ABSTRACT
This study assessed the nutritional vulnerability status of hospitalized older persons in Federal Medical Centre, Umuahia and Abia State University Teaching Hospital Aba, both in Abia State. This study was carried out using a semi-structured questionnaire which included information about their socioeconomic characteristic, living condition, dietary habit and anthropometric indices as well as factors affecting their nutritional vulnerability. Pearson’s correlation was used to identify the significant relationship (p<0.05) in this study. The nutritional vulnerability was assessed using the mini nutrition assessment (MNA) scores. The nutritional vulnerability scores were 17-23.5 for those at risk of malnutrition, <17 malnourished and 
was well nourished. BMI grade was <18.5kg/m2 for underweight, 18.5-24.5 kg/m2 (normal), 
overweight and 
30 kg/m2 (obese).The result revealed that most of the subjects (59.9%) resides in urban area. Occupation revealed that 43.1% were traders, 24.8% were farmers, pensioners (16.5%) and contractors (4.6%). The BMI showed that 27.5% were underweight, those that had normal BMI were 48.6%, those overweight were 20.2% and 3.7% were obese. The mean for weight, hip and waist circumference, mid- upper arm circumference, calf circumference and BMI were significantly lower in males (54.8
, 85.1
, 74.1
, 27.3
, 35.14
and 20.43
) than in females (59.9
, 92.3
, 79.2
, 28.3
, 37.3
and 22.6
) respectively except for height and waist/ hip ratio which was higher in males (1.64
and 0.87
) than in females (1.64
and 0.86
) respectively. The result on the nutritional vulnerability revealed that majority (62.4%) of the subjects were at risk of malnutrition, 27.5% were normal and 10.1% of the older persons were malnourished. The health conditions more prevalent among the older persons were diabetes mellitus (20.2%), hypertension (11.9%), stroke (10.1%), chronic kidney disease (7.3%), arthritis (3.7%), congestive cardiac failure (3.7%) and breast cancer (1.8%). The results showed a significant relationship (p<0.05) between nutritional vulnerability and age, marital status, residence and level of education. Sex, occupation and source of income were not significantly associated (p>0.05) with nutritional vulnerability. The results revealed that there was a significant relationship (p<0.05) between the subjects BMI, age and sex. Factors such as mobility, mode of feeding, food decline in the past three (3) months, physiological stress or disease and body mass index (BMI) were found to have a significant relationship (p<0.05) with nutritional vulnerability of the subjects. The overall result revealed that mobility, mode of feeding, food decline or inadequate food intake, physiological stress or disease, level of body mass index were found to increases risk of malnutrition. Also, majority of the subjects were at risk of malnutrition.
TABLE OF CONTENT
TITLE PAGE i
CERTIFICATION ii
DEDICATION iii
AKNOWLEDGEMENT iv
TABLE OF CONTENT v
LIST OF TABLES ix
ABSTRACT x
CHAPTER 1 1
INTRODUCTION 1
1.1 Statement of problem 4
1.2 Objective of the study 7
1.3 Significance of the study 7
CHAPTER 2 9
LITERATURE REVIEW 9
2.1 Prevalence of malnutrition across care settings 9
2.2 Importance of nutrition 9
2.2.1 Nutrition and health in older people 12
2.3 Aging and nutritional status 12
2.4 Nutritional requirement of older adults 13
2.4.1 Energy requirement 14
2.4.2 Protein requirement 14
2.4.3 Fat and cholesterol 16
2.4.4 Vitamins and minerals in older adults 16
2.4.5 Fluids 19
2.5 Forms of malnutrition 20
2.5.1 Protein-energy malnutrition 20
2.5.2 Obesity 20
2.5.3 Micronutrient deficiency 21
2.6 Physiological changes associated with malnutrition 22
2.7 Risk factors of malnutrition 23
2.7.1 Social factors 23
2.7.2 Physiological changes 23
2.7.3 Medical features 23
2.7.4 Functional limitations 24
2.8 Consequences of malnutrition 24
2.9 Nutrition assessment methods 25
2.9.1 Anthropometry measurement 25
2.9.2 Dietary intake assessment 26
2.9.3 Nutrition screening 27
2.9.4 Mini-Nutrition Assessment (MNA) 27
2.10 Prevention and treatment of malnutrition 28
CHAPTER 3 29
MATERIALS AND METHODS 29
3.1 Study design 29
3.2 Area of study 29
3.3 Population of the study 29
3.4 Sampling and sampling techniques 29
3.4.1 Sample size 29
3.4.2 Sampling procedure 31
3.5 Preliminary activities 31
3.5.1 Preliminary visits 31
3.5.2 Training of research assistants 31
3.5.3 Ethical approval 32
3.6 Data collection 32
3.6.1 Questionnaire administration 32
3.6.2 Interview 32
3.6.3 Anthropometric measurements 33
3.6.3.1 Instruments 33
3.6.3.2 Measurements 33
3.6.4 Dietary intake measurement. 35
3.7 Data analysis 35
3.8 Statistical analysis 38
CHAPTER 4 39
RESULTS AND DISCUSSION 39
4.1 socioeconomic and demographic characteristics of the subjects 39
4.2 Living conditions of the older adults 44
4.3 Anthropometric status of the older adults 46
4.3.1 Mean and standard deviation of anthropometric status by sex 48
4.4 Dietary habit of the older adults 50
4.5 Nutritional vulnerability of the older persons using mna scores 57
4.6 Medical condition of the older persons 59
4.7 Relationship between nutritional vulnerability and socio-economic/demographic
variables. 61
4.8 Relationship between nutritional status (using BMI) and socio-economic/demographic variables 64
4.9 Factors affecting nutritional vulnerability using MNA classification 66
CHAPTER 5 69
CONCLUSION AND RECOMMENDATION 69
5.1 Conclusion 69
5.2 Recommendation 69
REFERENCES 71
Appendix i 86
Appendix iii 93
Appendix iii 94
LIST OF TABLES
Table 4.1a: Socioeconomic and Demographic Characteristics of the older persons. 40
Table 4.1b: Socioeconomic and Demographic Characteristics of the older persons. (contd). 41
Table 4.2: Living Conditions of the older persons. 45
Table 4.3: Anthropometric Status of the older persons. 47
Table 4.3.1: Mean and Standard Deviation of Anthropometric Parameters by Sex. 49
Table 4.4a: Dietary habit of the older persons. 51
Table 4.4b: Dietary habits of the older persons (contd) 52
Table 4.4c: Dietary habit of the older persons (contd) 53
Table 4.5: Nutritional Vulnerability of the older persons Using MNA Scores 57
Table 4.6: Medical Condition of the Subjects 60
Table 4.7: Relationship between Nutritional Vulnerability and socio-economic/demographic variables 62
Table 4.8: Relationship between respondent’s nutritional status (using BMI) and socio-economic/demographic variables 65
Table 4.9: Factors affecting Nutritional Vulnerability Using MNA classification 67
CHAPTER 1
INTRODUCTION
BACKGROUND OF THE STUDY
Aging is accompanied by physiologic changes that can negatively impact nutritional status (Nutrition Institute, 2010). The older adult population can be defined using a threshold of 65 years (Dimaria and Elaine, 2005). Aging is coupled with increased risk of malnutrition because of the interaction of various physiological, psychological and socioeconomic factors (Ahmed and Haboubi, 2010). The process of aging refers to clinical symptoms and includes the effects of environment and disease (Umesh, 2012). Malnutrition in elderly is defined as a state of under-nutrition which has resulted from prolonged protein and energy restriction (Hickson, 2006).
Nutritional needs change during ageing and many factors affect nutritional status in older patients, including illnesses that affect digestion, absorption and metabolism (NICE, 2006). With aging, there are a number of factors that contribute to the risk of malnutrition. Chronic disease can be a major contributor. Many diseases, such as cardiac disease, renal impairment, and malignancy contribute to inflammation that can lead to significant loss of muscle mass (Jensen, 2006). Physical impairments such as physical immobility or the inability to feed oneself, can cause difficulty in acquiring, preparing, and eating foods. Elders also experience early satiety and physiological appetite loss (Visvanathan and Chapman, 2009). In addition, many diseases may prompt the prescription of restrictive diets that may not always be necessary. Overly restrictive diets may be unpalatable or difficult to follow, leading to a decline in oral intake and eventually, malnutrition (Kris and Dimaria-Ghalili, 2015).
According to Nzeagwu and Uwaegbute (2010), nutritional vulnerability is defined as the presence of risk factors for malnutrition. While the physiological changes that accompany ageing are important risk factors, there are many other social, economic, physical and psychological factors that also determine what and how much an elderly person eats (Hewitt et al., 2006). A nutritionally vulnerable older adult has a reduced physical reserve that limits the ability to mount a vigorous recovery in the face of an acute health threat or stressor (Kaiser et al., 2015). Often this vulnerability contributes to more medical complications, longer hospital stays, and increased likelihood of nursing home admission (Kaiser et al., 2015). Inadequate nutritional status in the elderly has important consequences for health and functional ability and their decline in a person leads to a loss of independence and an increased need for care (HewittI et al., 2006)
Malnutrition is a growing but under-recognized problem facing older adults (Wright, 2015). It is related to an excessive or imbalanced diet, a diet that lacks essential nutrients, or it can be tied to clinical conditions that impair the body’s absorption and/or use of food (Snider et al., 2014)
Malnutrition is the condition that develops when the body does not get the right amount of vitamins, minerals, and other nutrients (e.g. energy, protein) it needs to maintain health, promote cell and tissue growth and normal organ function. (Nutrition Institute, 2010)
Malnutrition is becoming increasingly more common among the elderly population (Danielle and Carol, 2015). This is a cause for concern considering the fact that malnutrition negatively affects the health of the older adult. An estimated 5-10% of elderly people living in the community setting are malnourished (Furman, 2006). About 60% of hospitalized older adults (age 65 or older) and 35-85% in long-term care facilities are experiencing malnutrition (Furman, 2006). Malnutrition seems to be even more prevalent in hospitals and long-term care facilities, as compared to community-dwelling older adults (Danielle and Carol, 2015)
Malnutrition in the elderly is a major concern because it can cause adverse outcomes. Malnutrition impacts morbidity, mortality, hospital length of stay, functional disabilities, and physical complications (Danielle and Carol, 2015). Malnutrition can cause increased infection, electrolyte imbalances, altered skin integrity, anemia, weakness, and fatigue (Furman, 2006). Inadequate nutritional status in the elderly has important consequences for health and functional ability and their decline in a person leads to a loss of independence and an increased need for care (Furman, 2006). The consequences of the risk factors outlined above are woven into the overall web of nutritional vulnerability.
Although there is no uniformly accepted definition of malnutrition in the elderly, some common indicators include involuntary weight loss, abnormal body mass index (BMI), specific vitamin deficiencies, and decreased dietary intake (Reuben et al., 2004). Malnutrition in the elderly is often underdiagnosed. Careful nutritional assessment is necessary for both the successful diagnosis and development of comprehensive treatment plans for malnutrition in this population (Jennie and Andrea, 2006). Malnutrition is a disorder of nutritional status that results in depletion of nutrient stores, leading to the impairment of physiological and biochemical processes and subsequently to cellular or tissue deterioration (Berner, 2003). Malnutrition is a key indicator of older adult health and needs to be recognized as such (Wright, 2015)
1.1 STATEMENT OF PROBLEM
Malnutrition can be found in all healthcare settings (Nutrition Institute, 2010). Hospitalized patients are at particular risk as 86% of them have been identified as malnourished or at risk of malnutrition (Kaiser, 2009). Malnutrition is expected to become an even greater problem as a result of an ageing population and an increase in chronic diseases that are often associated with malnutrition (Elia, 2008)
Despite the high prevalence of malnutrition, physician awareness of the important role nutrition plays in general well-being and disease treatment is quite low (Norman et al., 2008). This results in a delay or omission of appropriate nutrition intervention and leaves many people suffering the consequences of malnutrition (Norman et al., 2008). At the same time if left untreated, approximately two thirds of those patients will experience a further decline in their nutrition status during their hospitalization (Tappenden et al., 2013). Malnutrition continues to be underdiagnosed in many hospitals (Kirkland et al., 2013). A recently published study of the prevalence of malnutrition among older patients presenting to an emergency department found that 16% were malnourished and that 60% were either malnourished or at risk for malnutrition (Pereira et al., 2015). A review of studies on malnutrition in hospitalized older adults reported a prevalence rate of 12% to 70% (Heersink et al., 2010). In an earlier study in two hospitals in Nigeria, it was reported that 45.2% of the older persons studied were at risk of malnutrition and 37.9% were malnourished using MNA (Nzeagwu and Okorocha, 2012)
Poor nutritional care and the incidence of malnutrition in hospital patients have long been recognized as challenges (Maud and Webster, 2009). Older people are particularly vulnerable and at risk of becoming malnourished while in hospital (Amelia, 2016).
Malnutrition is a widespread but large unrecognized problem in the older adults, more as it is a contributing factor to the increased morbidity and mortality in this age group (Ojofeitimi et al., 2002). Out of the three vulnerable groups (pregnant women, infants and the elderly persons) that face nutritional and public health threats, the elderly population have been somewhat neglected (Ojofeitimi et al., 2002). It is known that nutrition and health risk increases with age (Nzeagwu, and Uwaegbute, 2010). Malnutrition in the older adults is poorly recognized and documented by healthcare providers, particularly nurses who are often in the best situation to assess and monitor the nutritional well-being of patients (Danielle and Carol, 2015). Elderly patients frequently pose many perioperative challenges that are not seen in younger patients. In general, older patients have longer hospital stays, incur greater costs, and have a higher risk of adverse outcomes compared to their younger counterparts (Rasheed and Woods, 2012)
Malnutrition significantly increases morbidity and mortality and compromises the outcomes of other underlying conditions and diseases (Furman, 2006). Malnutrition may delay recovery and prolong hospitalization, lead to increased susceptibility to infection, impede individuals’ independence and quality of life, and even increase the risk of death in many patients (Nutrition Institute, 2010). Malnutrition poses a huge economic cost to society. The malnourished elderly are more likely to require health and social services, have more hospitalizations, and cause a burden on caregivers (Nutrition Institute, 2010)
The high prevalence and consequences of malnutrition in older adults emphasizes the need for routine nutrition assessment (Nzeagwu and Uwaegbute, 2010). Malnutrition in elderly patients in institutions has become an issue of clinical concern. Nzeagwu and Okorocha (2012) reported a study on assessment of nutritional vulnerability of hospitalized elderly in two hospitals in one part of the south-east and this study was undertaken to ascertain the vulnerability of older persons in two hospitals in another part of the geo-political zone.
1.2 OBJECTIVE OF THE STUDY
The main objective of the study is to
Assess the nutritional vulnerability of hospitalized older patients
Specific Objectives
I. To identify the health problems of hospitalized older patients.
II. To determine the nutritional status of the hospitalized older patients in two hospitals using anthropometry (BMI, MUAC, calf circumference, waist circumference and hip circumference) and dietary habits.
III. To assess the nutritional vulnerability of the older persons using mini nutritional assessment tool.
IV. To identify factors affecting nutritional vulnerability of these hospitalized older patients.
1.3 SIGNIFICANCE OF THE STUDY
This study will be very important to health and social care professionals, and those working in Residential care homes to become aware of the prevalence of malnutrition, those at risk of malnutrition for intervention programmes for the hospitalized older persons.
Nutritionists and dietitians will find the results of this study helpful as it will provide information that will aid them in managing and counselling older persons at risk of malnutrition.
Nutrition educators, clinical dietitians and community dietitians can use findings from this study to educate health workers and the general public on healthy feeding habits and ways of reducing risk of malnutrition of older persons during hospital stay
This study will also generate information that could be useful in correcting and eliminating risk factors of malnutrition in older persons especially hospitalized ones.
The study will also be helpful to the Ministry of Health and other health and nutrition agencies to ascertain the prevalence of malnutrition in the hospital sector in order to provide effective intervention.
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