Nutrition Journal BioMed Central

Short report Open Access

Characteristics of undernourished older medical patients and the
identification of predictors for undernutrition status
Ilana Feldblum*1, Larisa German1,2, Hana Castel3, Ilana Harman-Boehm3,
Natalya Bilenko1, Miruna Eisinger4, Drora Fraser1 and Danit R Shahar1,2

Address: 1The S. Daniel Abraham International Center for Health and Nutrition, Ben-Gurion University of the Negev, Beer-Sheva, Israel, 2The
multidisciplinary center for gerontology and aging research, Ben-Gurion University of the Negev, Beer-Sheva, Israel, 3Department of Internal
Medicine C, Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel and
4Department of Internal Medicine F, Soroka University Medical Center Beer-Sheva, Israel

Email: Ilana Feldblum* - [email protected]; Larisa German - [email protected]; Hana Castel - [email protected]; Ilana Harman-
Boehm - [email protected]; Natalya Bilenko - [email protected]; Miruna Eisinger - [email protected]; Drora Fraser - [email protected];
Danit R Shahar - [email protected]
* Corresponding author

Published: 2 November 2007 Received: 18 July 2007

Accepted: 2 November 2007
Nutrition Journal 2007, 6:37 doi:10.1186/1475-2891-6-37
This article is available from: http://www.nutritionj.com/content/6/1/37
© 2007 Feldblum et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract
Background: Undernutrition among older people is a continuing source of concern, particularly among acutely
hospitalized patients. The purpose of the current study is to compare malnourished elderly patients with those
at nutritional risk and identify factors contributing to the variability between the groups.
Methods: The study was carried out at the Soroka University Medical Center in the south of Israel. From
September 2003 through December 2004, all patients 65 years-of-age or older admitted to any of the internal
medicine departments, were screened within 72 hours of admission to determine nutritional status using the
short version of the Mini Nutritional Assessment (MNA-SF). Patients at nutritional risk were entered the study
and were divided into malnourished or 'at risk' based on the full version of the MNA. Data regarding medical,
nutritional, functional, and emotional status were obtained by trained interviewers.
Results: Two hundred fifty-nine elderly patients, 43.6% men, participated in the study; 18.5% were identified as
malnourished and 81.5% were at risk for malnutrition according to the MNA. The malnourished group was less
educated, had a higher depression score and lower cognitive and physical functioning. Higher prevalence of
chewing problems, nausea, and vomiting was detected among malnourished patients. There was no difference
between the groups in health status indicators except for subjective health evaluation which was poorer among
the malnourished group. Lower dietary score indicating lower intake of vegetables fruits and fluid, poor appetite
and difficulties in eating distinguished between malnourished and at-risk populations with the highest sensitivity
and specificity as compare with the anthropometric, global, and self-assessment of nutritional status parts of the
MNA. In a multivariate analysis, lower cognitive function, education <12 years and chewing problems were all risk
factors for malnutrition.
Conclusion: Our study indicates that low food consumption as well as poor appetite and chewing problems are
associated with the development of malnutrition. Given the critical importance of nutritional status in the
hospitalized elderly, further intervention trials are required to determine the best intervention strategies to
overcome these problems.

Page 1 of 9
(page number not for citation purposes)
Nutrition Journal 2007, 6:37 http://www.nutritionj.com/content/6/1/37

Background nutritional status. Screening was performed by the short

Undernutrition among older people is a continuing version of the Mini Nutritional Assessment (MNA-sf)
source of concern [1], particularly among acutely hospi- [31], a simple, validated screening tool for nutritional risk
talized patients [2]. Undernourished elderly have longer in elderly persons or by a history of weight loss ≥10% of
periods of illness, longer hospital stays [3,4], higher rates their body weight in the 6 months prior to their admis-
of infection [5,6], delayed wound healing [7], reduced sion. Weight loss has been shown in several studies to be
appetite [8,9], and increased mortality rates [10]. the most important predictor for nutritional deterioration
[19] (weight loss in the last 3 months is part of the nutri-
Data from previous studies indicate that up to 55% of eld- tional evaluation of the MNA), thus it was included as an
erly hospitalized patients are undernourished or mal- independent screening question.
nourished on admission [11,12]. Both undernutrition
and malnutrition are associated with poorer recovery in a Subjects who were identified as being at nutritional risk by
broad range of patients and conditions [1-10]. Undernu- one of these parameters were entered into the study (Fig-
trition adversely affects both lifespan and quality of life in ure 1). Exclusion criteria included cancer, inability to be
community-dwelling older people [13-15] and is a critical interviewed, or unwillingness to sign an informed con-
determinant of outcomes among aging in-patients, influ- sent.
encing the outcome of the hospitalization [1,15] and cor-
relating with morbidity [16-21] and mortality [22-24] in The protocol of the study was approved by the ethics com-
this population. The risk for nutritional deterioration, is mittee of Soroka University Medical Center. An informed
greater than the prevalence of actual malnourishment consent form was signed by all participants.
reported [25,26].
Participants recruited into the study were interviewed by
In Israel, nutritional assessment of institutionalized trained interviewers. The data collected included demo-
[27,28,21] and home-dwelling [29,30] elderly has been graphic information as well as nutritional, health, cogni-
performed. Studies conducted in the Negev, the southern tive, emotional, and functional evaluation.
part of Israel, indicate that among community dwelling
elderly, the energy intake was below 78% of the RDA for Demographic data
men and 70% for women [30]. Data regarding the nutri- Demographic variables, including sex, age, marital status,
tional status of acutely hospitalized patients are sparse. In country of origin, education, and living arrangements,
a study conducted by our group, we found the prevalence were obtained from the patient and from the hospital
of nutritional risk among older patients on admission to admission form.
a medical ward to be 38.7% [9]. In previous studies that
were conducted in Israel [9,27-30] and other places [1- Nutritional assessment
8,10], no attention was given to the different health char- The short version of the MNA that was used for screening
acteristics of malnourished subjects and those at nutri- was used to complete the full version. The MNA consists
tional risk. of four parts:

The importance of distinguishing nutritional risk from

actual malnutrition lies in the difference between these
Screening by MNA-sf
conditions in terms of outcomes. While nutritional risk, if Or recent weight loss >10%
identified, is amenable to intervention which may reverse 589

its course, actual malnutrition is more likely to persist and

contribute to poorer outcome. Entered the study Not entered the study
At-risk/malnourished Well nourished
259 (43.97%) 330 (56.03%)
This study compares malnourished elderly patients with
those at nutritional risk and identifies factors contributing
Full MNA
to the variability between the groups.

Methods At risk Malnourished

The study was carried out at Soroka University Medical (MNA 17-23.5) (MNA<17)
211 (81.5%) 48 (18.5%)
Center (a 1000-bed university-affiliated acute care hospi-
tal) in the south of Israel. From September 2003 through
December 2004, all patients 65 years-of-age or older Figure
Flow chart
1 for study participant selection
admitted to any of the internal medicine departments Flow chart for study participant selection.
were screened within 72 hours of admission to determine

Page 2 of 9
(page number not for citation purposes)
Nutrition Journal 2007, 6:37 http://www.nutritionj.com/content/6/1/37

1. Anthropometric measurements – Questions 1–4 totally independent. The interviewers were trained to use
include current body mass index (BMI), mid-arm circum- these forms.
ference (MAC), calf circumference (CC), and weight loss
in the last 3 months. Statistical analyses
Statistical analyses were conducted using SPSS for Win-
2. Global assessment – Questions 5–10 include living dows version 14. Baseline characteristics were recorded
arrangements, number of prescribed medications, psy- and entered into a data management program. The data
chological stress in the last 3 months, mobility, neuropsy- were edited and the distribution of all the relevant varia-
chological problems, and pressure sores. bles was evaluated for normality. Comparison between
malnutrition and at risk for malnutrition based on the full
3. Dietary assessment – Questions 11–16 include number version of the MNA was conducted using t-tests for con-
of full meals per day, protein intake, fruit and vegetables tinuous variables and χ2 for categorical variables. To assess
intake (over 2 portions per day), decrease in food intake the predictive abilities of specific MNA topics (full ver-
in the last 3 months, fluid intake per day, and the ability sion) to the total score, we assessed the area under the
to eat alone. curve using a receiver operating characteristic curve
(ROC). Sensitivity and specificity were calculated based
4. Subjective assessment – Questions 17 and 18 include on the ROC curve. The sensitivity of the model was
subjective assessment of the participant's nutritional and defined as the percentage of malnourished participants
health status. who were correctly identified by the test. Alternately, spe-
cificity was defined as the percentage of participants at
The total score of the MNA distinguished between nutritional risk who were correctly identified. The sum of
patients at nutritional risk (MNA score between 17 and sensitivity and specificity defined the validity (area under
23.5) and patients with protein-calorie malnutrition the curve) of the specific MNA topics including anthropo-
(MNA score < 17) [32,33]. Participants with an MNA metric, dietary, global, and self-assessment.
score >23.5 who had lost more than 10% of their body
weight in the 6 months prior to the study period, were Multivariate analysis was conducted using a logistic
entered into the at risk group (Figure 1). regression model in which nutritional status, at risk or
malnutrition, was used as the dependent variable.
To assess specific eating problems we used selected ques-
tions from the Nutrition Risk Index (NRI) questionnaire Results
[34] that were analyzed separately. The questions related A total of 259 patients entered the study, 43.6% men, with
to swallowing and chewing problems, vomiting, constipa- a mean age of 75 years. Within the study group, 18.5%
tion and diarrhea, and use of special diets were included. were identified as malnourished and 81.5% were at nutri-
tional risk. The mean MNA score was 19.5. Baseline char-
Clinical data acteristics of the study population by nutritional status are
Clinical data obtained from the patients' charts included shown in Table 1. Malnourished participants had a signif-
biochemical measurements relevant to nutritional status icantly lower level of education and BMI, and lower mar-
such as albumin, total lymphocyte count (TLC), hemo- riage rates compared with those at risk for malnutrition.
globin, WBC, total cholesterol, and transferrin. The tests Almost 64% of the study population immigrated from
were performed at the central chemistry lab of Soroka Europe/America, 34% immigrated from Africa/Asia, and
University Medical Center using standard methods. the rest were born in Israel. Compared with the at risk par-
ticipants, a higher percent of immigrants from Africa/Asia
Functional measurements were included in the malnourished group. There was no
Cognitive status was determined using the Folstein Mini difference in age, sex, and living arrangement between the
Mental State Examination (MMSE) [35]. The MMSE score two groups. Examination of functional variables revealed
ranges from 0 to 30; a score of less than 24 indicates cog- significant differences between the two groups in several
nitive impairment. Depressive symptoms were assessed functional abilities. Higher rates of functional disability
using the short form of the Geriatric Depression Screening were found among the malnourished group. This group
Scale Short Form (GDS-sf) [36]. The GDS-sf score ranges also had a higher depression score (indicating more
from 0 to 15. A cutoff score of 5 or greater indicates depressive symptoms), and a lower cognitive function
depressive symptoms. Functional status was assessed score (indicating decreased cognitive ability). Interest-
using the modified Barthel Index [37], based on basic ingly, there was no difference between the groups in
activities of daily living (ADL). The score ranges from 0 to number of diagnosed diseases, number of prescribed
100, where 0 represents being totally dependent and 100 medications, number of hospitalizations in the year

Page 3 of 9
(page number not for citation purposes)
Nutrition Journal 2007, 6:37 http://www.nutritionj.com/content/6/1/37

before the study, number of family and specialist doctor MNAself-1 that represents self-assessment of nutritional
visits, and duration of hospitalization. and health status. The ROC curve (Figure 2) demonstrates
that the dietary assessment part within the MNA is associ-
Examination of social support variables revealed statisti- ated with greater area under the curve (AUC) (0.83, p <
cally significant differences between the two groups. Sub- 0.01) than the anthropometric assessment (0.75, p <
jects at risk for malnutrition had a higher frequency of 0.01), the global assessment part (0.51, p = 0.75), and the
phone calls and visitors compared to the malnourished self-assessment of nutritional status (0.79, p < 0.01).
group. Within the dietary assessment part, the prevalence of
severe decrease in appetite was significantly higher among
No difference was detected in biochemical measurements the malnourished group (16.7% vs. 8.5% among the at
– total lymphocyte count (TLC), hemoglobin, WBC, total risk population).
cholesterol, and transferrin – except for serum albumin.
Malnourished participants had a trend of lower serum Items of the NRI questionnaire were compared and
albumin concentration compared with those at risk for described in Table 2. In the whole group, almost 73% suf-
malnutrition (p = 0.06). fered from constipation or diarrhea. Chewing was a prob-
lem for 23.3%, swallowing was a problem for 11.6%,
In order to determine the sources of the difference in vomiting for 18.6%, and nausea for 31% of participants.
nutritional status between the groups, the relationship Almost 74% among the study participants reported that
between Nutritional Status and grouped Mini Nutritional they are on a special diet (Table 2). The malnourished
Assessment items were assessed and described in Figure 2. group suffered from more chewing (41.7% vs. 19%),
Items were grouped according to the content of the ques- vomiting (31.3% vs. 15.7%), and nausea problems
tions, as described in the methods section into MNA (47.9% vs. 27.1%) compared with those at risk of malnu-
anthro-1 that represents the anthropometric assessment, trition. The at risk group had significantly more artificial
MNAglobal-1 that represents global assessment, MNAdie- teeth compared with the malnourished group.
tary-1 that represents dietary assessment questions, and

Table 1: Characteristics of the Study Population by Nutritional Status.

Variable Malnourished Risk of malnutrition Total P value

No. of participants (%) 48 (18.5%) 211 (81.5%) 259

Age (Mean ± SD) 75.0+5.5 75.2+5.8 75.2+5.8 0.87
Sex (%)
Men 43.8% 43.6% 43.6% 0.99
Women 56.3% 56.4% 56.4%
Education ≤12 years (%) 89.6% 65.4% 69.9% 0.001
Living alone (%) 39.6% 36% 36.7% 0.64
BMI (Mean ± SD) 25.6+5.9 27.8+5.0 27.4+5.2 0.019
Family status (%)
Married 31.3% 49.8% 46.3% 0.06
Other 4.2% 4.3% 4.2%
Widowed 64.6% 46% 49.4%
Number of diagnosed diseases (Mean ± SD) 7.7 ± 2.8 7.35 ± 2.5 7.4 ± 2.6 0.36
Country of Origin (%)
Europe/America 52.1% 66.4% 63.7% 0.05
Africa/Asia 47.9% 30.8% 34%
Israel 0% 2.8% 2.3%
Number of medications (Mean ± SD) 6.3 ± 2.8 6.4 ± 2.6 6.4 ± 2.6 0.78
Length of stay (days) (Mean ± SD) 5.0 ± 4.5 4.9 ± 4.5 4.9 ± 4.5 0.89
No. of hospitalization last year (Mean ± SD) 2.2 ± 1.8 1.8 ± 1.6 1.9 ± 1.7 0.16
No. of visits to family doctor 3 months before hospitalization 7.1 ± 7.2 6.1 ± 9.5 6.2 ± 9.1 0.47
No. of visits to specialist doctors last year (Mean ± SD) 3.5 ± 4.5 2.5 ± 3.1 2.7 ± 3.4 0.15
No. of weekly phone calls (< 7 a week)(%) 60.4% 34% 38.9% 0.001
No. of visits (Mean ± SD) 4.6 ± 3.9 5.8 ± 3.6 5.6 ± 3.7 0.03
Functional status: Total Barthel Index (Mean ± SD) 86.8 ± 20 93.5 ± 14. 92 ± 16 0.03
Depression (GDS) (Mean ± SD) 7.1 ± 3.7 5.6 ± 3.2 5.8 ± 3.3 0.005
Cognitive function (MMSE) (Mean ± SE)* 25.1 ± 4.8 27.7 ± 3.2 27.2 ± 3.7 <0.001

Page 4 of 9
(page number not for citation purposes)
Nutrition Journal 2007, 6:37 http://www.nutritionj.com/content/6/1/37

ROC Curve

Source of the Curve

mnaanthro1
1.0 AUC=0.75
mnaglobal1
AUC=0.83
mnadietary1
AUC=0.51 mnaself1
0.8
Reference Line
AUC=0.79
Sensitivity

0.6

0.4

0.2

0.0
0.0 0.2 0.4 0.6 0.8 1.0

1 - Specificity
(mnadietary1),
A
Figure
Receiver
2 Operating
and self-assessment
Characteristic
ofcurve
nutritional
(ROC) status
for anthropometric
(mnaself1) using(mnaanthro1),
data from the global
full version
(mnaglobal1),
of the MNA
dietary
A Receiver Operating Characteristic curve (ROC) for anthropometric (mnaanthro1), global (mnaglobal1), dietary
(mnadietary1), and self-assessment of nutritional status (mnaself1) using data from the full version of the MNA.

The independent effect of individual health status and grams. Based on the MNA evaluation, we showed that
functional and dietary habit variables on nutritional risk 81.5% of the participants of this study were at risk for mal-
were evaluated in a multivariate model (Table 3). The nutrition and 18.5% were malnourished. Malnourished
model included variables that were significantly associ- participants were less educated, had more depressive
ated with nutritional status in the univariate analyses symptoms, and lower cognitive and functional status
including family status, depression level, and cognitive compared with participants at nutritional risk. Moreover,
and physical functioning. Lower cognitive function (OR = malnourished participants had fewer social contacts
1.1) and <12 years of education (OR = 3.2) were both risk including visits and phone calls. The following problems
factors for malnutrition, while lack of chewing problem were found to have a significantly higher prevalence
(OR = 0.3) was protective. among malnourished patients: chewing problems, nau-
sea, and vomiting. These findings indicate the severe
Discussion impact of these factors on the development of actual mal-
The main objective of the current study was to characterize nutrition.
malnourished and undernourished elderly people admit-
ted to an acute care ward and particularly to identify risk In a study that was conducted among subacute care
factors that could be the target for future intervention pro- patients in St. Louis, the prevalence of undernutrition was

Page 5 of 9
(page number not for citation purposes)
Nutrition Journal 2007, 6:37 http://www.nutritionj.com/content/6/1/37

Table 2: Relationship between Nutritional Status and selected items from Nutritional Risk Index (NRI)

Variable Malnourished Risk of malnutrition Total P value

Constipation/diarrhea 79.2% 71.4% 72.9% 0.28

Artificial teeth 64.6% 79% 76.4% 0.03
Chewing problems 41.7% 19% 23.3% 0.001
Swallowing problems at least 3 times last month 18.8% 10% 11.6% 0.09
Vomiting at least 3 times last month 31.3% 15.7% 18.6% 0.01
Nausea at least 3 times in the last month 47.9% 27.1% 31% 0.005
Are you on a special diet? 75% 73.7% 73.9% 0.85

evaluated, using the MNA. Among 837 patients consecu- Therefore its futility as an indicator of nutritional status is
tively admitted during 14 month, the prevalence of mal- limited in this scenario.
nutrition was 28.8% and 62.5% were at 'nutritional risk'
[19]. In another group of very old hospitalized patients Among the demographic parameters, we used country of
(mean age 84.8 ± 8.1 y), 33.2% were at risk for malnutri- origin as an important parameter. Israel is a multiethnic
tion and 49.4% were malnourished [21]. In institutional- country with ongoing waves of immigration from various
ized women in Spain the prevalence of malnutrition was countries: 63.7% of the study population immigrated
7.9% and 61.8% were at risk for malnutrition [38]. In our from Europe/America. The highest percent of malnour-
group, since we used participants who were already ished participants immigrated from Africa/Asia. It is our
screened for nutritional risk and malnutrition the rates assumption that the high prevalence of malnutrition in
were different although it is quite clear that the rate of this population may stem from the poor living conditions
malnutrition is relatively low. The differences observed and lower socioeconomic status (SES) highly prevalent in
may reflect the type of elderly people being screened in this population throughout their first years in Israel.
each study. Therefore, their retirement income is, on average, lower
than people who emigrated from European/American
The MNA is a dietary assessment tool that was validated in countries. Data from the Central Bureau of Statistics indi-
many different populations [11,32,33] and was shown to cate that older adults who emigrated from European/
be related to several outcomes including mortality, length American countries are more educated and their retire-
of hospitalization and complications [19-21]. In a study ment income is higher, compared with immigrants from
that assessed the impact of nutritional status measured by African and Asian countries [39].
the MNA on pressure sores, the MNA provided advantages
over using visceral proteins in screening [20]. In our study Over 64% of the malnourished participants were wid-
the laboratory measurements were not related to the MNA owed and over 39.6% were living alone. Marital status
results except for serum albumin which was slightly lower and social isolation, especially when combined with
among the malnourished group. It is likely that poor recent bereavement or poor social support, have been
nutrition takes considerable lag time until it is manifested shown in previous studies to be major risk factors for mal-
in laboratory measurements. The decline of serum albu- nutrition [40,41]. In a case control study comparing
min is certainly a late phenomenon in terms of malnutri- health and nutritional values between widowed and mar-
tion. Additionally, albumin is a negative acute phase ried participants, Rosenbloom [42] described reported
reactant which would likely be diminished in many hos- lack of appetite as an important parameter associated with
pitalized patients who do not suffer from malnutrition. depression and weight loss in widowed elderly people. In

Table 3: A Logistic Regression Model to Predict Malnutrition

Variable OR p value 95% CI

Education ≤12 years 3.22 0.029 1.13–9.19

Family status (being married) 0.75 0.13 0.52–1.09
Total Barthel Index 1.02 0.14 0.99–1.04
Depression (GDS) 0.99 0.82 0.88–1.11
Cognitive function (MMSE) 1.12 0.013 1.02–1.22
Chewing problems 0.35 0.005 0.17–0.72

Page 6 of 9
(page number not for citation purposes)
Nutrition Journal 2007, 6:37 http://www.nutritionj.com/content/6/1/37

another case control study [40], widowed community tions, number of hospitalizations during the year prior to
dwelling participants lost significantly more weight com- the study, number of family or specialist physician visits,
pared with a control married group. Poor appetite was a and duration of hospitalization, between the malnour-
significant risk factor for nutritional deterioration [40]. ished and at risk groups. However, subjective health eval-
uation compared with peers was significantly poorer
Poor appetite is an important risk factor for nutritional among the malnourished group. The difference in subjec-
risk. Payette et al. [43], who evaluated a community living tive health evaluation may indicate a difference in severity
elderly population, showed that reported good appetite of the disease. Subjective health evaluation in the elderly
appeared to be a significant predictor for dietary intake of is considered one of the most accurate measures of health
calories (p < .01) and protein (p < .05). In a previous status; its association with malnutrition indicates a close
study by Shahar et al. [44], approximately 20% of the par- relationship between health and nutritional status.
ticipants reported lack of appetite, or high frequency of
feeling no wish to eat. These subjects had lower energy The malnourished group suffered significantly more from
intake as well as lower intake of other nutrients, and thus chewing problems, vomiting, and nausea compared to the
were considered at risk for nutritional deterioration. In at risk group. Eating problems and their relation to nutri-
our study, severe loss of appetite was associated with mal- tional status clearly revealed the importance of identifying
nutrition. Among the malnourished group, the prevalence special problems related to eating and digestion. Mowe et
of severe loss of appetite was significantly higher (16.7% al. showed that chewing problems can lead to a reduced
vs. 8.5%). dietary intake and thus to poor nutritional status [49].
Therefore, these problems need to be given closer atten-
The dietary assessment part of the MNA includes ques- tion in patient care because of their cumulative effect on
tions regarding protein, vegetable and fruit intake, appe- dietary intake. Earlier identification of these risk factors
tite, fluid intake, and difficulties in eating. This part of the may allow a more efficacious intervention which may pre-
assessment has the highest sensitivity and specificity as vent actual malnutrition from occurring.
indicated in the ROC curve. This further highlights the
importance of dietary assessment as a mean of detecting Our study suffers from several limitations. The study
nutritional risk. examined a selected population of hospitalized elderly
patients at risk for malnutrition; however, characteriza-
Depression is the most common cause of unintentional tion of these groups and the distinction between the levels
weight loss and under-nutrition in older adults [45,46]. of undernutrition is important for developing targeted
Depression in the elderly is a frequent, treatable, but interventions. In addition, the study is a cross-sectional
under-recognized and under-treated, disorder. Patients survey and thus cannot serve to determine temporal rela-
with depressive symptoms are not identified and thus are tionships.
seldom treated for this condition [47].
Our study evaluated the association between in-hospital
In a retrospective chart review to determine the cause of malnutrition and several risk parameters. Of all the
weight loss in nursing home residents, Morley and Kraen- parameters studied, the difficulty in consuming foods was
zle [48] also concluded that depression was the most found to be highly associated with the development of
common cause for weight loss. In our study the average malnutrition. The most important predictors of actual
number of depressive symptoms was significantly higher malnutrition in these patients were lower education,
among the malnourished participants. We also found that poorer cognitive status, and chewing problems. At least
in the malnourished group 81.3% reported weight loss some of these parameters are amenable to pharmacologi-
compared to 50.7% among the at risk group. cal and non-pharmacological treatment modalities.
Therefore, given the critical importance of nutritional sta-
Nutritional risk is related to functional status [48,49]. Our tus in the hospitalized elderly and its impact on mortality
results indicate that the malnourished group suffered and morbidity [19-21], an emphasis should be placed on
from more functional disabilities according to the Barthel correcting these problems. An example of such interven-
Index and had a higher prevalence of impaired mobility. tions may be withholding medications, performing
This observation, however, does not provide conclusive speech therapy evaluation, or naturally changing food tex-
evidence regarding the causal relationship between ADL ture and constituents. We feel that our findings highlight
dependency and malnutrition, since each of these may be the need for a nutritional intervention trial among at risk
the cause of the other. and malnourished hospitalized patients.

We did not find any difference in health status between

the groups as measured by number of prescribed medica-

Page 7 of 9
(page number not for citation purposes)
Nutrition Journal 2007, 6:37 http://www.nutritionj.com/content/6/1/37

Competing interests 10. Payette H, Coulombe C, Boutier V, Gray-Donald K: Weight loss

and mortality among free-living frail elders: a prospective
The author(s) declare that they have no competing inter- study. J Gerontol A Biol Sci Med Sci 1999, 54(9):M440-445.
ests. 11. Guigoz Y, Lauque S, Vellas BJ: Identifying the elderly at risk for
malnutrition. The Mini Nutritional Assessment. Clin Geriatr
Med 2002, 18(4):737-757.
Authors' contributions 12. Constans T: Malnutrition in the elderly. Rev Prat 2003,
IF-Main writer and research coordinator 53(3):275-279.
13. Amarantos E, Martinez A, Dwyer J: Nutrition and quality of life in
older adults. J Gerontol A Biol Sci Med Sci 2001, 56(2):54-64.
LG-Data collection, study design and writing 14. Magni E, Bianchetti A, Rozzini R, Trabucchi M, Magni E, Bianchetti A,
Rozzini R, Trabucchi M: Influence of nutritional intake on 6-year
mortality in an Italian elderly population. J Nutr Elder 1994,
HC-Medical counseling, collection and evaluating medi- 13(4):25-34.
cal information of the patients 15. Giner M, Laviano A, Meguid MM, Gleason JR: In 1995 a correlation
between malnutrition and poor outcome in critically ill
patients still exists. Nutrition 1996, 12(1):23-39.
IH-Medical counseling, collection and evaluating medical 16. Sullivan DH, Walls RC: The risk of life-threatening complica-
information of the patients tions in a select population of geriatric patients: the impact
of nutritional status. J Am Coll Nutr 1995, 14:29-36.
17. Delgado-Rodriguez M, Medina-Cuadros M, Gomez-Ortega A, Mar-
NB-Data collection, statistical analyses and writing tinez-Gallego G, Mariscal-Ortiz M, Martinez-Gonzales MA, Sillero-
Arenas M: Cholesterol and serum albumin levels as predictors
of cross infection, death, and length of hospital stay. Arch Surg
ME-Medical counseling, collecting and evaluation of 2002, 137:805-812.
medical records in internal medicine department F 18. Potter J, Klipstein K, Reilly JJ, Roberts M: The nutritional status
and clinical course of acute admissions to a geriatric unit. Age
Ageing 1995, 24(2):131-136.
DF-Principle investigator, statistical analyses and writing 19. Thomas DR, Zdrowski CD, Wilson MM, Conright KC, Lewis C, Tariq
S, Morley JE: Malnutrition in subacute care. Am J Clin Nutr 2002,
75(2):308-313.
DS-Principle investigator, study design and writing 20. Langkamp-Henken B, Hudgens J, Stechmiller JK, Herrlinger-Garcia
KA: Mini nutritional assessment and screening scores are
All authors read and approved the final manuscript associated with nutritional indicators in elderly people with
pressure ulcers. J Am Diet Assoc 2005, 105(10):1590-6.
21. Kagansky N, Berner Y, Koren-Morag N, Perelman L, Knobler H, Levy
Acknowledgements S: Poor nutritional habits are predictors of poor outcome in
The study was supported by a grant from the Israeli National Institute for very old hospitalized patients. Am J Clin Nutr 2005, 82(4):784-91.
22. Bo M, Massaia M, Raspo S, Bosco F, Cena M, Molaschi M, Fabris F:
health policy Predictive factors of in-hospital mortality in older patients
admitted to a medical intensive care unit. J Am Geriatr Soc
References 2003, 51:529-533.
1. Van Nes MC, Herrmann FR, Gold G, Michel JP, Rizzoli R: Does the 23. Persson MD, Brismar KE, Katzarski KS, Nordenstrom J, Cederholm
mini nutritional assessment predict hospitalization out- TE: Nutritional status using Mini Nutritional Assessment and
comes in older people? Age Ageing 2001, 30(3):221-226. Subjective Global Assessment predict mortality in geriatric
2. Covinsky KE, Martin GE, Beyth RJ, Justice AC, Sehgal AR, Landefeld patients. J Am Geriatr Soc 2002, 50:1996-2002.
CS: The relationship between clinical assessments of nutri- 24. Potter JF, Schaffer DF, Bohi R: In-hospital mortality as a function
tional status and adverse outcomes in older hospitalized of body mass index: an age-dependent variable. J Gerontol Med
medical patients. J Am Geriatr Soc 1999, 47(5):532-538. Sci 1988, 43:M59.
3. Edington J, Boorman J, Durrant ER, Perkins A, Giffin CV, James R, 25. Keller HH: Malnutrition in institutionalized elderly: how and
Thomson JM, Oldroyd JC, Smith JC, Torrance AD, Blackshaw V, why? J Am Ger Soc 1993, 41(11):1212-1218.
Green S, Hill CJ, Berry C, McKenzie C, Vicca N, Ward JE, Coles SJ: 26. de Groot CP, van Staveren WA: Survey in Europe on Nutrition
Prevalence of malnutrition on admission to four hospitals in and the Elderly, a Concerted Action. Undernutrition in the
England. The Malnutrition Prevalence Group. Clin Nutr 2000, European SENECA studies. Clin GeriatrMed 2002,
19(3):191-195. 18(4):699-708.
4. Planas M, Audivert S, Perez-Portabella C, Burgos R, Puiggros C, 27. Dror Y, Stern F, Nemesh L, Hart J, Grinblat J: Macronutrient con-
Casanelles JM, Rossello J: Nutritional status among adult sumption and nutritional status in a selected well-estab-
patients admitted to an university-affiliated hospital in Spain lished group of elderly people in home for the aged in Israel.
at the time of genoma. Clin Nutr 2004, 23(5):1016-1024. J Am Coll Nutr 1996, 15(5):475-480.
5. Paillaud E, Herbaud S, Caillet P, Lejonc JL, Campillo B, Bories PN: 28. Dror Y, Stern F, Nemesh L, Hart J, Grinblat J: Estimation of vita-
Relations between undernutrition and nosocomial infections min needs-riboflavin, vitamin B6 and ascorbic acid – accord-
in elderly patients. Age Ageing 2005, 34(6):619-625. ing to blood parameters and functional-cognitive and
6. Schneider SM, Veyres P, Pivot X, Soummer AM, Jambou P, Filippi J, emotional indices in a selected well-established group of eld-
van Obberghen E, Hebuterne X: Malnutrition is an independent erly in a home for the aged in Israel. J Am Coll Nutr 1996,
factor associated with nosocomial infections. Br J Nutr 2004, 15(5):481-488.
92(1):105-111. 29. Dror Y, Ginsberg G, Cohen A, Stessman J, Berry EM: The nutri-
7. Allen B: Skin hair. In Human nutrition and dietetics Edited by: Garrow tional status of 70 years olds in Jerusalem. Isr J Med Sci 1996,
JS, James W. Edinburgh: Churchill Livingstone; 1993:668-684. 32(8):620-625.
8. Poulsen I, Rahm Hallberg I, Schroll M: Nutritional status and asso- 30. Shahar D, Shai I, Vardi H, Fraser D: Dietary intake and eating pat-
ciated factors on geriatric admission. J Nutr Health Aging 2006, terns of elderly people in Israel: who is at nutritional risk? Eur
10(2):84-90. J Clin Nutr 2003, 57(1):18-25.
9. Castel H, Shahar D, Harman-Boehm I: Gender differences in fac- 31. Rubenstein LZ, Harker JO, Salva A, Guigoz Y, Vellas B: Screening
tors associated with nutritional status of older medical for undernutrition in geriatric practice: developing the
patients. J Am Coll Nutr 2006, 25(2):128-134. short-form mini-nutritional assessment (MNA-SF). J Gerontol
A Biol Sci Med Sci 2001, 56(6):M366-372.

Page 8 of 9
(page number not for citation purposes)
Nutrition Journal 2007, 6:37 http://www.nutritionj.com/content/6/1/37

32. Vellas B, Guigoz Y, Garry PJ, Nourhashemi F, Bennahum D, Lauque S,

Albarede JL: The Mini Nutritional Assessment (MNA) and its
use in grading the nutritional state of elderly patients. Nutri-
tion 1999, 15(2):159-161.
33. Vellas B, Guigoz Y, Baumgartner M, Garry PJ, Lauque S, Albarede JL:
Relationships between nutritional markers and the mini-
nutritional assessment in 155 older persons. J Am Geriatr Soc
2000, 48(10):1300-9.
34. Wolinsky FD: Progress in the development of a nutritional risk
index. J Nutr 1990, 120:1549.
35. Folstein MF, Folstein S, McHugh PR: Mini-Mental-State: a practi-
cal method for grading cognitive state of patients for the cli-
nician. J Psychiatr Res 1975, 12:189-198.
36. Lesher EL, Berryhill JS: Validation of the Geriatric Depression
Scale – Short Form among inpatients. J Clin Psychol 1994,
50(2):256-260.
37. Mahoney FI, Barthel DW: Functional evaluation: the Barthel
index. Md State Med J 1965, 14:61-65.
38. Ruiz-López MD, Artacho R, Oliva P, Moreno-Torres R, Bolaños J, de
Teresa C, López MC: Nutritional risk in institutionalized older
women determined by the Mini Nutritional Assessment test:
what are the main factors? Nutrition 2003, 19(9):767-71.
39. Central Bureau of Statistics: Edited by: Bar-Yaakov M. Publication 01/
2005 booklet 137/; 2005.
40. Shahar DR, Schultz R, Shahar A, Wing RR: The effect of widow-
hood on weight change, dietary intake, and eating behavior
in the elderly population. J Aging Health 2001, 13(2):189-199.
41. Walker D, Beauchene RE: The relationship of loneliness, social
isolation, and physical health to dietary adequacy of inde-
pendently living elderly. J Am Diet Assoc 1991, 91:300-304.
42. Rosenbloom CA, Whittington FJ: The effects of bereavement on
eating behaviors and nutrient intakes in elderly widowed
persons. J Gerontol 1993, 48(4):S223-229.
43. Payette H, Gray-Donald K, Cyr R, Boutier V: Predictors of dietary
intake in a functionally dependent elderly population in the
community. Am J Public Health 1995, 85(5):677-683.
44. Shahar D, Shai I, Vardi H, Fraser D: Dietary intake and eating pat-
terns of elderly people in Israel: who is at nutritional risk? Eur
J Clin Nutr 2003, 57(1):18-25.
45. Wilson MM, Vaswani S, Liu D, Morley KE, Miller DK: Prevalence
and causes of undernutrition in medical outpatients. Am J
Med 1998, 104:56-63.
46. Evers MM, Marin DB: Mood disorders. Effective management
of major depressive disorder in the geriatric patient. Geriat-
rics 2002, 57(10):36-40.
47. Castel H, Shahar D, German L, Harman-Beohm I: Under-detection
of depression in older inpatients and related over-prescrip-
tion of depression-associated medications. Geriatrics and Geron-
tology International 2006, 6:248-253.
48. Morley JE, Kraenzle D: Causes of weight loss in a community
nursing home. J Am Geriatr Soc 1994, 42(6):583-585.
49. Mowe M, Bohmer T, Kindt E: Reduced nutritional status in an
elderly population (> 70 y) is probable before disease and
possibly contributes to the development of disease. Am J Clin
Nutr 1994, 59(2):317-324.

Publish with Bio Med Central and every

scientist can read your work free of charge
"BioMed Central will be the most significant development for
disseminating the results of biomedical researc h in our lifetime."
Sir Paul Nurse, Cancer Research UK

Your research papers will be:

available free of charge to the entire biomedical community
peer reviewed and published immediately upon acceptance
cited in PubMed and archived on PubMed Central
yours — you keep the copyright

Submit your manuscript here: BioMedcentral

http://www.biomedcentral.com/info/publishing_adv.asp

Page 9 of 9
(page number not for citation purposes)