Medical Journal of Babylon-Vol. 9- No.

1 -2012

2012 -&'(*) + -,-".* #$/ - !"! #$%

Nu2ri2ional 011e11?en2 of @lderly Aer1on1 in Babylon

9adeel :adhil :arhood ;ept. of .ommunity Medicine& .ollege of Medicine& <niversity of Babylon.9illa& .-ra4

MJ B

0b12rac2
3b4ec2i5e6 To assess the risk of malnutrition among elderly people living in Babylon using the Mini.Nutritional Assessment (MNA) and to study the characteristics of the instrument in this patient group 7e1i8n6 A cross-sectional study using the MNA score to assess the nutritional status of eligible elderly .persons from out patient clinic in Mar an hospital 9ub4ec216 A total of !"" out of #$% eligible elderly patients agreed to participate& men '(.') ( n* .( !!% ) and female #+.+) ( n* +( :e1ul216 #(." ) and $+.# ) of elderly are malnourished and at risk of malnutrition. The means of the body mass inde, ( BM- ) & mid arm circumference ( MA. ) and calf circumference (.. ) /ere about #+.$ kg 0m1 & #(.# cm and #%.( cm& respectively. elderly people & /ho /ere classified as malnourished & according to the (MNA) & had the lo/est (BM- )& ( MA. ) and (.. ) . 2hen the score of the (MNA) /as based on the diagnosis of the elderly& the results sho/ that elderly sub ects /ith more than one main diagnosis had a lo/est score. Based on the score of the (MNA) test& more than !3$ of the sub ects /ere malnourished. Most of the sub ects /ere consuming three meals and more than t/o serving of fruit and vegetables per day. -t seems that food intake /as satisfactory& among sub ects& despite that the present of malnourished sub ects reached #(."). The result of the (MNA) test indicates the necessary .of performing National nutritional assessment for this vulnerable group of people in -ra4

% ( &BM- ) $" # ! . ((/ & (,23 1""( - ."/0 ,-"* # .+ %"(' ) & & , 3" 897 7 (%43.2& %26.5 67 42"5 . 23 1" ) "(' % & $" # ! %9" 6# &. 9" 3" 897 7 =<:9;/ 897 697 (67 &&. 9" 29.6& 26 2.& 2, \ 3# 23.4 + %& # . + % "(' ) & % & $" # ! 1 5? 9 >(, 3" 1;7 ,-" 1" $"5 @ E C-D B# A 69>(@ . "(- ."/0 &.3" 897 697 (G7 B# 6F $5 , 1" $"5 F "? M&P- & N#9O >(" B# & # M. &JKL 69 "&HI 6F & &<, *S R & . # A97 69 N "&Q ,I; 6F F D . ,9 A 2R 1 @ :&E F 42 " "27 26.5 3" 897 7 (.5 .G"$ 9$ TTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTT TTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTT TTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTT TTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTT

factors such as dentition& neuropsychological problems and mobility and may be related to other health concerns 5#6. -ncreasing ill health and increasing disability are
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;n2roduc2ion lder adult are a potentially vulnerable group for malnutrition 5!6. Nutritional status is influenced by numerous
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Medical Journal of Babylon-Vol. 9- No. 1 -2012

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A total of !"" out of #$% agreed to participate& men (n * !!%& '(.'))& female (n* +(& #+.+ )). The data /ere collected /ith a structured H4uestionnaire that /as divided into 4uestions to determine body mass $ I (inde, (BM(Mid E Arm .ircumference (..I 2eight loss during last three I months Jlobal Assessment (( 4uestions I related to life style& medications& and .(mobility ;ietary Kuestionnaires (( I 4uestions& related to number of meals food and fluid intake& and autonomy of (feeding Aub ective assessment (# 4uestions I related to self E perception of health .5and nutrition)5% A score of less than !' points is regarded as indication of malnutrition& !' E #+." points indicate a risk of malnutrition and L #+." points indicate that the person is /ell nourished. -n addition& the aim /as to obtain more accurate information about eating habits for further use. Gsychological stress /as defined as if he 3she suffered bereavement recently or any cute disease or an aggravation of a chronic disease in the past + months. the consumptions of fruit and vegetables /as covered by if consumption t/o or more servings fruit and vegetables per day& consumption of markers for protein intake as at least one serving of dairy products (milk& cheese& yogurt) per day& t/o or more servings of legumes or eggs per /eek or( meat& fish or poultry) every day Neurological problems in the case of mild dementia /ere recorded on the basis of sub ective impression. Gatients on medication asked if take more than + prescription drugs per day or if suffers from any skin ulcer or pressure .sores The 4uestion concerning fluid (/ater& uice& coffee& tea& milk) /hich is
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linked /ith nutritional risk indicators 5+& $6. The nutritional status of ne/ly hospitali=ed elderly patients or institutionali=ed elderly is often poor5"6& even upon discharge these people>s nutritional status may remain poor and re4uire strict attention in other care settings and at home ((). -n the present situation /here old people /ith disabilities are encouraged to live in their o/n homes& it is important that accurate information is available about .their health and nutritional status Nutrition screening of older adults is e,tremely difficult? the shortcomings of e,isting screening tools don@t make the problem any easier 5'6. Aome of the screening methods can only be administered by trend clinicians& Biochemical markers are time consuming and e,pensive to use in nutritional evaluation& and the criteria for their interpretation in old age are unclear 5B6. A comprehensive tool Assessment (MNA)& this tool is designed for purposes of identifying the risk of malnutrition in the frail elderly and identifying those /ho may benefit from early intervention& MNA has been validated in three successive .5studies of more than (88 elderly 5% -t includes the anthropometric measures of /eight and height and derived body mass inde, (BM-)& /hich .5are reliable and simple tools to use 5B Cno/ledge about the use of MNA in -ra4 is limited& the present study setout to obtain information about the nutritional status of elderly by using .the MNA Ma2erial and Me2>od1 A cross sectional study using MNA score to assess the nutritional state of eligible elderly (D (" years old) randomly selected from out patient clinic in mer an hospital for period bet/een May E Fune 3#88'. Gatient /ith sever cognitive impairment /ere .e,cluded
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Medical Journal of Babylon-Vol. 9- No. 1 -2012

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for being malnourished and the /ellnourished elderly sub ect respectively .((table # The mean values of BM-& MA.& .. according to the three MNA categories sho/ in( table +) /hich are compared using one /ay analysis of variance .((one /ay AN7OA Plderly people& /ho /ere classified as malnourished according to MNA test& had the lo/est BM-& MA. and ... The elderly people /ho /ere classified at risk of being malnourished had a lo/er .. compared /ith the /ell.(nourished (table + No significant difference in the BMand MA. value /as observed bet/een those /ho /ere classified as at risk of being malnourished and the /ell.(nourished sub ects (GL 8.8" The MA. and .. /ere found to be significantly correlation /ith BM(M*8."+& GQ 8.88! and M* 8.(!& GQ8.888! respectively)& MA. and .. .((M*8."$ There /as a significant negative correlation bet/een age and BM.((GQ8.88! A significant correlation bet/een MNA score and individual 4uestions are presented in table $ and only five of MNA 4uestions (self-perceived nutritional status& skin problem& use of drink& ability to eat& independence) sho/ed no significant correlation to .(total MNA score(GL8.8" -n the MNA 4uestion !#'& B#) took more than three prescription drugs per day and +() (n*"() had suffered psychological stress or acute disease in the past three months. "B )( n*%8) regarded their health status as poorer than other in comparison /ith other people of the same age& #() (n*$8) /ere unable to give such an estimation& about !() considered their health as .good. !") (n*#+) had skin problem n*#8) vie/ self as being) !+) malnourished and +" )( n*"$) /ere unable to estimate their nutritional
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consumed per day by( less than +) cups&( +-") cups& (more than ") cups& loss of appetite& digestive problems& che/ing or s/allo/ing difficulties over the past + months& /eight loss during the last + months& mobility& number of meal does the patient eat daily& mode of feeding if the patient unable to eat /ithout assistance or self fed /ith some difficulty or /ithout any problem& self vie/ of nutritional status and health status and any history of .chronic diseases /ere recorded Mid arm circumference& calf circumference (..)& body mass inde, (BM-) (/eight in Cg 3 (height in m#) all /ere assess to the patients. A problem related to eating and digestion /ere named as che/ing and s/allo/ing problem& problems in eating because of dry mouth& constipation& diarrhea& indigestion and .other problem are also recorded The histories of chronic diseases /ere recorded Mesults /ere e,pressed as mean values .N A; and percentage Also using one /ay analysis of variance (one /ay-AN7OA) and .student@s test& correlation by AGAA :e1ul21 A total of !"" out of #$% of an eligible elderly took part. The main reasons for non-participation /ere fatigue or being .to ill The mean age of the elderly is '8.+ N ".+. The average BM-& MA.& .. value for /hole elderly (n*!"") /as #+.$ kg3m1& #(.# cm and #%.( cm .(respectively (table ! The nutritional status of investigated elderly is presented in table # & #(." ) of sub ects /ere malnourished& $+.#) of sub ects /ere at risk of malnourished and the remaining sub ects /ere considered to be /ell . nourished according to MNA The mean MNA value /ere !+.B& #!& #".! points for malnourished& at risk
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Medical Journal of Babylon-Vol. 9- No. 1 -2012

2012 -&'(*) + -,-".* #$/ - !"! #$%

together /ith che/ing and s/allo/ing problems lo/ered the MNA score even .(further (pQ8.888! Appro,imately !B ) (total number #B) out of all elderly /ere diabetic. B sub ects out of the #B diabetic sub ects /as classified as malnourished (MNAQ!'). Appro,imately ($()& #')& !%.")) out of all malnourished sub ects have more than ! main diagnosis& hypertension& ;M respectively& the elderly /ith more than one main diagnosis had the lo/est .(MNA score (mean !(.( N+.') (table " 7i1cu11ion The study /as performed to assess the nutritional status of elderly persons by using MNA. According to MNA& about $+.# ) of all patients in this study /ere at risk for malnutrition and #(." )/ere malnourished. Both of these groups /ere characteri=ed by lo/er BM-. ;epending on the score of the test& elderly sub ects involved in the study /ere classified in the follo/ing categoriesH !- 2ell-nourished (MNA points #$+8). #- At risk of malnutrition (MNA points !'-#+."). +- Malnourished (MNA points !'). The number of malnourished persons /as higher to that found by Aaletti (+))& Murphy (!()) in hospitali=ed patients 5!8& !!6. The difference in the mean MNA points is influenced by the ma or difference in BM-. The mean BMvalue in this study /as #+.$ kg3m1. Parlier studies have reported similar BM- values& by a mean BM- of #+.' kg3m1 5!!6. The percentage of elderly sub ects classified a set border of being malnourished and malnourished reached to (%.' ) compare to earlier study found ($) 5!86. Acore of neuropsychological problems depend on revie/ patient medical
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status and the remain vie/s self as .having no nutritional problem n*$") reported a loss of /eight ) #%) of more than + kg during preceding + .months n*B!) dose not kno/ if any) "#) /eight loss during the last three months& !%) (n*#%) /ere had /t loss bet/een ! and + kg during the last three months. (.") of participants had mild dementia and %+.") /ith no .neuropsychological problem Most elderly (B#.$)) /ere taking more than # servings of fruits or vegetables per day and most elderly( B%.')) drunk more than " cups of fluid per day. Most of the sub ects (B")) consuming + meals& and no one ate less than # meals of elderly had moderate lost of ) '$ appetite& $) had sever loss of appetite .and ##) /ith no loss of appetite of elderly able to get out of house B#) or go out door compare to !+) able to get out of bed but dose not get out the house and ") of patients are bed .bound About (') of elderly in this study live independency. "() of the elderly selffed /ithout any problem& and +") self fed /ith some difficulty and %) are unable to eat /ithout assistance. $%) (n*'() of them eat at least one serving of dairy products (milk& cheese& yogurt) per day and !# )( n*!%) eat (meat& fish or poultry) every day and +%) of them eat t/o or more servings .of legumes or eggs per /eek Most of the patients (n*!$$& %+)) had at least one problem associated /ith eating and digestion. the most fre4uency /ere constipation (n*B#& "+))& dry mouth (n*+!& #8)) andindigestion (n*$#& #')). che/ing and s/allo/ing /ere problem for +") (n*"$). ;iarrhea /as a problem for a fe/ participant (n*"& +)). Those /ho had che/ing and s/allo/ing problems had a significantly lo/er MNA score than others (pQ8.88!). ;ry mouth
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Medical Journal of Babylon-Vol. 9- No. 1 -2012

2012 -&'(*) + -,-".* #$/ - !"! #$%

care& (') of elderly in this study live independency. The 4uestions concerning medical drugs sho/s B#) of patients took more than three prescription drugs daily. Medication goes hand in hand /ith chronic diseasesH chronically ill patients /ill probably have medication. .hronic diseases can affect energy intake and contribute to poor nutritional status 5!"6. 7n the other hand& different drugs reduce saliva production and can further threaten oral health (!(). -n the study by Jriep 5!#6& the number of medications appeared to be the clinically most relevant parameter e,plaining lo/ MNA score in the elderly. Groblems related to eating /ere rather common in our study /hen .he/ing problems (+")) and reduced appetite ('$)) can lead to a reduced nutritional intake and thus to a poor nutritional status. The number of eating problems and their relation to the MNA score clearly revealed the importance of identifying special problems related to eating and digestion. These problems need to be given closer attention in patient care because of their cumulative effects and influence on diet intake 5!'6. The MNA is a practical& 4uick& easy test& non-invasive and cost effect instrument allo/ing for rapid nutritional evaluation. -t used to identify persons /ith under nutrition in /hich persons& identified as @at risk of being malnourished @ or Smalnourished S on the MNA test& /ould receive additional nutritional assessment in an attempt to pinpoint the specific nutrient deficiencies of the elderly to do the necessary medical and nutritional interventions . -n conclusion& although the number of sub ects involved in the study /as small& the results of the (MNA)
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record& ask relative /ho can provide information about the severity of the patient@s neuropsychological problem (dementia) Neurological problems in the case of mild dementia /ere recorded on the basis of sub ective impression & in this study %+.") /ith no neuropsychological problem . Most of the sub ects (B")) consuming + meals& and no one ate less than # meals -n addition& +") of our respondents /ere unable to estimate their nutritional status and !+) (n*#8) vie/ self as being malnourished /ith #() /ere unable to estimate their health status. Parlier research has nonetheless sho/n that sub ective assessments of health do have predictive value 5!#6. .hristensson concluded that Rselfe,perienced health status> had the most predictive value in MNA classifications 5!+6. The 4uestions concerning the amount of drinks& B%.') of participate drunk more than " cup of fluid per day& this can be e,plained by people in our study had problem /ith eating such as dry mouth (#8)) so tended to drink more than others. -ra4i habit of drink tea could play a significant role of drinking this reasonable amount of fluid. -n similarly to saletti the amount of li4uids consumed by the participants in this study /as 4uite satisfactory. The score for protein intake& only !#) of participants eat (meet& fish or poultry) every day? this may be due to finance causing& loss in appetite ('$)) or due to eating and digestion problem (%+)). The comple, relation bet/een oral health and nutrition has been highlighted in earlier studies (!$). The same applies to the relation of nutrition and function 5$6. The 4uestions concerning independency& this 4uestions refers to the normal living conditioning of the individuals& its purpose is to determine if the person is dependant on others for
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Medical Journal of Babylon-Vol. 9- No. 1 -2012

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More attention needs to pay to these vulnerable groups of people.

indicated the necessary of performing national nutritional assessment for elderly sub ects in the community.

Bable 1 mean and standard deviation of anthropometric measurement for elderly patients Anthropometric measurements Mean N A;I BM-(kg3m#) #+.$ N (.B MA.(cm) #(.# N ".+ ..(cm) #%.( N "." I A; (standard deviation) Bable 2 Mean& standard deviation and percentage of elderly sub ects in the three MNA categories. MNA categories Mean N A; N ) Malnourished !+.B N #." $! #(." MNA Q!' points At risk of malnutrition #!.8 N !.% (' $+.# MNA T !'-#+." points 2ell-nourished #".! N !." $' +8.+ MNA D #$ points Bable C Body mass inde,& mid-arm circumference and calf circumference in the three mini-nutritional assessment (MNA) categories. Anthropometric Malnourished At risk of malnutrition 2ell-nourished Aignificance level measurements MNA !' points MNA !'-#+." points MNA #$ points p-value N* $! N* (' N* $' BM-(kg3m#) !%.! N '.! #$.( N '.B #(." N $.+ 8.88" MA.(cm) ##.$ N +.B #(.! N ".( #B.( N +.+ Q8.88! ..(cm) #".# N $.B #B.% N ".$ ++.! N $.$ Q8.88" Bable D .orrelations (r) of MNA 4uestions to total MNA score (n*!"") MNA 4uestion r ( p Evalues ) -ndependency 8.8$ ( L8.8" ) <se of drink 8.8( (L8.8") Akin problems 8.8% (L8.8" ) Ability to eat 8.!8 (L8.8") Aelf perceived nutritional status 8.8%(L8.8") 2eight loss during the last + months 8.(! (Q8.88!) Gsychological stress 8."# (Q8.88!) :ood intake decline 8.$B (Q8.88!) Aelf-perceived health status 8.+ (Q8.88!) MA. 8.$#(Q8.88!) Mobility 8.8.##(Q8.8!) Numbers of meals eaten per day 8.#B (Q8.88!) .. 8.#$(L8.8!) Three prescription drugs per day 8.##(Q8.8!) <se vegetables and fruits 8.!'(Q8.8") Neuropsychological problems 8.!( (Q8.8" ) Grotein intake 8.$B(Q8.88!)
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Medical Journal of Babylon-Vol. 9- No. 1 -2012

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Bable E The Mini-Nutritional Assessment (MNA) points in the elderly according to the diagnosis
;iagnosis group ;iabetes 9ypertension 9eart3lung diseases Musculoskeletal L ! main diagnosis 7thers Numbers ()) #B (!B)) +%(#")) #!(!+.")) %(()) "!(++)) ' ($.")) MNAD#$ N7. !" B B # !! + MNAD!'-#+." N7. " #8 !! ' #! + MNAQ!' N7. B !! # 8 !% ! MNA Mean N A; #!.( N(.! !B.' N".% ##.# N+.B #+.$N(.! !(.( N+.' ##.$ N#.8

%- Juigo= X& Oellas B and Jarry G (!%%()H Assessing the nutritional status of the elderlyH the Mini Nutritional Assessment as part of the geriatric evaluation. Nutr. Mev. "$(Auppl #)& "%E(". !8- Aaletti A& Fohansson V and .ederholm T (!%%%)H Mini-Nutritional Assessment in elderly sub ects receiving home nursing care. F. 9um. Nutr. ;ietet. !#& +B!E+B'. !!- Murphy M.& Brooks .N& Ne/ AA and Vumbers MV (#888)H The use of the Mini-Nutritional Assessment (MNA) tool in elderly orthopaedic patients. Pur. F. .lin. Nutr. "$& """E "(#. !#- Jriep M-& Mets T:& .ollys C& Gon aert-Cristoffersen - and Massart ;V (#888)H Misk of malnutrition in retirement homes elderly persons measured by the RRMini - Nutritional Assessment>>. F. Jerontol. Med. Aci. ""A& M"'EM(+. !+- .hristensson V& <nosson M and Pk A-. (#88#)H Pvaluation of nutritional assessment techni4ues in elderly people ne/ly admitted to municipal care. Pur. F .lin. Nutr. "(& B!8EB!B. !$- Vamy M& Mo on G& Calykakis J& Vegrand M and But=-Forgensen P (!%%%)H 7ral status and nutrition in the institutionalised elderly. F. ;ent. #'& $$+E$$B. !"- Missanen GM& Vaakkonen P-& Auntioinen A& GenttilaY -M and <usitupa M- (!%%()H The nutritional status of :innish home%(

:eference1 !297 (#88#)H Active AgeingH A Golicy :rame/ork. Jeneva. 2illett 2 (!%%B)H Nutritional Ppidemiology& #nd edition. #- McJee M and Fensen J (#888)H Nutrition in the elderly. F. .lin. Jastroenterol. +8& +'#E+B8. +- Mc.ormack G (!%%')H <nder nutrition in the elderly population living at home in the communityH F. Adv. Nurs. #(& B"(E B(+. $Aharkey FM (#88#)H The interrelationship of nutritional risk factors& indicators of nutritional risk& and severity of disability among home-delivered meal participants. Jerontologist $#& +'+E+B8. "- Aullivan ;9 (!%%#)H Misk factors for early hospital readmission in a select population of geriatric rehabilitation patientsH the significance of nutritional status. F. Am. Jeriatr. Aoc. $8& '%#E '%B. (- Thomas ;M& Udro/ski .;& 2ilson M-M& .onright C.& Ve/is .& Tari4 A and Morley FP (#88#)H Malnutrition in subacute care. Am. F. .lin. Nutr. '"& +8BE+!+. '- Achneider AM and 9ebuterne W (#888)H <se of nutritional scores to predict clinical outcomes in chronic diseases. Nutr. Mev. "B& +!E+B. B- Meuben ;B& Jreendale JA and 9arrison JJ (!%%")H Nutrition screening in older persons. F. Am. Jeriat. Aoc. $+& $!"E$#".
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Medical Journal of Babylon-Vol. 9- No. 1 -2012

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B!-& and B(-year-old inhabitants in 9elsinki& :inland. F. ;ent. Mes. '!& !B'"- !BB8. !'- Mo/eZ M& Bohmer T and Cindt P (!%%$)H Meduced nutritional status in an elderly population ($'8 y) is probable before disease and possibly contributes to the development of disease. Am. F. .lin. Nutr. "%& +!'E +#$.

living elderly people and the relationship bet/een energy intake and chronic diseases. Age Ageing #"&!++E !+B. !(- NaYrhi T7& Meurman F9& Ainamo A& Nevalainen MF& AchmidtCaunisaho C-J& Aiukonsaari G& Oalvanne F& Prkin untti T& Tilvis M and MaYkilaY P (!%%#) Association bet/een salivary flo/ rate and the use of systemic medication among '(&

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