nutritional status mini nutritional assessment food vulnerability scale hospital malnutrition geriatric patient

Abstract

The prevalence of malnutrition in hospitalized older adults (over 65 years old) varies widely at a national level and a standardized methodology for an accurate assessment has not yet been established. The link between nutritional status with the Food and Nutrition Vulnerability Scale provides a more comprehensive perspective of the overall patient’s condition. The aim of this study is to examine the relationship between the risk of hospital malnutrition in geriatric patients and food vulnerability in the state of Sinaloa, Mexico. The Mini Nutritional Assessment and the Food and Nutritional Vulnerability Scale were used for the analysis. Data from 276 geriatric patients aged 60-91 years were included. The results revealed that 78.26% of the participants showed mild vulnerability, while 19.56% exhibited moderate vulnerability, and 2.17% had severe vulnerability. The majority of geriatric patients presented a risk for malnutrition (58.7%) or malnutrition (15.21%). A moderate negative correlation was identified between the nutritional status score and food vulnerability (r= -0.5845, p < 0.0001). In conclusion, the Mini Nutritional Assessment significantly correlated with the Food Vulnerability Scale, suggesting that this comprehensive approach can help to establish more appropriate nutritional therapies for hospitalized geriatric patients, reducing length of hospital stay and morbidity in the older population.

INTRODUCTION

The population of adults over 60 years old in Sinaloa and in Mexico has been growing in recent years, generating a demographic and also an epidemiological transition, and raising concerns from a nutrition perspective, due to the presence of multiple risk factors for the development of malnutrition in these group of patients, mainly related with their nutritional and food vulnerability 1.

One concerning issue regarding aging is the change in dietary quality, associated with serious health problems and also food safety problems in older adults. We know that many factors influence dietary habits, factors that may depend on the population and evolve over time 2.

The dietary habits of older adults differ from other age groups due to multiple reasons, including changes in body composition, poor oral health, decreasein economic resourcesand pathological processes affecting nutrient absorption, metabolism, and utilization. Also, the use of various prescribed medications, the presence of sensory impairmentand disability, all these factors combined may lead to malnutrition and subsequently hospitalization in many elderly patients 3.

Previous studies by Osuna et al. in 2015 and Galván et al. in 2015 have shown that malnutrition in the geriatric population varies widely from hospital to hospital, this in part explained by the use of different nutritional scales that are used for the assessment of these patient. More studies are needed in order to assess this problem in the Mexican patient population 4,5.

In the present study, with the implementation and use of scales to determine the nutritional state and food vulnerability, we aim to establish timely multidisciplinary prevention measures in order to reduce prolonged hospital stay, and consequently to lower mortality in this group of patients.

The primary objective of the study was to evaluate the relationship between the degree of malnutrition and dietary vulnerability in elderly patients at the time of their hospital admission. The secondary objective was to provide information to improve nutritional status and reduce hospital stay in the elderly population.

MATERIALS AND METHODS

A cross-sectional study was conducted with a sample of 276 hospitalized patients over 60 years of age obtained through consecutive non-probabilistic sampling, from January 5 to November 1, 2020, at the General Hospital of Culiacan “Dr. Bernardo J. Gastelum” in Culiacan, Sinaloa, Mexico.

This study followed the ethical guidelines from the 1975 Helsinki Declaration, as well as the agreement published by the Secretariat of Health on January 26, 1982, and the Ethics and Research Committee of the General Hospital of Culiacan “Dr. Bernardo J. Gastelum”.

INCLUSION CRITERIA

All individuals over 60 years old who visited the General Hospital of Culiacan “Dr. Bernardo J. Gastelum”, regardless of the reason for hospitalization, and who agreed to participate in the study by signing an informed consent letter, were included.

EXCLUSION CRITERIA

Any person under 60 years old and geriatric patients who did not wish to participate in the study or were in a coma, burned, amputated, or otherwise unable to answer the surveys were excluded.

NUTRITIONAL STATUS ASSESSMENT

The nutritional status of geriatric patients was evaluated using the “Mini Nutritional Assessment” questionnaire (MNA®). This simple and validated tool is widely used in clinical practice to assess the nutritional status of older adults 6. The MNA consists of 18 items covering anthropometry (weight, height, arm, and calf circumference), global assessment (lifestyle, medication, mobility), dietary assessment (number of meals, feeding autonomy), and self-perceived health. Each item contributes to the overall assessment score of 30 points. Participants were categorized into three groups: Normal nutritional status (24 to 30 points), Risk of malnutrition (17 to 23.5 points), and Malnutrition (less than 17 points). The questionnaires were administered by trained clinical staff once the patients were admitted to the hospital.

FOOD AND NUTRITIONAL VULNERABILITY ASSESSMENT

The food vulnerability of geriatric patients was assessed using the Food and Nutritional Vulnerability Scale for older adults. This questionnaire consists of 19 items covering various dimensions related to food, such as meal quality and variety, food availability, physical problems affecting food intake, social support, and the ability to purchase food, among other relevant aspects for the long-term nutritional status of older adults. Response options for each item include “never” (0 points), “sometimes” (1 point), “frequently and always” (3 points). Participants were classified into four vulnerability categories based on the total sum of scores obtained: No vulnerability (0 points), mild vulnerability (1 to 21 points), moderate vulnerability (22 to 42 points), and severe vulnerability (43 to 57 points) 7.

STATISTICAL ANALYSIS

Categorical variables are presented as absolute values and percentages. As numerical data did not follow a normal distribution, they are presented as median and interquartile range. Spearman correlation was used to assess the relationship between nutritional status and food vulnerability in the sample of 276 hospitalized geriatric patients. A p-value of < 0.05 was considered statistically significant. GraphPad Prism Version 9.0 software (GraphPad Software, San Diego, CA, USA) was used to analyze the data. In order to prevent the possibility of bias, the scales for nutritional evaluation and food vulnerability were validated with the Crombach’s alpha test, obtaining a reliability value between 74 and 92%.

RESULTS

Table I presents the demographic characteristics of the study population, including a total of 276 patients. The median recorded age was 66.0 years, with an interquartile range of 63.0 to 73.0 years. The minimum observed age was 60 years, and the maximum was 91 years. The sample consisted of 34.8% female patients and 65.4% male patients. Regarding hospitalization services, 60.86% (n = 168) of patients were in the internal medicine service (MI), 28.26% (n = 78) in the surgery servicer, and 10.86% (n = 30) in Traumatology and Orthopedic service.

Regarding the Mini Nutritional Assessment, most patients were classified as at risk of malnutrition (58.7%, n = 162) or malnutrition (15.21%, n = 42), while 26.0% were classified as having a normal nutritional status (n = 72).

As for the Food and Nutritional Vulnerability Scale, it was observed that the majority of hospitalized patients presented a mild vulnerability to food (78.26%, n = 216), while 19.56% (n = 54) and 2.17% (n = 6) showed moderate and severe food vulnerability respectively.

The correlation analysis revealed a moderate negative correlation between the nutritional status assessment score (MNA) and food vulnerability in the sample of 276 hospitalized geriatric patients (r = -0.5845, 95% CI: -0.6592 to -0.4984, p < 0.0001) (Fig. 1). This result indicates that as the food vulnerability score decreases, the nutritional status tends to improve. In other words, patients with lower food vulnerability have a better nutritional status.

DISCUSSION

Nutritional status in hospitalized patients is a public health problem that has been poorly studied in Mexico, as not all hospitalshave trained personnel to care for hospitalized older adults, even in tertiary care level hospitals. Nutritional status plays a critical role in the prevention and prognosis of diseases that affect this age group of patients, especially in patients with chronic comorbidities. Nutritional status is highly relevant in hospitalized geriatric patients since a large proportion of older adults have malnutrition problems, affecting their health-disease process, significantly increasing morbidity and mortality, as well as healthcare costs 8,9.

The prevalence of malnutrition in older adults in non-hospitalized patients has been reported around 15-20% 10, and there are reports in some countries of Latin America as high as 40.4% 11. This prevalence increases on hospitalized patients, with reports of around 69% 12 and as high as 95% 13. This represents a public health problem and a clinical challenge for the health system.

As an essential part of the evaluation of geriatric patients, a comprehensive geriatric assessment should be included for all individuals over 60 years of age at the time of hospital admission. In Mexico, medical personnel rarely refer patients for nutritional assessment, likely because thereare not enough trained professionals in nutrition, particularly in geriatric nutrition. A study conducted by Cali et al. (2018) to determine the risk of malnutrition in hospitalized older adult patients using the MNA found that 79% of older adults were at risk of malnutrition, 16% were malnourished, and only 4.8% were well-nourished. The study showed that 58.7% of the studied population in this hospital presented nutritional risk, 15% malnutrition, and only 26% had a normal nutritional status when the same survey was administered. These results indicate a high risk of nutritional risk in hospitalized patients, with only a minority of those patients being evaluated and treated by nutritionists. Therefore, we believe it is essential to implement tools to determine the nutritional status in geriatric patients promptly upon admission to the hospital, in order to reduce morbidity and mortality related with malnutrition and risk of malnutrition 9.

Food and nutritional vulnerability are a poorly studied problems, to the best of our knowledge there is only one article published in Mexico addressing this specific issue, it was conducted at a geriatric center in Pachuca, Mexico by Galván et al. (2019), reporting that 92% of their study population showed mild vulnerability, and 7.5% had moderate vulnerability 5. In our study we found that 78% of our sample presented mild food vulnerability, 19.6% moderate vulnerability, and 2.2% severe food vulnerability. Comparing the results of Galvan et al with our results in the present study, we found more cases of moderate and severe vulnerability; this might represent a possible worsening of the problem over time, however is difficult to reach to a solid conclusion comparing only these two studies. Future research projects are needed in order to evaluate this specific problem and more evidence can clarify and lead to more solid conclusion statements.

The opportunity of having analyzed the nutritional status of food vulnerability in elderly patients through the MNA and the EVAN allowed us to know the conditioning factors and to be able to propose the implementation of timely care measures in terms of access and availability for this group of patients with the ultimate goal of achieving a better alimentary and nutritional stability.

We believe it is of outmost importance to implement inter-institutional agreements in Mexico in order to conduct multicenter studies that will allow to create care nutritional protocols to detect patients at risk, to improve food and nutritional vulnerability, to evaluate the prevalence of malnutrition and thus the comorbidities of geriatric patients.

CONCLUSIONS

The Mini Nutritional Assessment is correlated with the Food Vulnerability Scale and are tools that can be reliably used to identify nutritional disorders in geriatric hospitalized patients in Mexico, in order to establish more appropriate nutritional therapies, reduce hospital stay, and decrease morbidity and mortality in this specific group of patients.

Acknowledgements

The authors thank all the staff of the General Hospital of Culiacan “Dr. Bernardo J. Gastelum”.

Conflict of interest statement

The authors declare no conflict of interest.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author contributions

FJC-A, VL-M: conceptualization, writing, original draft; GMP-G, CM-M: data curation; MG-R, JM-Ll: formal analysis; FG-I, AC-R: investigation, supervision; DM-O, JAM-G: methodology, software; YLC-F, JGA-G, ET-C: project administration; FG-I, AC-R: supervision; MG-R, JM-L: validation; FG-I, YLC-F, JGA-G, ET-C: writing, review and editing.

Ethical consideration

This study was approved by the Ethics Committee of the Women’s Hospital, Secretariat of Health (No. 202409-60). The research was conducted ethically, with all study procedures being performed in accordance with the requirements of the World Medical Association’s Declaration of Helsinki. Written informed consent was obtained from each participant/patient for study participation and data publication.

History

Received: April 14, 2024

Accepted: August 27, 2024

Figures and tables

Figure 1.Correlation between the nutritional status assessment score (MNA) and the food and nutritional vulnerability score of 276 geriatric patients.

Age (years) 66.0 (IQR, 63.0–73.0) GenderFemale 34.8% (n=96) Male 65.2% (n=180) ServiceInternal Medicine 60.86% (n=168) Surgery 28.26% (n=78) Traumatology and Orthopedics 10.86% (n=30) Food vulnerability riskMild 78.26% (n=216) Moderate 19.56% (n=54) Severe 2.17% (n=6) Nutritional statusNormal 26.0% (n=72) Risk of Malnutrition 58.7% (n=162) Malnutrition 15.21% (n=42) Table I.Characteristics of the study population. ReferencesShamah-Levy T, Cuevas-Nasu L, Mundo-Rosas V. Health and nutrition status of older adults in Mexico: results of a national probabilistic survey (Article in Spanish). Salud Publica Mex. 2008; 50:383-389. DOI OMS. Envejecimiento y salud.Publisher Full Text Perez Rios M, Ruano Raviña A. La nutrición en el anciano, 2003. Offarm: farmacia y sociedad. 2003; 22:100-106. Osuna-Padilla IA, Verdugo-Hernandez S, Leal-Escobar G. Estado nutricional en adultos mayores mexicanos: estudio comparativo entre grupos con distinta asistencia social. Rev Esp Nutr Hum Diet. 2015; 19:12-20. DOI Galván M, Rivera Aguilar A, López Rodríguez G. Relación de la vulnerabilidad alimentaria con el estado de nutrición y fragilidad en adultos mayores mexicanos. Nutr Clín Diet Hosp. 2019; 9:32-39. DOI Vellas B, Villars H, Abellan G. Overview of the MNA – Its history and challenges. J Nutr Health Aging. 2006; 10:456-463. Salgado T, Candela Y, Bernal J. Use of mixed methods to evaluate access to food and nutritional food vulnerability in risk groups. An Venez Nutr. 2011; 24:65-71. Porter Starr KN, McDonald SR, Bales CW. Nutritional vulnerability in older adults: a continuum of concerns. Curr Nutr Rep. 2015; 4:176-184. DOI Hernández-Rodríguez SM, Albear-de la Torre D, Valle-Yanes I. Caracterización del estado nutricional, funcional, antropométrico y dietético de adultos mayores jubilados del Ministerio del Interior. Mediciego. 2019; 25:254-266. Abajo del Alamo C, Garcia Rodicio S, Calabozo Freile B. A protocol of assessment, follow-up and nutritional action at a nursing home. Nutr Hosp. 2008; 23:100-104. Vargas Puello V, Alvarado Orellana S, Samur Eduardo A. Inseguridad alimentaria en adultos mayores en 15 comunas del Gran Santiago: un tema pendiente. Nutr Hosp. 2013; 28:1430-1437. DOI Guitierrez Reyes J, Serralde Zuniga A, Guevara Cruz M. Prevalencia de desnutrición del adulto mayors al ingreso hospitalario. Nutr Hosp. 2007; 22:702-709. Cali NV, Robles J, Centeno ML. Riesgo de desnutrición en adultos mayores hospitalizados: estudio transversal en un hospital de Quito-Ecuador. Rev Med Vozandes. 2018; 29:73-80.