subjects aged over 60 years were included in this study. Nutritional status was evaluated
by anthropometric measurements to calculate the Body Mass Index, W/H ratio, and Tri-
ceps skin fold thickness and by data collected through the Mini Nutritional Assessment. A
total of two hundred and ten subjects participated in this study. The study subjects were
constituted by 108 inmates of old age homes and 102 people who were residing at their
houses. The results showed that the elderly at home had higher BMI (p<0.001) and higher
MNA scores (p<0.001) compared to those living in old age homes. The MNA results re-
vealed that 19.4% of subjects were malnourished and 57.4% were at risk of malnutrition
among the old age home residents. The prevalence of malnutrition by MNA was 2%, those
at risk of malnutrition were 14.7% in free living elderly. The results of this study show a
high risk of malnutrition (p<0.05) in the old age home residents, and confirm the need for
increased surveillance of nutritional status among residents of old age homes.

Key words: Elderly, malnutrition, anthropometric measurements, Mini Nutritional Assessment

Accepted August 27 2010

Introduction living at old age homes and in community, in the city of

Mangalore combining anthropometry and mini nutritional
India has acquired the label of aging nation with 7.7% of assessment. Nutrition screening of older adults is ex-
its population being more than 60 years old .There has tremely difficult; the shortcomings of existing screening
been a sharp increase in the proportion of elderly popula- tools do not make the problem any easier [5].Some of the
tion in India as a result of demographic transition [1]. The screening methods can only be administered by trained
proportion of elderly persons in the population of India clinicians. Biochemical markers are time consuming and
rose from 5.63 per cent in 1961 to 6.58 per cent in expensive to use in home situations, and the criteria for
1991[2] and to 7.5 per cent in 2001and it has been esti- their interpretation in old age are unclear [6].A compre-
mated that they would become 12% of total population by hensive tool specifically developed for use with elderly
2030[3].This is attributed to decrease in mortality arising people is the Mini-Nutritional Assessment (MNA): this is
from longer lifespan of individuals and improvements in a rapid and simple tool for evaluating the nutritional state
public health and medical services leading to control of of the frail elderly, which allows, if necessary, for nutri-
infectious diseases. The rapidly increasing aging popula- tional intervention and/or diet modification[7].The MNA
tion adds to the socio economic challenges that face India is a test composed of 18 simple and rapid easy to measure
[2, 3]. The scientific progress has reached a level where items which can be performed in less than 15 minutes.
nutritional interventions may play a part in the prevention (Table 8)[8]. The MNA has been validated in three suc-
of degenerative conditions of age, improvement of quality cessive studies of more than 600 elderly [7]. The MNA
of life and impact on health care burden and resources. detects risk of malnutrition before severe change in
Moreover a timely intervention can stop weight loss in weight or serum proteins occur [4].
elderly at risk of malnutrition or undernourished
[4].Evaluation of nutritional status is important for any Materials and Methods
nutrition or dietary modification. We therefore did a com-
parative study to evaluate the nutritional status of elderly
A total of 210 subjects above 60 years of age were studied did not require any modification to be applied in the study
over a period of 30 days. As it was a time bound study, population. A score was given to each subject on the basis
those elderly subjects available during the limited time of MNA questionnaire. The scoring categorizes the eld-
period were included. The study subjects were constituted erly subjects in the following manner.
by 108 inmates of old age homes and 102 people who >23.5 - satisfactory nutritional status
were residing at their houses. The standard informed con- 17-23.5- at risk of malnutrition
sent was taken from all the subjects following approval < 17 -malnutrition
from the college ethics committee. The old age home in-
mates were studied from Abhaya Ashram at Kodialbail, Gender, categories of MNA score and W/H ratio were
Prashanti Nivas Jeppu, Geriatric ward of Kasturba Medi- summarized using frequency and percentage across the
cal College, Mangalore. The members of KMC Ashraya elderly at old age home and at home. Chi Square test was
were also included in this study. KMC Ashraya is an or- used to compare the differences in nutritional status be-
ganization within KMC, working for the welfare of senior tween two groups and to find the association between
citizens, and physically disabled. nutritional status and co morbid illness at old age home
and home separately. Age, Height, Weight, BMI, Mid
Inclusion criteria upper arm circumference, Calf circumference, Triceps
Subjects over 60 years of age were included in this study skin fold thickness, Waist and Hip circumferences, and
as this is the geriatric age group as defined by the World MNA scores were summarized using median and Inter-
Health Organisation. quartile range across the two elderly groups. Mann Whit-
ney U test was used to compare the median differences
Exclusion criteria between the two groups. Pearsons correlation coefficients
Subjects with cancer, end-stage renal disease or terminal were performed for linear relations between total MNA
illness. scores and BMI, MUAC, CC and age.

Those receiving artificial enteral or parentral nutrition. The data were analysed using SPSS for windows version
15 (Bangalore). A p value of less than 0.05 was consid-
A detailed history was taken and clinical examination was ered to be statistically significant.
done for each subject.
Results
Persons with chronic illness (diabetes, hypertension,
COPD) were categorized into the co-morbidity group. Out of the total 210 elderly population studied, 108 sub-
Every subject under study was individually assessed for jects were inmates of old age home and 102 subjects were
nutritional status with anthropometry and Mini nutritional residing at their houses. Table 1 shows the distribution of
assessment. elderly subjects according to residence and gender. The
age and anthropometric measurements of the subjects
Anthropometry according to the residence are depicted in Table 2. The
Height, weight, mid upper arm circumference (MUAC), mean MNA scores of the subjects were higher in the sub-
calf circumference (CC) and triceps skin fold thickness jects at home compared to those in old age homes
(TSF) of all subjects were measured by standard tech- (p<0.001). The prevalence of malnutrition was 2.0% in
niques. Lange calipers were used to measure triceps skin the free living elderly and 19.4% in old age home resi-
fold thickness. Body mass index (BMI) of all subjects dents (by MNA) (Table 3).Age wise prevalence of mal-
were calculated. Waist and hip circumferences were also nutrition is shown in Table 4. Table 5 gives the distribu-
measured and W/H ratio calculated. tion of elderly subjects according to co morbid illness.
There was no significant difference between at risk, mal-
Waist-Hip ratio >1.0 in men and >0.85 in women have a nourished and well-nourished groups
greater risk of stroke, coronary artery disease and diabetes (p=0.397 at old age home, p=0.197 at home). Total MNA
mellitus [9].Accordingly the W/H ratio of the elderly sub- scores positively correlated with mid upper arm circum-
jects were divided into normal or at risk groups. ference both in old age home residents (r=0.472,p=0.001)
Mini nutritional assessment- and in residents at home. (r=0.32,p=0.001).There was
significant positive correlation between MNA scores and
The test involves (1) anthropometric assessment (weight, calf circumference in both the groups (r=0.521,p<0.001 in
height, mid arm and calf circumferences, weight loss) (2) old age home subjects, r=0.38,p<0.001 in subjects at
general assessment (six questions related to lifestyle, home).With BMI there was significant correlation only
medication and mobility) (3)dietary assessment (eight with elderly at old age home (r=0.299,p<0.002).There
questions related to number of meals, food and fluid in- was no correlation of MNA scores with age. (Table
take, and autonomy of feeding); and (4) subjective as- 6).The waist hip ratio was at risk in 47% of subjects in old
sessment (self perception of health and nutrition). The test
age home and 60% in elderly at home. The difference was statistically different (p<0.027) (Table 7).

Table 1. Distribution of subjects according to residence and gender

Gender Elderly at old age home Elderly at home

n (%) n (%)

Male 65 (60.2) 45 (44.1)

Female 43 (39.8) 57 (55.9)
Total 108 (100) 102 (100)

Table 2. Age, Anthropometric measurements and MNA scores of elderly

Measurements Elderly at old age home Elderly at home (n=102) p value

(n=108) Median (Q1-Q3)
Median (Q1-Q3)

Age (years) 71.5 (60-90) 66.5 (60-85) 0.001

Body weight (kg) 50 (30-78) 62 (35-79) 0.001
Height (cm) 156 (124-170) 160 (138-179) 0.001
BMI (kg/m2) 22 (13.8-40) 24.6 (17.3-33) 0.001
MUAC (cm) 22 (11-34) 26 (15-34) 0.001
CC (cm) 29 (18-39) 33 (15-34) 0.001
TSF (mm) 10 (3-38) 13 (5-29) 0.001
Waist circumference (cm) 64 (48-108) 76.5 (52-109) 0.001
Hip circumference (cm) 69.5 (52-120) 85 (56-110) 0.001
MNA scores 20.67 (7.5-28) 24.93 (16-29) 0.001

p<0.05 by Mann Whitney U test

Table 3. Assessment of Malnutrition according to Mini Nutritional Assessment

MNA score points Elderly at home Elderly at old age home Total
n=102 n (%) n=108 n (%) n=210 n (%)
malnourished <17 2 (2) 21 (19.4) 23 (11)
At risk of under- 17-23.5 15 (14.7) 62 (57.4) 77 (36.6)
nutrition
wellnourished >23.5 85 (83.3) 25 (23.1) 11 (52.4)

p<0.001 by Chi Square test.

Table 4. Age wise prevalence of nutritional status according to Mini Nutritional Assessment

Residence of elderly Age group Malnourished At risk of undernutrition Wellnour- Total

(years) (17) n (%) (17-23.5) n (%) ished n (%) n (%)

Old age home 60-69 6 (11.3) 32 (60.37) 15 (28.3) 53 (100)

70-79 10 (27.8) 18 (50) 8 (22.23) 36 (100)
>80 5 (26.3) 12 (63.15) 2 (10.53) 19 (100)
total 21 (19.4) 62 (57.4) 25 (23.14) 108 (100)
Home 60-69 1 (1.3) 11 (14.1) 66 (84.61) 78 (100)
70-79 1 (4.5) 4 (18.18) 17 (77.27) 22 (100)
>80 0 (0) 0 (0) 2 (100) 2 (100)
Total 2 (2) 15 (14.7) 85 (83.3) 102 (100
Table 5. Distribution of subjects according to co-morbid illness
Residence of Co-morbid Malnourished and Well Total p value
elderly illness At risk of malnutrition nourished

Old age home yes 47 (85.5) 8 (14.5) 55 (100) 0.397

no 42 (79.2) 11 (20.8) 53 (100)
total 89 (82.4) 19 (17.6) 108 (100)
Home yes 14 (28.6) 35 (71.4) 49 (100) 0.162
no 9 (17) 44 83) 53 (100)
total 23 (22.5) 79 (77.5) 102 (100)

Table 6. Correlation coefficients for MNA score according to residence

Measurements MNA SCORE

Elderly at old age home Elderly at home
(n=108) r (p) (n=102) r (p)
Age (year) -0.157 (0.104) -0.059 (0.559)
BMI (kg/m2) 0.299 (0.002) 0.147 (0.142)
MUAC (cm) 0.476 (0.001) 0.32 (0.001)
CC (cm) 0.521 (0.001) 0.38 (0.001)

p<0.05 by Pearsons test

Table 7. Comparison of Waist-Hip Ratio in Two study groups

Waist-Hip ratio Elderly Total p value

Old age home home
Normal (%) 61 (56.5) 42 (41.2) 103 (49) 0.027
At risk (%) 47 (43.5) 60 (58.8) 107 (51)
Total (%) 108 (100) 102 (100) 210 (100)

p<0.05 by chi square test

Table 8. The Mini Nutritional Assessment Form

Name Age Sex Weight (Kg) Height (cm) BMI Mid upper arm circumference (cm) Calf circumference
(cm) Anthropometric Measurement
Ref: Guigoz Y, Vellas , Garry PJ. Mini Nutritional Assessment: A practical assessment tool for grading the nutritional
state of elderly patients. Facts Res Gerontol 1994; 4 (suppl 2):15-59

1.Body mass index BMI (weight in Kg/Height 12.Selected consumption markers for protein intake
in m2) at least one serving of dairy products (milk, cheese or yo-
a. less than 19 = 0 points b.19 to less than 21 ghurt)per day?
=1 points c.21 to less than 23 = 2 points d.23 or yes no
greater = 3points two or more servings of legumes or eggs per week? Yes no
2.Mid – upper arm circumference (MUAC) in Meat, fish or poultry every day? Yes no
cm a.0 or 1 yes=0.0 points b.2 yes =0.5 points c.3 yes =1.0 points
a. less than 21 cm = 0 points b. 21 or 22
=0.5points 13. Consumes two or more servings of fruits or vegetables per
c.MAC 22 or greater =1points day?
0= No 1= Yes
3.Calf circumference (CC) in cm
a. less than 31 = 0points b. CC 31 or great- 14. Has food intake declined over the past three months due to
er=1point loss of appetite, digestive problems, chewing or swallowing
4. Weight loss during last 3 months? difficulties?
a. Weight loss greater than 3 kg=0 points a. Severe loss of appetite=0 points b .Moderate loss of appe-
b. Does not know= 1 point tite= 1 point
c. Weight loss between 1 and 3 kg= 2 points c. No loss of appetite= 2 points
d. Weight loss = 3 points

15. How much fluid (water, juice, coffee, tea, milk) is con-
General Assessment sumed per day?
5.Lives independently (not in nursing home or a. less than 3 cups =0 points
hospital) b. 3-5 cups =0.5 points
a =0 point b= 1 point c. more than 5 cups =1 point
16.Mode of feeding
6.Takes more than 3 prescriptions per day a. unable to eat without assistance =0 points
a =0 point b= 1 point b. self fed with some difficulty =1 points
7.Has suffered psychological stress or acute c. self fed without any problem =2 points
disease in past 3 months Self Assessment
a = 0 points b = 1 point 17.Self view of nutritional status
8.Mobility a. view self as being malnourished=0 points
a. Bed or chair bound=0 points b. Able to get b. is uncertain of nutrition states =1 point
out of bed or chair but does not go out=1 point c. view self as having no nutritional problem =2 points
c. Goes out=2 point
9.Neuropsychological problems 18.In comparison with other people of the same age, how do
a. Severe dementia or depression=0 points they consider their health status
b. Mild dementia=1 point a. not as good =0 points b .does not know =0.5point
c .No psychological problems=2 points c. good =1.0 points d. better =2.0 points

10.Pressure sores or skin ulcers ASSESSMENT TOTAL maximum (30 points)

a. yes=0 points b= 1 point
Dietary Assessment MALNUTRITION INDICATOR SCORE
11. How many meals does the patient eat daily? >23.5 - satisfactory nutritional status
a.1 meal=0 point b.2 meals=1 points c.3 17-23.5 - at risk of malnutrition
meals=2 points < 17 - malnutrition
nutrition were 57.4% in old age home residents and
14.7% in free living elderly subjects. Thus 76.8% subjects
in old age home were either malnourished or were at risk
of malnutrition. Even without an acute or chronic disease,
the composition of body changes with age [14].Loss of
muscle mass starts in the middle of adulthood and contin-
ues through old age. A dietary nutrient deficit with lower
energy expenditure is associated with decreased weight
and height in the elderly [15, 16].The decreased height in
elderly is also result of shortening of spinal column with
associated osteoporosis and kyphosis [17]. The nutritional
Figure 1. Assessment of malnutrition according to Mini status is independent of associated co morbid illness (ta-
Nutritional Assessment ble 5).So aging perse with decreased nutrient intake and
lack of exercise would have resulted in lower BMI (table
2) and increased risk of malnutrition in elderly at old age
Discussion home.

In the present study the prevalence of malnutrition was The MNA score showed significant correlation with mid
2.0% in the free living elderly and 19.4% in old age home upper arm circumference and calf circumference in both
residents (by MNA) (table 3).The prevalence of malnutri- the groups. With BMI, there was significant correlation
tion in free living elderly is similar to that found by Soini only in nursing home residents (table 6). Thomas et al
et al [10] but less than in Maliheh et al[11]. In old age had found high correlation of MNA score only with BMI
home residents, the number of people who were malnour- [18].However with age, there was no correlation with
ished is less than in Souminen et al [12] more than Lan- MNA score. Anja Saletti et al showed that age correlated
giano et al [13]. According to MNA, those at risk of mal with MNA score and BMI [19]. A study on 1564 elderly
volunteers in Turkey showed a decrease in MNA score
with increase in age [20].
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Correspondence to:

Kirtana M Pai
Department of Physiology
Kasturba Medical College
Manipal-576 104, India