The Nutritional Status among Elderly People

residing in Care Facilities in Klang Valley in

Malaysia

Author: CHAN SIONG KENT

Student ID: 14UMB04285
Supervisor: Dr. Leong Pooi Pooi and Ms. Woo Li Fong

Second Year
MBBS

Faculty of Medicine & Health Sciences

Universiti Tunku Abdul Rahman

2016
Table of content

Abstract 1

Introduction 2-5

Literature Review 6-8

Materials & Methods 9-15

Results & Data Analysis 16-25

Discussion 26-28

Conclusion 29

Acknowledgement 30

References 31-36

Appendices 37-77
 Abstract

Introduction: There are about 1.9 million of elderly people in 2016 while the total

population of Malaysia is around 30.9 million. This indicated that the elderly population in

our country is nearly made up the 10% of our total population in overall. The prevalence of

malnutrition and at risk of malnutrition in Malaysian elderly population is about twenty one

percent.

Materials & Methods: A cross-sectional descriptive study was carried out among the elderly

people residing in the care facilities around Klang Valley, Malaysia by using structured

questionnaire, student face-to-face interview, simple physical examination, anthropometric

measurement, blood pressure measurement and also observational survey on the care

facilities environment as well.

Results & Discussion: About 37% of the elderly people who residing in care facilities in

Klang Valley, Malaysia have a normal nutritional status while there are 33% of them who at

risk of malnutrition and 15% of them who are malnutrition. The mobility factors and

psychological problems did have a significant effect on the nutritional status of the elderly

people while taking more than three prescription drugs pre day did not have any significant

association with the nutritional status of the elderly people.

Conclusion: The mobility factors like having difficulty in walking, mobility ability and mode

of feeding have a statistically significant association with the nutritional status of the elderly

people. Moreover, psychological problems like severe dementia, mild dementia and

depression also affect the elderlys nutritional status in a significant way. However, taking

more than three prescription drugs per day does not show any significant link to the

nutritional status of the elderly.

 Introduction

Nowadays, the elderly population in the world is at an increasing rate in which the

geriatric care is becoming more and more important as compared to the previous time. This

global phenomena can be due to the better health care facilities available to the people and

can also be part of the consequence of the overall low birth rate which results in the rising

number of the elderly population. The elderly is defined as people who aged 60 years and

above (H A Karim, 1997).

According to the Department of Statistics in Malaysia, there are about 1.9 million of

elderly people in 2016 while the total population of Malaysia is around 30.9 million. This

indicated that the elderly population in our country is nearly made up the 10% of our total

population in overall. Nevertheless, this elderly population is estimated to increase over the

next few decades in which it will surely more than the current population. Hence, with the

ongoing increasing rate of the elderly population, more attention should be given to them by

the health care professional as well as the authority in order to provide them better quality of

life and enable them to enjoy their retirement lives after they have contributed so much to the

development of our country.

The prevalence of malnutrition and at risk of malnutrition in Malaysian elderly

population is 21% according to the survey done by Camilia Jing et al. in 2015. As the people

grow older, there are several impacts and consequences of malnutrition on the elderly like

physical well-being, mental health and quality of life. In terms of physical well-being, older

age in the elderly have weaken their bones and joint, increased vulnerability to infections and

susceptible to cancer as well as vision loss caused by common disorders such as diabetes.

Meanwhile, in regard to the mental health aspects, the elderly are more prone to or
susceptible to degenerative disorders likes Alzheimer disease and Parkinson disease in which

can in turn affect their quality of life (Nootropics, 2015).

In addition, an estimated 510% of elderly people living in the community remain

malnourished and hence it is a major cause of concern among the health care professional as

malnutrition have a negative impact on the elderlys health and life style (Furman, 2006).

Apart from that, depression in elderly population also known as one of the most common and

usual geriatric psychiatric disorders which are closely related to their psychological, social,

and physical health problems. The prevalence of depression in elderly population varies from

12.9% to 21.2% in many countries (Eman & Mohamed, 2011). The World Health

organisation (WHO) stated that the factors which can boost the risk of depression in elderly

population include genetic susceptibility, pain and frustration culminating from limitation in

daily activities, chronic disease and disability.

Other than that, the elderlys personality traits (dependent, anxious or avoidant), lack

of adequate social support especially those elderly who lived in care facilities and having

some adverse life events like separation, divorce, bereavement, poverty, and social isolation

can also have a vital role to play in the development of depression which indirectly leads to

malnutrition in the elderly population (WHO, 2001).

In addition, malnutrition can also occur due to other causes like dietary deficiencies,

chewing or swallowing problems, gastrointestinal or endocrine disorders, loss of taste or

smell, decreased appetite, consuming different kinds of drugs, immobility, social isolation,

inflammatory diseases, chronic diseases, alcoholism, malignancies and cognitive disorder

especially depression (Isaia G, 2011). The reason why depression can lead to malnutrition in

elderly population is that our body and mental status have a powerful relationship. Thus,

lower level of neurotransmitters in those elderly who have depression can cause the decrease
of mental flexibility and subsequently lead to significant disorders like functional limitation,

anorexia and weight loss and malnutrition (Nihon Ronen, 2000).

Furthermore, there are numerous studies which have demonstrated a significant link

between depression and various socioeconomic variables such as advanced age, low

education, poverty, and manual occupation (Murata, Kondo, Hirai, Ichida, & Ojima, 2008).

As a result, depression is one of the most important factors that cause malnutrition in elderly

population due to its inseparable association with the nutritional status in the elderly

population. Thus, the factors associated with the nutritional status in elderly in care facilities

in Klang Valley in Malaysia were chosen to study.

Problem statement/ Research question:

What are the factors associated with nutritional status in elderly in care facilities in Klang

Valley?

Hypotheses:

1) Most of the elderly in care facilities are malnourished.

2) There is a positive association between mobility factors like difficulty in walking,

mobility and mode of feeding with the nutritional status in elderly.

3) There is a positive association between psychological problems such as recent stress

and acute illness, neuropsychological problems with the nutritional status in elderly.

4) There is a negative association between elderly who take more than 3 prescription

drugs per day with their nutritional status.

Objectives:

General:

To study the factors that affect nutritional status in elderly in care facilities in Klang Valley.

Specific:

i. To determine the nutritional status of elderly in care facilities.

ii. To investigate the association between mobility factors and nutritional status in

elderly.

iii. To examine the association between psychological problems and nutritional status in

elderly.

iv. To assess the association between elderly who take more than 3 prescription drugs per

day and nutritional status.

 Literature Review

In the aspect of epidemiological data of malnutrition in the elderly population in

Malaysia, Camilia Jing et al. (2015) stated that the prevalence of malnutrition or at risk of

malnutrition in Malaysian elderly population is 21%. Meanwhile, Kaiser MJ et al. (2010) also

stated that the prevalence of malnutrition in the elderly population in 12 different countries

was 22.8%, with considerable differences between settings (rehabilitation, 50.5%; hospital,

38.7%; nursing home, 13.8%; community, 5.8%). According to the Department of Statistics,

Malaysia (2016), there are a total of about 1.9 million of elderly people who aged 60 years

and above in a total population of 30.9 million in Malaysia. This means that the elderly

population is approximately 6.0% of the total population in Malaysia. Hence, the nutritional

status in elderly population should be taken into serious consideration by all the health care

professional and the authority as well in order to ensure that the quality of life of the elderly

population will not be deteriorated by this problem. As the elderly population will keep on

growing on the coming next few years, it is very crucial for all the health care professional

and authority to tackle this problem as soon as possible.

In addition, there are various impacts of malnutrition on the elderly like in the aspect

of physical well-being such as malnutrition weakens the bones and joints of the elderly,

increase their risk and vulnerability to viral or bacterial infections, lead to vision loss caused

by common disorders affecting the eyes and more susceptible to cancer. Besides, in the

aspect of mental health, malnutrition also made the elderly more susceptible to degenerative

disorders like Alzheimer disease and Parkinson disease in which can in turn affect their

quality of life (Nootropics, 2015).

Apart from that, in the aspect of malnutrition in the elderly population, Haboubi N.

(2010) mentioned that the malnutrition is related to a decline in general functional status.
Moreover, D.H. Sullivan (1998) said that it is responsible for many clinical outcomes like

increased rate of infections, extended wound healing, admissions to hospital stays and

mortality. In addition, malnutrition is also an important cause of mortality and morbidity in

the elderly (H. Simsek, 2013).

Furthermore, Raynaud A. et al. (2007) said that there are several criteria to define

malnutrition in elderly population as listed in the following:

1) Weight loss 5% in 1 month or 10% in 6 months

2) Body mass index (BMI) <19 kg/m

3) Global Mini Nutritional Assessment (MNA) score <17

4) Mid upper arm circumference (MUAC) <21cm and calf circumference (CC) <31cm

Raynaud A. et al. (2007) also mentioned the elderly must have at least two or more criteria

listed above in order to be considered as undernourished.

Other than that, Park (2000) also mentioned that there are numerous factors which are

associated with the nutritional status in elderly like mobility factors, psychological problems,

taking more than 3 prescription drugs per day, changes in the body both physically and

physiologically as a part of aging, psychosocial and environment factor, income and food

accessibility as well. In our study, we mainly focus on the three factors which are mobility

factors, psychological problems, and taking more than 3 prescription drugs per day in order to

compare their association with the nutritional status in the elderly population residing in care

facilities in Klang Valley, Malaysia.

Besides that, we also do literature review on the three factors that we chose to study in

our community project. In the aspect of mobility factors, Wendy J. Dahl (2013) mentioned

that the problems with chewing and swallowing may lead to lower food intake in the elderly

population as well as the problems of the elderly population to prepare themselves with
nutritious meals. Hence, Singh et al. (2014) also stated that the consequences of

undernourishment and decreased mobility in elderly are debilitating and increases cost of care

as there are 21.7% of those elderly who are at risk of protein energy malnutrition. There is a

significant correlation (P<0.05) between hand grip strength and ferritin & between self-

reported mobility tiredness and BMI.

Meanwhile, in the aspect of psychological problems in elderly, anxiety and depression

are the most frequent mental health disorders in the elderly population. Therefore, nutritional

screening of elderly people with mental health symptoms is needed and mental health

symptoms should be included in the assessment of elderly people who are at risk of

malnutrition (Kvamme et al., 2011). In addition, depression is also associated with low BMI

& under nutrition as the study done by Visvanathan et al. (2006) stated that there are 95% of

elderly with no family member around them generally have a negative responses to statement

3 & 5 of the National Health Checklist and in the same time also having a low BMI. The two

statements are Statement 3 which indicates that the elderly themselves are eating few fruits or

vegetables or milk products while Statement 5 indicates that the elderly themselves are

having tooth or mouth problems that make it hard for them to eat.

Last but not least, in the aspect of taking more than 3 prescription drugs per day,

according to Harugeri et al. (2011) that a drug combination may sometimes cause synergistic

toxicity which is greater than the sum of the risks of toxicity of either agent used alone.

Moreover, many drugs like lipid lowering drugs, antihistamines, antibiotics, anti-

inflammatories can change both the taste and smell of the particular elderly people who took

the drug and thus causes an elderly person who takes an average of 3 medications needs 11

times as much salt and almost 3 times as much sugar in order to have the appetite as a normal

person (M Hickson, 2006).

 Materials and Methods

Description of study design:

Cross-sectional descriptive study was used in which the data obtained from a

population, or a representative subset, at one time point or over a short period in the several

care facilities around Klang Valley in Malaysia was analysed. The several care facilities

around Klang Valley are in the following:

1) My Fathers Home in Damansara Perdana

2) Pusat Jagaan Rumah Love and Care in Kajang

3) Rumah Kasih in Taman Setapak

4) On On in Ayer Lombong, Setapak

5) House of Joy (Joy Garden) in Semenyih

6) Eldercare Nursing Home, third mile Old Klang Road

Meanwhile, this cross-sectional descriptive study carried out from 22nd August to

30th September 2016 by using structured questionnaire, student face-to-face interview, simple

physical examination, anthropometric measurement, blood pressure measurement and also

observational survey on the care facilities environment as well. The reason why this cross-

sectional study was chosen is due to that it is more cost-effective, direct, less time-consuming

and convenient than other study design like cohort study. This is due to the interview or

examination needed only once and it can be quickly done. In addition, the association

obtained from the study can use to produce hypothesis. Moreover, prevalence rate also can be

obtained and used to plan health needs or to know about the disease burden. In the same time,

it also normally does not need a high expenditure to do it.

Description of method:

Participant & setting

Participants were chosen based on the inclusion criteria in which the candidates

eligible for this study are the elderly people who aged 60 years and above with informed

consent. The setting were the care facilities in Klang Valley in Malaysia listed in the

following:

1) My Fathers Home in Damansara Perdana

2) Pusat Jagaan Rumah Love and Care in Kajang

3) Rumah Kasih in Taman Setapak

4) On On in Ayer Lombong, Setapak

5) House of Joy (Joy Garden) in Semenyih

6) Eldercare Nursing Home, third mile Old Klang Road

Meanwhile, there were also several exclusion criteria like:

Elderly people aged less than 60 years

Elderly without consent form

Elderly who are mentally unstable

Elderly having severe neuropsychological problems

Elderly who are terminally ill

Sample size & sampling

The sample size was chosen based on the prevalence rate of malnutrition among elderly

people which is 21% of total elderly population in Malaysia. The formula used to calculate

the sample size for this study is listed below:

n= [t p (1-p)] m

Description:

n= required sample size

t= confidence level at 95% (standard value of 1.96)

p= estimated prevalence in the project area

m= main of error at 5% (standard value of 0.05)

Calculation:

n= [1.96 0.21(0.79)] 0.05

n= 254.9

n= 255

Apart from that, the sampling method used in this study was cluster sampling in which six

old folks homes were selected randomly in Klang Valley in Malaysia. There were a total of

156 old folks being selected randomly as participants in this study but only 141 data were

obtained for the analysis of result due to some missing data.

Description of variables

The independent variables in this study were mobility factors, psychological problems

and taking more than 3 prescription drugs per day. Meanwhile, the dependent variable was

the nutritional status of the elderly which indicated by the MNA malnutrition indicator score.

In the same time, there were several confounding factors that can affect the accuracy of our

data like the presence of oedema and ascites can affect the weight measurements of the

particular participants. Furthermore, vertebral compression, loss of muscle tone and postural

changes also can affect the height measurements of the participants as well (Dylan Harris et

al., 2004).

In the mobility factors, there were three main aspects that were used to determine the

association between the mobility factors and the nutritional status of the elderly. The three

main aspect were difficulty in walking, mobility and mode of feeding. Other than that, in

terms of psychological problems, both the presence of recent stress or acute illness and

presence of neuropsychological problems were used to determine its association with the

nutritional status in the elderly. Apart from that, taking more than three prescription drugs per

day was also linked to the nutritional status in the elderly in order to find out its association.

There were several biases like measurement bias, selection bias and report bias. In the

measurement bias, there were recall bias in which the participants might not be able to recall

the number of drugs taken during the last few days and also observer bias in which there was

a difference in the opinions and judgement regarding certain thing. Hence, in order to avoid

these two measurement bias, we confirmed the number of drugs taken with the caretaker of

those elderly in order to ensure there was no any bias which can affect the accuracy of our

data. In the same time, we also followed the same guidelines in the taking of measurements
as discussed later in the following page in order to overcome the difference in personal

judgement and opinion regarding the data collected.

Meanwhile, the selection bias like those elderly who are not able to respond to the

question being asked and those elderly who were staying in the hospitals. Thus, we set the

inclusion and exclusion criteria for the eligible participants to take part in this study as well as

to prevent the inaccuracy of data. Moreover, we also made sure that there was no any report

bias due to the selective revealing of suppression of information by the participants through

reconfirming of the data obtained by asking in a different way like rephrasing the question

being asked.

Study tools & methods of measurement

The assessment of the nutritional status of the elderly was carried out by using the

Mini Nutritional Assessment (MNA) in a face-to-face interview with the elderly. The sample

of the MNA is in the section 6 of the questionnaire in Appendix 2 in the following page of

this report. After the interview was done, the MNA malnutrition indicator score was

calculated for each elderly to find out their respective nutritional status.

Anthropometry measurements were done to obtain the elderlys height, weight and

other measurements. The body mass index (BMI) of the elderly was then calculated based on

the following formula:

Body Mass Index (BMI) = weight (kg) / height (m2)

The Asian criteria was used to categorize the elderly into different nutritional status group

with regard to their respective BMI (Luisito et al., 2011). However, due to the smaller sample

size of our study, we regrouped the elderly into four group only which were shown in the

following table:

Nutritional Status BMI cut-off

Underweight <18.5

Normal 18.5 22.9

Overweight 23 24.9

Obese 25

The SECA digital weighing scale was used to measure the weight and height of the

elderly by following the World Health Organization (WHO) guidelines. Meanwhile, the
measuring tape was used to measure the elderlys mid-arm circumference and calf

circumference by following the Centre of Disease Control (CDC) guidelines.

There were several general guidelines for all the measuring and recording like before

taking the anthropometric measurements, the participants were informed politely about the

procedure as professionalism was maintained at all times. Prior to initiate the measurement,

the participants were asked to remove any belongings from his or her pockets in order to

ensure the accuracy of the data. All measurements were taken from the side of the

participants body which there were free from any physical abnormality or lesser injury

compared to the other side.

The position of the eye was perpendicular to the scale of the measuring tape in order

to avoid parallax error and all the measurements were repeated three times in order to get the

average value for more accurate data. The rest of the guidelines followed by our study can be

referred in the Appendix 5.

Description of statistical analysis

SPSS version 23 was used to analyze the data in which the statistical significance

level of p<0.05 was set. The data obtained were also tabulated into tables and graphs. There

were mainly two types of analysis being carried out which were descriptive analysis and

inferential analysis. Chi-square test and Fishers exact test were used to determine the

association between the independent variables with the dependent variable.

 Results

Results & Data Analysis

Descriptive statistical analysis

Table 4.1: Descriptive analysis for number of participants.

Homes Number of Elderly Number of Interviewed Number of Participants
in the Homes Participants After Exclusion Criteria

My Fathers Home 98 87 82

Rumah Kebajikan 15 11 11
Love and Care
On On 23 13 10

Rumah Kasih 10 7 5

Eldercare Nursing 23 23 23
Home
House of Joy 13 15 13

Total 182 156 144

The response rate of the elderly was calculated as shown in the following:

Response Rate = 156 / 182 = 0.857 = 85.7%

Table 4.2: Descriptive analysis for age, gender, weight, height, body mass index (BMI), mid-
arm circumference and calf circumference. (N=144)
Variable Valid, n (%) Mean sd

Gender 47 (32.6)
Male 93 (64.6)
Female

Age (years) 47 (100.0) 76.92 9.139

Male 92 (98.9) 74.55 9.247
Female 78.10 8.992

Weight (kg) 44 (93.6) 53.38 14.413

Male 86 (92.5) 60.45 10.376
Female 49.76 14.889

Height (cm) 44 (93.6) 153.58 9.645

Male 87 (93.5) 162.17 5.872
Female 149.24 8.162

BMI (kg/m2) 22.41 5.069

Underweight (<18.5) 23 (16.0) 15.65 2.222
Normal (18.5-22.9) 52 (36.1) 20.74 1.330
Overweight (23-24.9) 23 (16.0) 24.03 0.568
Obese (>25) 31 (21.5) 29.03 3.947

Mid-arm cir. 19 (13.2) 25.09 4.434

<21cm 10 (6.9) 18.44 2.763
21-22cm 101 (70.1) 21.50 0.432
22cm 26.69 3.421

Calf cir. 68 (47.2) 31.08 4.467

<31cm 62 (43.1) 27.66 2.529
31cm 34.82 2.804

N = Sample size, n = number of participants, sd =standard deviation, cir. = circumference

Table 4.3: Descriptive analysis for Mini Nutritional Assessment (MNA). (N=144)

Variable Valid, n (%) Mean sd

MNA score 53 (36.8) 21.87 5.038

Normal (24-30) 47 (32.6) 26.04 3.392
At risk (17-23.5) 22 (15.3) 20.68 1.909
Malnourished (<17) 14.39 2.017

N = Sample size, n = number of participants, sd =standard deviation.

Inferential statistical analysis
Table 4.4: Association between Difficulty in Walking and Nutritional Status

Difficulty Nutritional Status 2 df p value

in
walking
Normal At risk of Malnourished
malnutrition
n (%) n (%)
n (%)

Yes 22 (36.1) 22 (36.1) 17 (27.9) 8.265* 2 0.016

No 31 (50.8) 25 (41.0) 5 (8.2)

*Chi-Square test was performed, Level of significance at p<0.05, df = degree of freedom

H0: There is no association between difficulty in walking and nutritional status of the elderly

people.

H1: There is association between difficulty in walking and nutritional status of the elderly

people.

Interpretation: The percentage of elderly people with normal nutritional status who has

difficulty in walking (36.1%) is lower than those without difficulty in walking (50.8%). The

percentage of elderly people who are at risk of malnutrition who has difficulty in walking

(36.1%) is slightly lower than those without difficulty in walking (41.0%). The percentage of

malnourished elderly people among those with difficulty in walking (27.9%) is higher than

those without difficulty in walking (8.2%). The difference in percentage is statistically

significant. Therefore, the null hypothesis (H0) is rejected. There is an association between

difficulty in walking and nutritional status of the elderly people.

Table 4.5: Association between Mobility and Nutritional Status

Mobility Nutritional Status 2 df p value

Normal At risk of malnutrition Malnourished

n (%) n (%) n (%)

Bed or 3 (17.6) 5 (29.4) 9 (52.9) 41.279* 4 <0.001

chair
bound

Able to 5 (16.1) 15 (48.4) 11 (35.5)

get out of
bed/chair
but does
not go out

Goes out 45 27 (36.5) 2 (2.7)

(60.8)

*Fishers Exact test was performed, Level of significance at p<0.05, df = degree of freedom

H0: There is no association between mobility and nutritional status of the elderly people.

H1: There is association between mobility and nutritional status of the elderly people.

Interpretation: The percentage of elderly people with normal nutritional status increases as

mobility increases, where Bed/chair bound (17.6%), Able to get out of bed/chair but does not

go out (16.1%), and Goes out (60.8%). The percentage of elderly people who are at risk of

malnutrition is the highest when he/she is able to get out of bed/chair but does not go out

(48.4%) compared to those who are Bed/chair bound (29.4%) and Goes out (36.5%). The

percentage of malnourished elderly people decreases as mobility increases, where Bed or

chair bound (52.9%), Able to get out of bed/chair but does not go out (35.5%), and Goes out

(2.7%). The difference in percentage is statistically significant. Therefore, the null hypothesis

(H0) is rejected. There is an association between mobility and nutritional status of the elderly

people.
Table 4.6: Association between Feeding Without Assistance and Nutritional Status

Feeding Nutritional Status 2 df p value

without
assistance
Normal At risk of Malnourished
malnutrition
n (%) n (%)
n (%)

Yes 37 (36.6) 47 (46.5) 17 (16.8) 6.495* 2 0.025

No 1 (11.1) 3 (33.3) 5 (55.6)

*Fishers Exact test was performed, Level of significance at p<0.05, df = degree of freedom

H0: There is no association between feeding without assistance and nutritional status of the

elderly people.

H1: There is association between feeding without assistance and nutritional status of the

elderly people.

Interpretation: The percentage of elderly people with normal nutritional status who can feed

without assistance (36.6%) is higher than those who cannot feed without assistance (11.1%).

The percentage of elderly people who are at risk of malnutrition who can feed without

assistance (46.5%) is higher than those who cannot feed without assistance (33.3%). The

percentage of malnourished elderly people who can feed without assistance (16.8%) is lower

than those who cannot feed without assistance (55.6%). The difference in percentage is

statistically significant. Therefore, the null hypothesis (H0) is rejected. There is an association

between feeding without assistance and nutritional status of the elderly people.
Table 4.7: Association between Mode of Feeding and Nutritional Status

Mode of Nutritional Status 2 df p value

feeding
Normal At risk of Malnourished
malnutrition
n (%) n (%)
n (%)

Unable to 1 (12.5) 1 (12.5) 6 (75.0) 18.853* 4 <0.001

eat without
assistance

Feeds self 2 (22.2) 3 (33.3) 4 (44.4)

with some
difficulty

Feeds self 50 (47.6) 43 (41.0) 12 (11.4)

without
any
problems

*Fishers Exact test was performed, Level of significance at p<0.05, df = degree of freedom

H0: There is no association between mode of feeding and nutritional status of the elderly

people.

H1: There is association between mode of feeding and nutritional status of the elderly people.

Interpretation: The percentage of elderly people with normal nutritional status increases as

mode of feeding becomes more independent, where Unable to eat without assistance (12.5%),

Feeds self with some difficulty (22.2%), and Feeds self without any problems (47.6%). The

percentage of elderly people who are at risk of malnutrition is the highest when he/she Feeds

self without any problems (41.0%) compared to Unable to eat without assistance (12.5%) and

Feeds self with some difficulty (33.3%). The percentage of malnourished elderly people

decreases as mode of feeding becomes more independent, where Unable to eat without

assistance (75.0%), Feeds self with some difficulty (44.4%), and Feeds self without any

problems (11.4%). The difference in percentage is statistically significant. Therefore, the null
hypothesis (H0) is rejected. There is an association between mode of feeding and nutritional

status of the elderly people.

Table 4.8: Association between recent stress or acute illness and nutritional status.

Recent Nutritional Status 2 df p value

stress or
acute Normal At risk of Malnourished
illness malnutrition
n (%) n (%)
n (%)

Yes 1 (4.8) 13 (61.9) 7 (33.3) 15.629* 2 <0.001

No 52 (51.5) 34 (33.7) 15 (14.9)

*Chi Square Test was performed, level of significant at p<0.05, df = degree of freedom.

H0: There is no association between recent stress or acute illness and nutritional status of the

elderly people.

H1: There is association between recent stress or acute illness and nutritional status of the

elderly people.

Interpretation: The percentage of elderly people with normal nutritional status who have

recent stress or acute illness (4.8%) is lower than those without recent stress or acute illness

(51.5%). The percentage of elderly people who are at risk of malnutrition who have recent

stress or acute illness (61.9%) is higher than those without recent stress or acute illness

(33.7%). The percentage of malnourished elderly people among those with recent stress or

acute illness (33.3%) is higher than those without recent stress or acute illness (14.9%).

Therefore, the null hypothesis (H0) is rejected. There is statistically significant association

between recent stress or acute illness and nutritional status of the elderly people.
Table 4.9: Association between neuropsychological problems and nutritional status.

Neuropsychological Nutritional Status 2 df p value

problems
Normal At risk of Malnourished
malnutrition
n (%) n (%)
n (%)

Severe dementia/ 1 (8.3) 9 (75.0) 2 (16.7) 12.630* 4 0.013

depression

Mild dementia 10 (32.3) 13 (41.9) 8 (25.8)

No psychological/ 42 (53.2) 25 (31.6) 12 (15.2)

cognitive problems

*Chi Square Test was performed, level of significant at p<0.05, df = degree of freedom.

H0: There is no association between neuropsychological problems and nutritional status of

the elderly people.

H1: There is association between neuropsychological problems and nutritional status of the

elderly people.

Interpretation: The percentage of elderly people with normal nutritional status who have

neuropsychological problems of either severe dementia (8.3%) or mild dementia (32.3%) is

lower than those without neuropsychological problems (53.2%). The percentage of elderly

people who are at risk of malnutrition who have neuropsychological problems of either

severe dementia (75.0%) or mild dementia (41.9%) is higher than those without

neuropsychological problems (31.6%). The percentage of malnourished elderly people

among those with neuropsychological problems of either severe dementia (16.7%) or mild

dementia (25.8%) is higher than those without neuropsychological problems (15.2%).

Therefore, the null hypothesis (H0) is rejected. There is statistically significant association

between neuropsychological problems and nutritional status of the elderly people.

Table 4.10: Association between taking more than 3 prescription drugs per day and
nutritional status.

>3 drugs Nutritional Status 2 df p value

/day
Normal At risk of Malnourished
malnutrition
n (%) n (%)
n (%)

Yes 24 (42.9) 23 (41.1) 9 (16.1) 0.403* 2 0.817

No 29 (43.9) 24 (36.4) 13 (19.7)

*Chi Square Test was performed, level of significant at p<0.05, df = degree of freedom.

H0: There is no association between taking more than 3 prescription drugs per day and

nutritional status of the elderly people.

H1: There is association between taking more than 3 prescription drugs per day and

nutritional status of the elderly people.

Interpretation: The percentage of elderly people with normal nutritional status who take

more than 3 prescription drugs per day (42.9%) is slightly lower than those who do not take

more than 3 prescription drugs per day (43.9%). The percentage of elderly people at risk of

malnutrition who take more than 3 prescription drugs per day (41.1%) is higher than those

who take more than 3 prescription drugs per day (36.4%). The percentage of malnourished

elderly people who take more than 3 prescription drugs per day (16.1%) is lower than those

who do not take more than 3 prescription drugs per day (19.7%). However, the difference in

percentage is not statistically significant. Therefore, the null hypothesis (H0) is failed to be

rejected. There is no association between taking more than 3 prescription drugs per day and

nutritional status of the elderly people.

 Discussion

In the aspect of mobility factors, our results showed a significant difference in the

nutritional status among elderly who have difficulty in walking and in those without the

difficulty in walking. Moreover, elderly people with mobility issues such as bed or chair

bound had more significant impact on their nutritional status in overall. Hence, chair-bound

or bed-bound can significantly increase the risk of malnutrition in the elderly people (NC

Shum et al., 2005).

In addition, elderly people who can feed themselves without assistance had a

significantly better nutritional status compared to the elderly people who are unable to feed

themselves. Besides that, different modes of feeding among the elderly have also caused a

significantly different in the nutritional status of the elderly people. This was coincided with

Maria RM Oliveira et al. (2009) which mentioned that eating partial or complete dependence

was found in more than half of the malnourished elderly. This can affect the amount of food

taken in by the elderly which in turns leading to poor nutrition in the elderly people.

Apart from that, our study also indicated that there was a statistically significant

association between psychological problems and nutritional status of the elderly. This was

due to psychological problems like recent stress or acute illness, mild dementia and severe

dementia can have a directly and significantly effect on the nutritional status of the elderly

people.

Moreover, depression is one of the most grave and commonplace contributions to

nutritional risks (Yap et al., 2007). Meanwhile, different grades of depression either mild or

severe have an effect on nutritional status (Yap et al., 2007). Ahmed et al. (2014) also stated

that the elderly who live in care facilities were more prone to stress due to lack of family

support. This was due to the body and mental status have a powerful relationship in which a
decrease in neurotransmitter can decrease the elderlys mental flexibility and cause functional

limitation, anorexia and weight loss and malnutrition (Nihon Ronen et al., 2000).

In the aspect of taking more than 3 prescription drugs per day, our results did not

show any significant association of its effect on the nutritional status of the elderly. However,

some studies show that the number of medications used by elderly was associated with poorer

nutritional status (Ortolani, 2013). The role of polypharmacy on nutritional status among

elderly people is unclear while some diseases do promote malnutrition (Jyrkk et al., 2012).

Furthermore, some paper also suggested that a longitudinal study with adjustments for

underlying diseases can be used to explore the association between drugs and nutritional

status. Caroline Boscatto et al. (2013) stated that the use of 3 or more medications was

negatively associated with underweight. Meanwhile, Peel, Runganga and Hubbard (2014)

also mentioned that drugs alone may not directly affect nutritional status but polypharmacy

was significantly associated with frailty & poor functional outcomes.

In the same time, there are some limitations in our study like the number of

participants was lesser than the required sample size due to some of the participants are

excluded with regard to the exclusion criteria. There is also presence of recall bias in the

elderly people which leads to the inaccuracy in our data. Inaccuracy of data might also have

occurred due to lack of understanding and unable to recall their memory. In addition, the lack

of validation of self-reports from the elderly people interviewed.

Thus, in order to overcome and minimize the limitations effect on the accuracy of

our data, we tried to double check with the caretaker of the elderly people. Moreover, we also

made sure that there was no any report bias due to the selective revealing of suppression of

information by the participants through reconfirming of the data obtained by asking in a

different way like rephrasing the question being asked.

 Moreover, we also recommend that a larger sample size will be used in the future

study so that it can more reliably reflect the population mean and provide a more significant

outcome. Besides that, data should be validated with medical records or medical attendants in

order to further limit the inaccuracies due to recall bias. Meanwhile, the interpretation should

be done by caretakers instead of the self-report by the participants in order to increase the

accuracy of given information.

Apart from that, our results suggest that the at risk population should be given more

merit in terms of health care and education in order to prevent them from becoming

malnourished. Furthermore, the caretakers in care facilities should be more aware of the

elderly food intake, especially those with mobility and/or psychological problems so that the

nutritional status of the elderly people can be maintained at a good and healthy level

throughout all the times.

 Conclusion

In conclusion, this study showed that there are about 37% of the elderly people who

residing in care facilities in Klang Valley, Malaysia have a normal nutritional status while

there are 33% of them who at risk of malnutrition and 15% of them who are malnutrition.

In the aspect of mobility factors with the nutritional status of the elderly, this study

showed that there is a statistically significant association between the mobility factors and the

nutritional status in elderly.

Meanwhile, there is also a statistically significant association between the

psychological problems and the nutritional status in elderly as dementia and depression can

affect the nutritional status of the elderly in a significant way mentioned earlier.

Nevertheless, taking more than three prescription drugs per day does not show any

significant association with the nutritional status in the elderly people. This can be explained

that drugs alone may not affect the nutritional status as other factors may be necessary for it

to cause an effect on the nutritional status of the elderly people.

 Acknowledgement

This project was successfully conducted on a few care facilities around Klang Valley

in Malaysia with the full commitment, hard work, collaboration and participation of thirty

nine Year 2 M.B.B.S students and lecturers from Universiti Tunku Abdul Rahman. In

addition, I want to give my sincere appreciation to my research supervisor Dr. Theingi

Maung Maung for her valuable advice and guidance throughout this project.

Moreover, I would also like to express my gratitude to Dr Leong Pooi Pooi and Ms.

Woo Li Fong who have given a continuous guidance and support to me throughout the

research.

Furthermore, I would love to acknowledge Dr. Razzaq, Dr. Gary, Dr. Myo, Prof Dr.

Choo and Dr. Thaw for teaching me the Managing Research Project and Statistical Analysis

subject which has played a big role in this project.

A whole-hearted appreciation to the staff who provided me the equipment needed to

conduct this research successfully. Apart from that, I would like to thank all the elderly

involved in this project for allowing us to interview them.

Last but not least, we would love to appreciate all our lecturers in charge of this

project and our fellow teammates and friends who made this community project a success.
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 Appendices

Appendix 1

Consent Form
 Appendix 2

Preliminary Screening Questionnaire

 Appendix 3

Community Project Pre-visit Schedule

 Appendix 4

Community Project On-site Supervision Schedule

 Appendix 5

General Guidelines for Measuring and Recording