According to the PORDATA website, 21.7% of the total Portuguese population was 65 years old or older in 2018, an increase over recent years (1). Ageing is a process, conditioned by biological, social, environmental, historical, and cultural factors (2,3). Elderly adults generally have a reduced appetite and energy expenditure, which may be related to the decline in biological and physiological functions, such as reduced lean body mass, and/or changes in the levels of cytokines and hormones, and/or changes in the regulation of electrolytes in body fluids, which have an independent effect on the delay of gastric emptying which may lead to a decrease in smell and taste (2,3). Additionally, pathological and social changes of ageing, such as chronic diseases, psychological illnesses, depression, social isolation, and medication intake, play an important role in the complex etiology of malnutrition in aged adults (2,4).
Malnutrition is defined as "a state in which a deficiency or imbalance of energy, protein, or other macro-and micronutrients, causes adverse effects on form, function, and clinical outcome" (2). The etiology is multifactorial, and it is not possible to present only one cause (2). It is in this sense that malnutrition is a fundamental element of the health of the elderly population as it largely affects the ageing process, causing a decline in functional status, impaired muscle function, decreased bone mass, immune dysfunction, anemia, reduced cognitive function, poor wound healing, delayed recovery from surgery, higher rates of hospitalization and consequently higher mortality (2,3).
The prevalence of malnutrition is higher in the elderly population as compared to any other age group, especially in the institutionalized elderly population (2,5). According to the Portuguese elderly nutritional status surveillance system (PEN 3S) study (6), 4.8% of the elderly residing in nursing homes are malnourished while only 0.6% of the elderly residing in their homes were in the same clinical situation. In the case of risk of malnutrition, it was found to be 38.7% in nursing homes while for those residing in their usual homes it was 16.9%. Other international studies have also described that more than 30% of patients at hospital admission were at nutritional risk (7). These data in Portugal are between 28.5% and 47.3% (8). However, the assessment of the nutritional risk of institutionalized elderly individuals specifically in each home, in a recurrent manner and a multidisciplinary team, is of special interest to provide information on the nutritional status. This same nutritional risk analysis is extremely relevant to promote the coordination of several areas of action, as for (appropriate) adequacy of human resources, including the presence of a nutritionist, as it promotes better use of resources toward positive effects in the correction and treatment of this condition, and consequently in the longevity and quality of life of the elderly adults.
For all these reasons, the main objective of the present study was to assess the nutritional status and malnutrition risk in elderly people institutionalized in a senior residence in Lisbon, as well as to evaluate the factors related to and influencing this malnutrition.
Materials and Methods
Design and study population
This study consists of cross-sectional observational analysis specially designed to assess the nutritional status of institutionalized elderly people within a private senior residence in the district of Lisbon between February and March 2019. The entire resident population, a total of 47 adults, was considered eligible for inclusion, however, two did not authorize their participation. Thus, the study sample consisted of 45 elderly adults (96% of the resident population), 36 females, and 9 males. This study was conducted following the ethical standards outlined in the 1964 Declaration of Helsinki and its subsequent amendments or comparable ethical standards. The management of the evaluated senior residence approved the conduct of the present study. All participants gave informed consent before the evaluation.
Evaluation of nutritional status
The complete Mini Nutritional Assessment (MNA) was applied by the nutritionist in the presence of the nurse who accompanies the resident to assist in some answers (9-11). This tool consists of 18 questions and is divided into two parts: Screening and Global Assessment. The MNA was applied to provide a quick and unique assessment of the nutritional status of elderly residents in the senior residence. The questionnaire can be applied to elderly patients in outpatient clinics, hospitals, and nursing homes, and has been translated into several languages and validated in various clinical settings around the world (3). It consists of simple anthropometric measurements and short questions that can be completed in about 10 minutes. The sum of the MNA score distinguishes between elderly people with adequate nutritional status (with a score greater than or equal to 24 points), malnourished (with a score less than 17 points), and at risk of malnutrition (for scores between 17 and 23.5 points). Anthropometric measurements were performed according to standard procedures using calibrated equipment (5,8). Weight was measured by trained professionals using an electronic scale and recorded to the nearest decigram (0.1 kg). Height was measured using a calibrated stadiometer, and the value was recorded to the nearest millimeter (0.1 cm). Height was also assessed with participants standing with their backs to the stadiometer and with feet and knees together, head positioned so that the gaze remained horizontal, according to the Frankfurt plane. All participants wore light clothing and no shoes during all measurements.
Weight and height data in wheelchair-bound and bedridden elderly people who were unable to stand (12) were obtained using estimated measurements, namely for weight by the arm and leg (twin) circumferences (13), and height by the heel-knee distance (14), using the specific formulas. A fixed length (non-elastic) anthropometric tape with a resolution of 0.1 cm was used to measure both perimeters and the heel-knee distance.
The Body Mass Index (BMI) was calculated using the normalized formula [Weight (in kg)/Height2 (in m)].
Data are presented as means and standard deviation (SD) for continuous variables or numbers (n) and percentages (%) for categorical variables. The distribution of selected characteristics was compared between groups, gender, or nutritional status categories according to MNA, using Pearson χ2 tests for categorical variables or Student's t-tests or analysis of variance (ANOVA), as appropriate, for continuous variables. All statistical tests were two-tailed, and the significance level was set at p<0.05. All analyses were performed using SPSS software version 23.0 (SPSS Inc, Chicago, IL, USA).
Forty-five participants (36 women and 9 men) with a mean age of 84 years (SD: 9 years) participated in the present analysis. The demographic and nutritional characteristics of the population (total and by gender) are shown in Table 1.
No statistically significant differences were found for age, weight, arm circumference, leg circumference, and BMI. However, men are significantly taller than women and a lower proportion of men were found in the BMI categories <19 kg/m2 and >23 kg/m2.
Table 2 shows the assessment of indicator characteristics of nutritional status based on the MNA for the total sample and according to the gender of the participants. No significant differences were observed in any of the parameters previously analyzed. Also, no statistical differences were observed regarding the final MNA score or its categories in the distribution by gender.
Finally, nutritional status was assessed based on the three categories of the final MNA score (Table 3). Of the total sample, 5 participants had an adequate nutritional status, 18 had malnutrition, and 22 were at risk. There were no relationships between nutritional status and gender, age, or BMI. However, there were significant differences in the variables "decreased food intake in the past three months," "weight loss in the past three months," "mobility," "experiencing psychological stress or acute illness in the past three months," "neuropsychological problems," "presence of skin lesions or bedsores," and "fluid intake." The largest percentage of malnourished participants had a moderate to severe decrease in intake in the three months prior the interview, as well as greater weight loss during the same period. Concerning mobility, there is a higher percentage of bedridden or wheelchair-bound individuals presenting malnutrition: 88.90% of the bedridden or wheelchair-bound individuals and 11.10% of ambulatory individuals presented malnutrition. Of the institutionalized users with malnutrition, 66.70% had experienced some type of psychological stress or acute illness in the three months prior to completing the questionnaire. It is also noteworthy that the majority of patients with severe dementia presented malnutrition, as did all the participants with the presence of skin lesions or bedsores. Finally, half of the elderly users with malnutrition consumed less than three cups of liquid per day.
Nutritional risk assessment through the MNA may contribute to the early diagnosis of nutritional status and prevention of a possible deterioration of the general health status. In the present study, the MNA was applied to elderly adults institutionalized in a senior residence in the district of Lisbon, and we found that 40.0% were malnourished and 48.9% were at risk of malnutrition. The high prevalence of the elderly at nutritional risk has been recently observed both nationally and worldwide (15).
The residential situation of elderly adults also determines their nutritional status, their quality of life, and even their physical and psychological well-being (16). In a systematic review and meta-analysis of data on nutritional status in older persons using the MNA, the prevalence of malnutrition was differentiated between the healthcare settings: 3.1% in the community, 6.0% in the outpatient clinic, 8.7% in home care services, 22.0% in the hospital level, 17.5% in nursing homes, 28.7% in long-term care units, and 29.4% in rehabilitation units (17). In Portugal, the prevalence of malnutrition .in the elderly community in general is low, although a high number of elderly are at nutritional risk, compared to institutionalized elderly who are generally malnourished (16). According to the PEN 3S study, 4.8% of the elderly residing in nursing homes are malnourished while only 0.6% of the elderly residing in their homes were found with this clinical condition. In nursing homes, the risk of malnutrition was 38.70%, while the risk was 16.90% for those residing in their own homes (6). A similar situation has been found in Brazil, where the majority of the population is at risk of malnutrition, particularly the institutionalized elderly (18). Differing from the conclusions of this study and other scientific evidence, Saka et al., Serrano-Urrea and García-Meseguer showed that in Turkey and Spain, respectively, the elderly living in institutions were better nourished than in their usual homes (19,20).
The high levels of malnutrition and risk of malnutrition found in our studied senior residence, higher than the data found in the literature, may also be related to its lack of a specialized nutritional technician to carry out these assessments routinely and support any consequent nutritional intervention to avoid these high levels, with clear consequences for the health of these elderly people.
During the ageing process, there is a decrease in both balance and functional mobility, and immobility is one of the factors associated with decreased oral intake (20,21). Our results can be partially explained by this statement, as we observed that only the elderly with adequate nutritional status had normal mobility. In addition, the presence of psychological stress was observed only in the elderly at risk of malnutrition and in the malnourished elderly. It is known that a high incidence of neuropsychological problems can interfere with autonomy and social or professional performance in elderly individuals (22). In this study, malnutrition was associated with severe dementia, a situation also reported in other studies (23,24). On the other hand, the presence of skin lesions or bedsores was only observed in the malnourished elderly. Previously published studies have likewise indicated the existence of associations between malnutrition and the development of pressure ulcers and consequently the difficulty of their healing (21).
Our study has several strengths, including the use of a validated and published tool for the assessment of nutritional status. However, some limitations should be assumed. This is a case study with a small sample size which limits the significance of the results, and the existence of other potential correlations. In our small sample, we observed a high prevalence of malnutrition, which negatively affects the general health status of elderly populations and particularly within the institutionalized elderly. However, this study reflects the reality within a single institution. It is important to conduct more systematic and frequent studies in other senior residences and to increase the sample size to strengthen the scientific evidence on the prevalence of states of nutritional risk and malnutrition in institutionalized elderly in our country.
In this senior residence, we found that the malnutrition and malnutrition risk values are high, highlighting the need for nutritional intervention, as these places need specialized technicians in the area in order to promote a good nutritional status, which is so important, particularly in this age group.
Authors Contributions Statement
BS conceptualization and study design; BS, DP experimental implementation, and data collection; C.F.-P. data analysis; DP, C.F.-P. drafting, editing, and reviewing; C.F.-P. tables, figures, and graphics; C.F.-P., BS supervision; C.F.-P., BS final writing.
Cíntia Ferreira Pêgo is funded by Foundation for Science and Technology (FCT) Scientific Employment Stimulus contract with the reference number CEEC/CBIOS/NUT/2018. This work is funded by national funds through FCT - Foundation for Science and Technology, IP, under theUIDB/04567/2020 and UIDP/ 04567/2020 projects, and ALIES-COFAC - PADDICC2021.
The authors acknowledge all the participants.
Conflict of Interests
All authors have stated that there are no financial and/or personal relationships that could represent a potential conflict of interest.
1. PORDATA - Base de Dados Portugal Contemporâneo. (2015). População residente: total e por grandes grupos etários em Portugal. PORDATA.
2. Ahmed, T., & Haboubi, N. (2010). Assessment and management of nutrition in older people and its importance to health. Clinical interventions in aging, 5, 207–216. https://doi.org/10.2147/cia.s9664.
3. World Health Organization. (2015). World Report on Aging and Health. Geneve.
4. Serván, P.R., Poyatos, R.S., Rodríguez, J.S., Gómez-Candela, C., Luna, P.P.G., Serra-Majem, L. (2015). Consideraciones y recomendaciones en el caso de estudios nutricionales realizados en adultos mayores. Revista Española de Nutrición Comunitaria 21 (Supl. 1), 81-87. DOI: 10.14642/RENC.2015.21.sup1.5055
5. Bernstein, M., & Munoz, N. (2012). Position of the Academy of Nutrition and Dietetics: Food and Nutrition for Older Adults: Promoting Health and Wellness. Journal of the Academy of Nutrition and Dietetics, 112(8), 1255–1277.
6. Madeira, T., Peixoto-Plácido, C., Sousa-Santos, N., Santos, O., Alarcão, V., Goulão, B., Mendonça, N., Nicola, P. J., Yngve, A., Bye, A., Bergland, A., Amaral, T. F., Lopes, C., & Gorjão Clara, J. (2018). Malnutrition among older adults living in Portuguese nursing homes: the PEN-3S study. Public Health Nutrition, 22(3), 486-497. doi:10.1017/S1368980018002318
7. Direção-Geral da Saúde. 2019. Rastreio Nutricional – Documento de apoio à implementação da avaliação do risco nutricional. Lisboa: Direção-Geral da Saúde.
8. Matos, L., Teixeira, M.A., Henriques, A., Tavares, M.M., Alvares, L., Antunes, A., et al. 2007. Nutritional status recording in hospitalized patient notes. Acta Médica Portuguesa, 20(6):503-510.
9. Vellas, B., Villars, H., Abellan, G., Soto, M. E., Rolland, Y., Guigoz, Y., Morley, J. E., Chumlea, W., Salva, A., Rubenstein, L. Z., & Garry, P. (2006). Overview of the MNA® - Its History and Challenges. The journal of nutrition, health & aging, 10, 456-465.
10. Rubenstein, L.Z., Harker, J.O., Salva, A., Guigoz, Y., Vellas, B. (2001). Screening for Undernutrition in Geriatric Practice: Developing the Short-Form Mini Nutritional Assessment (MNA-SF). The journals of gerontology. Series A, Biological sciences and medical sciences, 56A, M366-377.
11. Guigoz, Y. (2006) The Mini-Nutritional Assessment (MNA®) Review of the Literature - What does it tell us? The journal of nutrition, health & aging, 10, 466-487.
12. Chumlea, W.C., Roche, A.F., Steinbaugh, M.L. (1985). Estimating Stature from Knee Height for Persons 60 to 90 Years of Age. Journal of the American Geriatrics Society, 33(2),116–120.
13. Stewart, A., Marfell-Jones, M., Olds, T., De Ridder, H. (2011). ISAK: International Society for Advancement of Kinanthropometry. International standards for anthropometric assessment.
14. Chumlea, W.C., & Guo, S. (1992). Equations for predicting stature in White and Black elderly individuals. Journal of gerontology, 47(6), M197-203. http://doi.org/10.1093/geronj/47.6.m197
15. Lage, J., Simões, C.D., Combadão, J., Silva, A.P., Valente, A. (2018). Avaliação do risco nutricional em idosos utentes de um centro de saúde de Lisboa. Acta Portuguesa de Nutricao,14,6–9.
16. Bernardo, S. C. (2013). Estado Nutricional dos Idosos que Frequentam os Centros de Dia e Centros de Convívio do Concelho de Paços de Ferreira (Tese de mestrado, Faculdade de de Ciências da Nutrição e Alimentação da Universidade do Porto). Repositório aberto da Universidade do Porto. https://repositorio-aberto.up.pt/bitstream/10216/66544/4/23883.2.pdf
17. Cereda, T., Pedrolli, C., Klersy, C., Bonardi, C., Quarleri, L., Cappello, S., Turri, A., Rondanelli, M., Caccialanza, R. (2016). Nutritional status in older persons according to healthcare setting: A systematic review and meta-analysis of prevalence data using MNA®. Clinical nutrition (Edinburgh, Scotland), 35(6),1282-1290. http://doi.org/10.1016/j.clnu.2016.03.008
18. Damo, C.C., Doring, M., Alves, A.L.S., Portella, M.R. (2018). Risk of malnutrition and associated factors in institutionalized elderly persons. Revista Brasileira de Geriatria e Gerontologia 21(6), 711–717. https://doi.org/10.1590/1981-22562018021.180152
19. Saka, B., Ozkaya, H., Karisik, E., Akin, S., Akpinar, T.S., Tufan, F., Bahat, G., Dogan, H., Horasan, Z., Cesur, K., Erten, N., Karan, M.A.(2016). Malnutrition and sarcopenia are associated with increased mortality rate in nursing home residents: A prospective study. European Geriatric Medicine 7(3), 232–238. https://doi.org/10.1016/j.eurger.2015.12.010
20. Serrano-Urrea, R., & García-Meseguer, M.J. (2014). Relationships between nutritional screening and functional impairment in institutionalized Spanish older people. Maturitas, 78(4), 323–328. https://doi.org/10.1016/j.maturitas.2014.05.021
21. Alfieri, F. M., Silva, N. O. V. E, Kutz, N. A., & Oliveira, M. M. H. de A. de. (2016, abril-junho). Relações entre equilíbrio, força muscular, mobilidade funcional, medo de cair e estado nutricional de idosos da comunidade. Revista Kairós Gerontologia 19(2), 147-165.
22. Loução, A.T. (2013). Avaliação Nutricional no Idoso (Tese de mestrado, Faculdade de Medicina da Universidade de Coimbra). Repositório Científico da Universidade de Coimbra. http://hdl.handle.net/10316/47650
23. Dos Santos, T.B.N., Fonseca, L.C., Tedrus, G.M.A.S., Delbue, J.L. (2018). Alzheimer's disease: nutritional status and cognitive aspects associated with disease severity. Nutricion hospitalaria, 35(6),1298-1304. http://doi.org/10.20960/nh.2067.
24. Vicente de Sousa, O., Mendes, J., Amaral, T.F. (2020). Nutritional and Functional Indicators and Their Association With Mortality Among Older Adults With Alzheimer's Disease. American journal of Alzheimer's disease and other dementias, 35, 1533317520907168. http://doi.org/10.1177/1533317520907168