Abstract
Background
Brazilian population has passed for a process of demographic transition throughout latest years, characterized for the increase of the elderly population. Malnutrition is a serious problem to frail elderly.
Objective
The objective of this study was o evaluate the risk of malnutrition among institutionalized elderly resident in municipal shelters in the city of Rio de Janeiro, Brazil, using the tool Mini Nutritional Assessment (MNA).
Design
344 institutionalized elderly aged over 60 years old were tested in a cross-sectional study using MNA. This tool classifies the nutricional status of the elderly in three groups: malnutrition (score < 17), risk of malnutrition (score 17–23,5) and well-nourished (score > = 24). Anthropometric measurements such as calf circumference (CC), mid-arm circumference (MAC) and Body mass index (BMI) were also evaluated. The variables were evaluated using the chi-square or A NOVA test. To correlate it was used Pearson's Correlation Coefficient (r).
Results
Mean age were 75.4 (+− 9.4) years old. Most of the elderly were female gender (59.6%). According to MNA 8.3% were with malnutrition, 55.6% at risk of malnutrition and 36.1% well-nourished BMI classified 10.0% of the elderly as underweight. CC classified 10.0 % of them as inadequate in muscular mass. MNA was well correlated to BMI (r=0.41 2 p=0.000), age (r=−0.124 p=0.031), CC (r=0.399 p = 0.000) and MAC (r=0.391 p=0.000).
Conclusion
Risk of malnutrition was high among the institutionalized elderly from public shelters in Rio de Janeiro — Brazil. MNA is a useful diagnostic tool for the identification on the frail elderly at risk of malnutrition.
Keywords: Nutritional status, malnutrition, elderly, MNA, institutionalized, aging
Introduction
The proportion of people age 60 and over is growing faster than any other age group. In 2002, almost 400 million people aged 60 and over lived in the developing world. By 2025, this will have increased to approximately 840 million representing 70 percent of all older people worldwide 1, 2, 3, 4.
Brazilian population is aging, as well as the world-wide population, what it can be explained by a gradual increase of the average life expectancy, possibly generated for a technological-scientific advance, beyond the rise of the level of life of the population, still that far of the ideal, better medical conditions, sanitation, hygienical-sanitary conditions, etc. A great increase of the ratio of aged was observed in Brazil with passing of the years, changing of 10,7 million (7,3%) in 1991 for 15,4 million (8,8%) in 2002 2, 5.
Protein-energy malnutrition (PEM) is a common state in elderly institutionalized people. Available data from published studies show different results on its prevalences, but generally accepted values are close to 50%, varying from 10 to 85% 6, 7, 8. Institutionalized elderly with PEM have worse outcomes than well nourished subjects. PEM has also been related to higher morbidity and mortality 9, 10, 11, 12, 13, 14, 15.
Prevention and treatment of malnutrition is the important goal in clinical nutrition. The early and precise diagnosis of malnutrition is essential in order to initiate nutritional therapy as soon as possible. In elderly people “without overt disease”, low-degree malnutrition is often overlooked and no therapy is offered (16).
Leanness and overweight consists in risk of death, but to aged people leanness means a higher risk. Sarcopenia has been recognized as the change more functionally significant in aged 17, 18, 19, 20.
Vellas, Garry, Guigoz and Albarede have developed and validated the Mini Nutritional Assessment (MNA) to provide a rapid assessment of the nutrition status of frail elderly people, in order to facilitate nutrition intervention. MNA is easy, quick, and economical to perform and enable staff to check the nutritional status of elderly people when they enter the hospitals or institutions, and to monitor changes occurring during their stay. This allows the necessary nutricional status or to restore it to normality 21, 22.
The present study was undertaken to evaluate the risk of malnutrition in institutionalized elderly residents in municipal shelters in the city of Rio de Janeiro, Brazil, using the tool Mini Nutritional Assessment (MNA).
Methods
Subjects
This study used data from the cross-sectional “Nutritional and health profile of the elderly residents in municipal shelters in Rio de Janeiro - Brazil” with 344 elderly subjects during the year of 2001.
It was included in the study people with age above 60 years, according to OMS criteria for elderly in development countries, that were residents in one of the 12 municipal shelters in Rio de Janeiro. The elderly who were not able to answer to the questionnaire and to be submitted to the anthropometric evaluation were excluded.
Nutritional questionnaire
The MNA is composed of 18 questions witch involves: 1-Anthropometric measurements (weight, height, and weight loss); 2- Global assessment (six questions related to lifestyle, medication, and mobility); 3- Dietary questionnaire (eight questions, related to number of meals, food and fluid intake, and autonomy of feeding); 4- Subjective assessment (self-perception of health and nutrition).
The MNA score was calculated as the sum of the points assigned to the responses of the 18 items. A person was considered well-nourished with a score > 24, has a risk of malnutrition with a score from 17 to 23,5 and has a malnutrition with a score < 17 (21).
Anthropometric measurements
Anthropometric measurements included: weight, height, body mass index (BMI), Mid-arm circumference (MAC) and calf circumference (CC). The body weight was measured with digital balance, with 0.1 Kg precision and body height to the nearest 0.1 cm in the anthropometer.
BMI or Quetelet's index was calculated as weight (kg) divided by the square of height (m2). The BMI was also classified according to the World Health Organization (WHO) criteria. MAC was measured with a tape measure the mid-point of the arm between the tips of the acromion process and the olecranon process. CC in measured with the elderly person seated, with a 90° angle in the leg, placing the measuring tape around the calf in the largest circumference (23).
Statistical analysis
The analysis of data involved descriptive statistics such as mean, standard deviation and simple frequency. It was used test F, analysis of variance (ANOVA), to compare means between the continuous variables, and the test Chi-square to the categorical variables, with level of significance statistics of p< 0,05. 24 To correlation it was used Pearson's Correlation Coefficient. The data had been analyzed with statistical package SPSS for Windows, version 9.0.
Ethics
The local ethics committee of the Federal University of Rio de Janeiro - UFRJ, approved the study protocol. All the participants gave informed consent.
Results
Data on 344 elderly subjects were recorded. Their mean age was 75.4 (+- 9.4) years old. Descriptive statistic including minimum and maximum values, mean and standard deviation are shown in table 1.
Table 1.
Mean, Standard Deviation, Minimum and Maximum values of anthropometric variables and length of stay of the sheltered elderly of Rio de Janeiro - Brazil
| n | Minimum | Maximum | Mean | Std. deviation | p-value* | |
|---|---|---|---|---|---|---|
| MNA score | 302 | 10.0 | 29.0 | 22.3 | 3.6 | 0.000 |
| Age (y) | 344 | 60.0 | 117.0 | 75.4 | 9.4 | 0.072 |
| Height (cm) | 322 | 126.2 | 182.0 | 155.4 | 10.5 | 0.233 |
| Weight (kg) | 320 | 28.5 | 116.0 | 59.5 | 14.0 | 0.000 |
| Calf circumference | 311 | 23.1 | 62.5 | 33.6 | 4.7 | 0.000 |
| (cm) | ||||||
| Mid-arm circumference | 314 | 15.0 | 45.0 | 27.8 | 4.6 | 0.000 |
| (cm) | ||||||
| Length of stay (m) | 308 | 1.00 | 325.0 | 51.4 | 63.8 | 0.236 |
| BMI (kg/m2) |
320 |
13.2 |
50.0 |
24.7 |
5.6 |
0.000 |
p -value according to MNA, by the test One-way ANOVA
Characteristics of the subjects such as gender, age, income, scholarship, civil state, body mass index and calf circumference are in table 2.
Table 2.
Prevalence of economical, social and demographic factors, Body Mass Index (BMI) and Calf Circumference (CC) according to the Mini Nutritional Assessment (MNA)of the sheltered elderly of Rio de Janeiro - Brazil
| Total % (n) | MNA Malnourished At Risk % (n) % (n) | Well nourished | % (n) | p-value* | |
|---|---|---|---|---|---|
| Gender | 0.519 | ||||
| Female | 59.6 (180) | 5.6 (17) | 31.8 (96) | 22.2 (67) | |
| Male | 40.4 (122) | 2.6 (8) | 23.8 (72) | 13.9 (42) | |
| Ages | 0.034 | ||||
| 60-69 y | 31.1 (94) | 2.6 (8) | 13.6 (41) | 14.9 (45) | |
| 70-79 y | 32.8 (99) | 1.7 (5) | 21.9 (66) | 9.3 (28) | |
| 80-89 y | 29.1 (88) | 3.3 (10) | 15.6 (47) | 10.3 (31) | |
| 90+ y | 7.0 (21) | 0.7 (2) | 4.6 (14) | 1.7 (5) | |
| Income | 0.606 | ||||
| < 2 SM | 90.1 (210) | 8.2 (19) | 50.2 (117) | 31.8 (74) | |
| 2+ SM | 9.9 23, 24 | 0.4 (1) | 6.4 (15) | 3.0 (7) | |
| Scholarship | 0.048 | ||||
| 0-3 y | 65.9 (195) | 7.4 (22) | 35.8 (106) | 22.6 (67) | |
| 4+ y | 34.1 (101) | 1.0 (3) | 19.6 (58) | 13.5 (40) | |
| Civil state | 0.447 | ||||
| Single | 45.3 (134) | 4.1 (12) | 27.0 (80) | 14.2 (42) | |
| Widower | 34.5 (102) | 3.7 (11) | 16.9 (50) | 13.9 (41) | |
| Married / partner | 7.4 (22) | 0 | 4.7 (14) | 2.7 (8) | |
| Divorced | 12.8 (38) | 0.7 (2) | 7.4 (22) | 4.7 (14) | |
| BMI (kg/m2) | 0.000 | ||||
| Underweight | 10.0 (29) | 1.4 (4) | 8.7 (25) | 0 | |
| Normal | 90.0 (260) | 6.9 (20) | 45.7 (132) | 37.4 (108) | |
| Calf circumference (cm) | 0.000 | ||||
| Inadequate | 34.3 (69) | 4.6 (13) | 16.5 (47) | 3.2 (9) | |
| Adequate |
75.7 (215) |
3.9 (11) |
38.4 (109) |
33.5 (95) |
p -value according to MNA, by the test Chi-square
Most of the elderly were female gender (59.6%), but there were no difference statistically significant between them (p=0.519). The income was low, 90.1% earn less than 2 minimum salaries. The majority subjects had less than 4 years of formal education (65.9). Most of them were single (43.5%) or widower (34.5%). The BMI classified 10.0% of the elderly as underweight. CC classified 10.0 % of them as inadequate in muscular mass (Table 2).
Figure 1.
Prevalence of nutritional status according to MNA
According to MNA classification, more than half of the subjects (55.6%) were at risk of malnutrition, 8.3% was with malnutrition and 36.1% well nourished.
The bivariate analysis showed a significant correlation between MNA and age (r=-0,214 p=0,031), CC (r=0,399 p=0,000) and MAC (r=0,391 p=0,000). The correlation between MNA and BMI (r=0,412 p=0,000) was also high (Figure 2, Figure 3). The length of stay (LS) (r=0,013 p=0,833) wasn't well correlated to MAN.
Figure 2.
Scatterplot of body mass index (BMI) according to Mini Nutritional Assessment (MNA) score. r= Pearson Correlation Coefficient
Figure 3.
Scatterplot of calf circumference (CC) according to Mini Nutritional Assessment (MNA) score. r= Pearson Correlation Coefficient
Discussion
We found a considerable prevalence of risk of malnutrition in this community, almost two-third of the institutionalized elderly, which means a lot considering that these people are social and biological vulnerable.
Malnutrition is a serious threat to elderly life because it can lead to lower physical strength, greater inactivity, higher risk of accidents and a weakened immune system, among other health problems 25, 26. It represents an important public health problem to elderly population (27).
Nutritional deficiencies, frequently observed among the frail elderly, have been associated with increased morbidity and dependency. Protein-energy malnutrition appears to be a strong independent risk factor for nonelective hospital readmission, especially among the highest-risk patients, those who are functionally independent and cognitively intact (28). It has been argued that the inverse association of weight and mortality in old age is related to smoking and reflects illness related weight loss. In a longitudinal study, elderly women with lower energy intake than recommended by international organizations in 1980 were three times more likely to die in 10 years than those with satisfactory energy intake 29, 30.
A prospective follow-up study with 65 + years old patients showed that the group classified as at risk by the MNA had an increased need of public help compared to the well-nourished group. They had a higher prevalence of use of home care (31).
This population presented low income and precarious scholarship, that was expected, since they live in public shelters proper to needy people. Despite of that the prevalence of malnutrition found in this study (8,3%) was near to the national average, that is of 8.4% the population under risk sufficiently is high (55,6%) (32). Moreover, this population effectively undernourished, is frequently not detected and does not receive any kind of nutritional intervention. There are no official standards to evaluate nutritional status of the Brazilian elderly population, and it is often not applied.
Age demonstrated to be inversely proportional to MNA, that is, the most aged people had lowers MNA score, and ages was also statistically significant associated to MNA (table 2). Studies on normative populations in high-income countries demonstrate that body weight increases during adult life until 50-59 years, after which it declines (33).
It was reported that with advancing age, lean body mass decreases and the amount of body fat generally increases until age 70 after which it decreases again 34, 35, 36, 37. Thus it seems likely that the relation between body fatness and body mass index changes with advancing age (38). BMI was well correlated to MNA, as expected.
CC is considered to provide the most sensitive measure of muscle mass in the elderly. It indicates the changes in fat-free mass that occur with aging and with decreased activity, (23) and it was highly correlated to MNA.
The measurement of the MAC, an indirect measure to assess two important components of the body: fat and fat-free mass also showed high correlation with MNA.
Length of stay in the municipal shelters didn't seem to be associated to MNA. Although in the studied shelters the conditions of health and nutrition have been precarious, 17, 39 there were no association between length of stay and nutritional status, which can lead to believe that other factors such as morbidity may be leading to the malnutrition, and not only the institutionalization itself.
Conclusion
Risk of malnutrition was high among the institutionalized elderly from municipal shelter in Rio de Janeiro - Brazil. However, malnutrition was similar to the whole country, and both are usually underdiagnosed.
The nutritional status assessed by the MNA was well correlated with age, body mass index, calf circumference and mid arm circumference. It was also associated to scholarship, BMI, CC and MAC.
Although the evaluated anthropometric measurements are part of the tool, these data suggest that the MNA is a useful diagnostic tool for the identification on the elderly patients at risk from malnutrition and those who are already malnourished.
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