How to cite this article: Guerrero-García NB, Gómez-Lomelí ZM, Leal-Mora David, Loreto-Garibay O. [Frailty in the elderly and nutritional status according to the Mini Nutritional Assessment]. Rev Med Inst Mex Seguro Soc. . 2016 May-Jun;54(3):312-7.
Received: February 2nd 2015
Judged: April 28th 2015
Nadia Belén Guerrero-García,a Zoila Margarita Gómez-Lomelí,b David Leal-Mora,c Oscar Loreto-Garibayb
aServicio de Geriatría
bDepartamento de Salud Pública, Universidad de Guadalajara
cJefatura del Servicio de Geriatría
a,cHospital Civil de Guadalajara “Fray Antonio Alcalde”
Guadalajara, Jalisco, México
Communication with: Nadia Belén Guerrero-García
Background: The aging process involves psychosocial and physiological changes, which modify the nutritional status in the elderly. The objective was to assess the nutritional status of a group of elderly patients using the Mini Nutritional Assessment (MNA) and the Fried frailty index, as well as the relation between both.
Methods: From June to July, 2013, we carried out a cross-sectional study with consecutive sampling of 146 patients of both sexes, from the Hospital Civil “Fray Antonio Alcalde”, in Guadalajara, México. We applied the MNA and the Fried frailty index.
Results: The mean age was 81.7 years (± 7.65). One hundred and six patients (72.6 %) were females, and 40 were males (27.4 %). Basic anthropometric data showed that the mean weight was 57.67 kg (± 13.7), with a mean of 1.52 (± 0.09) meters in size; body mass index was 24.85 (± 5.32) kg/m2. The results showed that 14.1 % of patients with a normal nutritional status suffered from frailty, while 42.1 % had risk of malnutrition and frailty.
Conclusion: Frailty in the elderly is still present even if they have a normal nutritional status; when the nutritional status decreases, there is a higher prevalence of frailty in this age group.
Keywords: Frail elderly; Nutritional status; Nutrition assessment
Aging is a process that involves psychosocial and physiological changes that contribute to changing the nutritional status in older adults.1,2 This state is a valid predictor of longevity and quality of life in this stage.2
One of the physiological and anatomical changes that older adults face is the loss of oral function, which is reflected in the motor actions of the mouth, including chewing, swallowing, salivation, and lack of teeth,3 as well as altered or decreased discerning of the taste of food and beverages (usually related to the consumption of certain drugs, neuropathies, gastrointestinal or endocrine disorders, inflammatory diseases, chronic diseases, malignancies, immobility, social isolation, economic constraints, and poor quality of life).3,4 All this causes older adults to eat less food.
However, insufficient dietary intake in energy and the establishment of a persistent catabolic state results in the progressive reduction in skeletal muscle mass, weight loss, and decreased strength and function in people who belong to this age group.5,6 Faced with this situation, nutritional status plays a central role in the embrittlement of older adults.2
Nutritional status is the situation an elderly person is in, in relation to ingestion and physiological adaptations that take place after the ingestion of food.7 The nutritional status of older adults can be assessed with the Mini Nutritional Assessment (MNA), which is a tool used to detect the risk of malnutrition with a score of 17 to 23.5 and malnutrition with a score < 17; a normal nutritional status is between 24 and 30 points in older adults in the community, nursing home, or institutions.8,9 The MNA includes several risk factors for embrittlement, such as body mass index (BMI), lower mobility, the progressive reduction of muscle mass, or low caloric intake.1,5,10
Frailty in an older adult is a lengthy process of disability indicating vulnerability and predisposition to functional decline of physiological reserves, reducing homeostasis.5,6 Five measurable criteria were established to consider an older adult frail, being low physical activity, weight loss, physical exhaustion, hand grip strength, and decreased speed. For this, term the frail was used for persons obtaining 3 to 5 points, pre-frail for 1 to 2, and robust with no points.1,6,11,12
We note the existence of three studies that focus on the relationship between nutrition assessment with the MNA and frailty in the older adult.1,11,12
The project objective was to assess the nutritional status of older adults who attend the outpatient clinic of the Hospital Civil "Fray Antonio Alcalde" in Guadalajara, Jalisco. This was done with the application of the Mini Nutritional Assessment,8,9 Fried’s criteria,6 and their relationship to each other.
Cross-sectional study with consecutive sampling, whereby a total of 179 patients were obtained at the Hospital Civil de Guadalajara "Fray Antonio Alcalde", from the Geriatrics outpatient service from June to July 2013. Of the study subjects, 146 (81.56%) were 60 years of age or older. All were from the metropolitan area of Guadalajara and outside, of both sexes, by appointment (follow-up patients, i.e. told by doctors to come back to the Geriatrics outpatient area) or with an interclinical referral (document given by the doctor of another service for the patient to be treated at the Geriatrics service for the first time). 33 patients (18.43%) were excluded because their files were not complete, and two due to amputation (1.11%) in the lower extremities.
Patients were studied and if they could not answer the questions of the Mini Nutritional Assessment, the survey was applied to the primary caretakers of the morning shift (from 9:00 AM to 1:00 PM) of the Hospital Civil "Fray Antonio Alcalde" in the Geriatrics outpatient area. On one occasion three nurses and a medical intern were trained from the Geriatrics outpatient area to improve their ability to perform the activities and recorded them in the form.
The Mini Nutritional Assessment (MNA) was used to assess nutritional status. This is a tool that consists of 18 questions divided into four blocks. The first block refers to the anthropometric status (arm circumference, calf circumference, body mass index, and weight loss); the second block, with six questions, is dedicated to the general assessment; the third block is responsible for the assessment of dietary habits, and the fourth block contains the subjective assessment of the patient’s quality of health and nutrition.8,9
For the anthropometric assessment weight was taken in kilograms with a model Seca® 762 scale and, in case of mobility problems, an MR chair scale was used (and the weight of the chair used was recorded). The patient was asked to go onto the scale in light clothing, without support from any person or their arms, and with the weight evenly distributed between both feet. Height was measured in centimeters with a Seca® model 213 stadimeter (precision of 1 mm), in a position with the patient standing up with heels together, with the buttocks and the upper back in line. The mean arm circumference (MAC) was measured in centimeters, with a metal belt approved by ISAK, manufactured by Rosscraft®, at the acromiale-radiale point, placing the tape perpendicular to the axis of the arm. The calf circumference (CC) was measured in centimeters, with the most prominent part of the leg placed at a 90° angle. The triceps skinfold (TCS) was measured in millimeters with a Harpenden model caliper, approved by ISAK (accuracy of 2 mm), and with arms at the sides the fatty fold was taken parallel to the longitudinal axis of the arm. BMI (kg/m2) was calculated from the weight and height data.13
For frailty, Fried’s criteria that were used, which are as follows:
|Table I Criteria for measuring grip strength in both arms|
|BMI ≤ 24||≤ 29||BMI ≤ 23||≤ 17|
|BMI 24.1-26||≤ 30||BMI 23.1-26||≤ 17.3|
|BMI 26.1-28||≤ 30||BMI 26.1-29||≤ 18|
|BMI ≥ 28||≤ 32||BMI ≥ 29||≤ 21|
The older adult was seen as frail if they met three or more criteria and pre-frail if they met one or two criteria.6,11,12
As for diseases, data about patient diseases were recovered through the hospital’s electronic record; diseases were categorized based on the systems of the human body.
For statistical analysis SPSS Statistics program for Windows, version 17.0 (IBM, Chicago) was used to analyze the age and anthropometric data, using the mean and standard deviation; for diseases, the percentage was used to identify their frequencies. In the statistical test a p-value of < 0.05 was considered significant. To analyze all the data and to compare proportions, the Epiinfo application EPITABLE 6 version 6.04d was used.
Upon beginning the study, 179 patients were reviewed; 33 (18.43%) were excluded because their records were not complete and two had limb amputations. Among the 146 patients enrolled, 106 (72.6%) were female and 40 (27.4%) were male, ranging from 64-100 years old, with an average of 81.7 ± 7.65 years. The results of nutritional assessment by anthropometric parameters gave the average weight of 57.67 ± 13.74 kg, height 1.52 ± 0.99 m, and BMI of 24.85 ± 5.32 kg/m2; the TCS was 15.92 ± 8.85 mm and MAC was 26.75 ± 5.53 cm. The average MNA was 20.5 ± 4.6 points and prevalence of nutritional status showed that 79 people (54.1%) were at risk of malnutrition, while to a lesser extent there were older adults with malnutrition, at 21.2%. Table II shows in detail the differences and similarities found in anthropometry.
|Table II Anthropometry by sex of patients included in study|
Mean ± SD
Mean ± SD
|Age||85.08 ± 7.02||80.42 ± 7.57|
|Weight (in kg)||60,80 ± 13.93||56.49 ± 13.91|
|Height (in m)||1.61 ± 0.08||1.49 ± 0.08|
|BMI (kg/m2 )||23.27 ± 4.21||25.44 ± 5.59|
|MAC (in cm)||24.53 ± 4.27||27.59 ± 5.73|
|TCS (in mm)||11.43 ± 7.93||17.62 8.62 ±|
|Calf (in cm)||31.78 ± 3.93||31.55 ± 4.89|
|SD = standard deviation; BMI = body mass index; MAC = mean arm circumference;
TCS = triceps skinfold
The prevalence of circulatory system diseases was the most common in the population, and the least frequent was the immune system; Table III shows diseases ordered by body system.
|Table III Diseases classified by human body systems|
|System and diseases||n||%|
|1 Circulatory: Dyslipidemia, hypertension, heart failure, atrial fibrillation, anemia||94||64.4|
|2. Endocrine: diabetes mellitus, thyroid||47||32.2|
|3. Bone: arthritis, gout, osteoarthritis, osteoporosis||44||30.1|
|4 Nervous: sequelae of cerebrovascular event, dementia, depression, Parkinson's
|6. Respiratory: chronic obstructive pulmonary disease, respiratory failure,
|7. Digestive: diarrhea, colitis, and gastritis||11||7.5|
|8. Urinary: urinary tract infection, kidney failure, and proteinuria||11||7.5|
|9 Muscular: Fibromyalgia, sarcopenia, muscular contracture||4||2.7|
|10 Reproductive: breast, prostatism, and cervix||4||2.7|
|11. Immune: pemphigus||1||0.7|
In the section of frailty, 54.1% of older adults at risk of malnutrition (79) had some criterion of frailty; while the older adults with malnutrition had fewer cases. Table IV shows the relationship between frailty and nutritional status according to the MNA in more detail.
|Table IV Frailty and nutritional status of patients included in study|
|Risk of malnutrition||62||55.4||17||50.0||79||54.1||0.583 †|
|Norma, risk of malnutrition, and malnutrition are terms of the Mini Nutritional Assessment (MNA); frail and pre-frail are the terminology of the Fried frailty criteria
*p < 0.001; † p > 0.05; ‡ p < 0.05
Life expectancy in Mexico has been increasing in recent decades. At 70 years in the nineties, it advanced to 74 years in 2013 and is forecast to increase to 77 years by 2030; however, in our study, the group of older adults exceeded the estimated age for 2013 and was still higher than the average established for 2030,14 suggesting that there is a more rapid increase in octogenarians. It is known that women tend to have a longer life expectancy compared with men. In Mexican women life expectancy is 77 years and in men 72 years,14 however, in this paper the results were the opposite: men were older than women, which implies that despite lower participation from men, they have a greater longevity than women.
For decades, malnutrition in hospitalized older adult patients has ranged between 12 and 60%, whereas in the institutionalized elderly (nursing home) it fluctuates between 23 and 60%, and ranges from 1 to 15% in those treated at clinics located in communities and attending medical offices.2,15 Malnutrition values found in the present study show a figure higher than expected: it shows that our older adults are at the same percentage level as hospitalized individuals. As seen, the prevalence of malnutrition risk among the elderly in this study (54.1%), as in Dorner’s (51.1%),12 is above the figures found in the Hospital Nacional Cayetano Heredia, Peru, in Xinzo de Limia Ourense, Spain, and Nuremberg, Germany, ranging between 15.1 and 31.4%;11-19 these results set the tone for the future existence of a greater number of older adults with malnutrition and, therefore, the arrival of these patients to hospitals, which will generate an increase in health sector spending.
Moreover, the prevalence of frailty found in this study (76.7%) is much higher (between 8.4 and 59%) than that reported in Peru; at the Hospital de la Universidad Estatal in Campinas, Brazil; and in Colombia.16,17,19 The possible discrepancy between results may be due to the methods used; this study used not only the Fried criteria, but added different scales to evaluate them. However, the percentage of pre-frail older adults decreases compared with other studies, with ranges almost double or more (between 41 and 61.8%) than reported in the studies from Peru, Brazil, and Colombia.16,17,19 It is important to mention that these older adults will soon be frail; however, it should be noted that none was found in robust condition; i.e., there was no one who did not present any criteria, as happened in Abre da Silva’s study in 2011, which concluded that older age is associated with being frail.
The most important factor is related to nutritional status and frailty. Significantly, despite having a normal nutritional status, older adults suffered from frailty; so those older adults who are at risk of malnutrition have a higher percentage of frailty, as in Dorner.12 One can say that more than 50% of the older adults surveyed have some degree of frailty.11,12 This is because, regardless of the cause of poor dietary intake, even if the older adult returns to his usual diet after a period of low food consumption, they do not recover the lost weight, unlike young people who tend to eat more food to recover,20 which in turn causes loss of muscle mass, the main cause of decreased strength, and leads the older adult to reduced mobility and the inability to perform basic or instrumental activities of daily living.1,6,11,12
It should be noted that our study has limitations; the implementation period was short and the selection of the sample was done in one place; moreover, the care of elderly patients depended on the weather: icy or rainy days.
We can say that frailty is present in older adults even if they have a normal nutritional status, according to MNA terminology; however, it increases as this state deteriorates. However, there are fewer cases of malnourished frail older adults, because they are more prone to death.
One can say that the MNA tool and the Fried criteria are valid and effective tools to relate the risk of malnutrition and malnutrition with risk factors for frailty, such as low weight, decreased mobility, progressive muscle mass reduction, and low caloric intake.6,8,9
The binomial of nutritional status and frailty in aging plays an important role in older adults, so continuous verification of the parameters that reflect their nutritional status is necessary. We see the need for further studies that can combine these issues in order to get closer to preventing the state of frailty in the aging process.
Conflict of interest statement: The authors have completed and submitted the form translated into Spanish for the declaration of potential conflicts of interest of the International Committee of Medical Journal Editors, and none were reported in relation to this article.