DOI: 10.1111/ajag.12410

Research
Malnutrition risk of older people across district health board
community, hospital and residential care settings in New
Zealand
Carol Wham, Emily Fraser, Julia Buhs-Catterall, Rebecca Watkin
and Cheryl Gammon
School of Food and Nutrition, Massey University, Auckland, New
Zealand

Jacqui Allen
Department of Surgery, University of Auckland, Auckland, New
Zealand

Objective: To determine the prevalence of malnutrition
risk in older people across three settings.
Methods: Older people living in the community or newly
admitted to hospital or residential care were assessed for
malnutrition risk using the validated Mini-Nutritional
Assessment – Short Form and dysphagia risk using the
Eating Assessment Tool-10. Demographic, physical and
health data were collected.
Results: Of 167 participants, 23% were malnourished and
35% were at high risk of malnutrition. Those recently
admitted to residential care versus a hospital or living in
the community had a higher prevalence of malnourishment
(47% vs 23% and 2%) (P < 0.001). Risk of dysphagia
differed with settings (P < 0.001) with highest risk in
residential care. Hospitalised and residential care
participants were significantly more likely to have ≥4
comorbidities, take ≥5 medications and have below normal
cognition compared to community participants.
Conclusion: Choice of nutrition intervention is setting
dependent.

population [1] and have a life expectancy slightly higher
than for M 
aori but lower than the NZ average.
Older people are known to be at disproportionate risk of
malnutrition, with health conditions both contributing to
having an inadequate food and nutrition intake and occurring as a consequence of an inadequate intake [3]. The NZ
government’s ‘Ageing in Place’ policy highlights the need to
understand the factors that could lead to malnutrition among
older people. Maintaining good nutritional status is important for remaining independent; yet far too often key aspects
of food provision for older people are disregarded or taken
for granted especially among those with health disparities.
In NZ, the prevalence of risk of malnutrition among community-living older people has been reported in the range
of 31–49% [4,5], but the prevalence among older people
who have been recently admitted to hospital Assessment,
Treatment and Rehabilitation (AT&R) wards or residential
care is largely unknown. In Australia, reports of malnutrition risk on admission to rehabilitation wards are variable:
49% of inpatients in New South Wales [6]; 33% of inpatients in Queensland (QLD) [7]; and 35–43% in people
over 65 years in South Australia [8]. Rates are higher for
new admissions to residential care facilities; 50% or more
reported for malnutrition risk in QLD residents [7]
consistent with the high rates reported from other overseas
studies [9].

New Zealand’s (NZ’s) population is ageing, and by 2051,
it is predicted there will be a greater proportion of people
aged over 65 years, than under 15 years [1]. M 
aori, the
indigenous people of NZ, are a much younger population
than the overall population. The M aori ethnic group makes
up 5.6% of the 65+ population [1], and there is a disparity
in longevity of 7–8 years for M aori, which relates to the
history of settlement in Aotearoa (NZ) [2]. However,
demographic projections suggest that the M aori population
is ageing faster than non-M aori, expanding the population
of older M aori. Pacific peoples makes up 2.4% of the 65+

Elimination of particular foods or food groups from the
diet due to chewing and swallowing difficulties aggravates
the risk of malnutrition [10]. Furthermore, malnutrition in
turn can contribute to dysphagia via deglutitive muscles
undergoing atrophy from reduced food intake. This can
compromise the integrity of the swallow and initiate a
vicious cycle further decreasing food intake and exacerbating poor swallow function. Although deglutitive disorders
may result in life-threatening problems such as aspiration,
pneumonia, weight loss and death, older people may
under-report swallowing problems and not seek assistance.
Among older people over 65 years from an independentliving facility in the United States, 15% reported difficulties
with swallowing; however, 23.4% believed this to be a
normal part of ageing, although 37.4% did not [11].

Correspondence to: Associate Professor Carol Wham, School of Food
and Nutrition, Massey University. Email: c.a.wham@massey.ac.nz

Risk of malnutrition is a burden on older people and
health-care facilities. In community-living older New
Zealanders high malnutrition risk has been shown to

Key words: aged, dysphagia, New Zealand, nutrition.

Introduction

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impact health-related quality of life [5] and be associated
with negative outcomes for older people, including higher
infection rates, loss of muscle mass, strength and function
[12], longer length of hospital stay [13] as well as increased
morbidity and mortality [14].
The treatment of malnutrition first requires a malnourished
or at risk patient to be identified via either screening or
assessment. Screening for nutrition risk, using a validated
tool such as the Mini-Nutritional Assessment – Short Form
(MNAâ-SF), provides a simple and rapid method to identify those at risk of becoming malnourished [3].
In NZ, nutrition screening in the community or upon
admission to hospital or residential care is not mandatory.
The 2015 Australian and New Zealand Society for Geriatric Medicine revised position statement on undernutrition and the older person [15] does, however, s
uggest that screening needs to occur in all settings. In
addition, it is recommended that all screening processes
should lead into a care plan. Malnutrition and nutrition
risk is therefore likely to be under-reported and poorly
documented in NZ.
In the United Kingdom, the 2006 National Institute for
Health and Clinical Excellence quality standard (QS24)
[16] on nutrition support in adults proposes people in
care settings are screened for the risk of malnutrition
using a validated screening tool. The guidelines suggest
screening should take place on initial registration at general practice surgeries, in all hospital inpatients and care
homes on admission or when there is clinical concern in
any setting.
Similarly, guideline recommendations for nutrition screening and assessment are provided by the American Society
for Parenteral and Enteral Nutrition [17] and in the United
States, the Joint Commission on Accreditation of Healthcare Organizations mandates nutrition screening within
24 hours of admission to an acute care centre [18].
In order to gain a greater understanding of malnutrition
risk in this country, the aim of this study was to establish
the prevalence of nutrition and dysphagia risk in three
accommodation settings and to identify factors associated
with high nutrition risk. Identification of risk and factors
associated with risk may enhance awareness and provide
useful insights for the importance of screening.

Methods
A descriptive multi setting cross-sectional study was undertaken within the Waitemata District Health Board (DHB)
of Auckland. Waitemata is made up of a defined geographical region (North Shore City, Waitakere City and the Rodney district of Auckland) and provides services to the
largest DHB population in NZ. The Northern A Health
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and Disability Ethics Committee of New Zealand granted
ethical approval for the study in June 2014 (NTX/ 14/
NTA/70).
Eligibility and recruitment
Those aged ≥65 years (European ethnicity) or ≥55 years
(M 
aori and Pacific), who were able to understand and give
consent for the study, undertake a questionnaire and
anthropometric measures were eligible. Younger M aori
and Pacific participants were recruited as they have a lower
life expectancy than the NZ European. Exclusion criteria
included participants with any known dysphagia risk.
Community participants
Participants were recruited from the Primary Health
Organisation (PHO) Comprehensive Care. As one of two
PHOs funded by Waitemata DHB, Comprehensive Care
supports 50 general practices across urban and rural settings. Eligible patients (368) enrolled in general practices
that agreed to participate in the study were sent a letter of
invitation on two separate occasions. The invitation letter
contained an opt-out option and 10 days were allowed for
the participant to respond. Those who did not respond
were contacted by telephone. For participants who verbally
agreed to take part in the study, a one-off interview was
organised in their home at a time of convenience.
Hospital participants
Within five days of admission to the AT&R wards at
North Shore and Waitakere hospitals, eligible patients were
consecutively invited to participate in the study between
April and July 2014.
Residential care participants
To recruit eligible participants newly admitted to residential care, an information flyer was sent out to 59 agerelated residential care (ARRC) facilities in the Waitemata
DHB region. The facilities were contacted on a weekly
basis to ascertain new admissions. In addition, eligible participants who were soon to be admitted to an ARRC facility were identified by the Needs Assessment Service
Coordination team.
A thorough explanation of the study was provided to all
participants and their family members if applicable. Written informed consent was obtained before interviews were
conducted in all settings.
Measures
Study measures were obtained from a structured face-toface standardised questionnaire. Socio-demographic characteristics including age, sex, ethnicity, marital status and
education were recorded. Education was ascertained by
any primary, secondary and tertiary education attendance.
Physical assessments included measures of height, weight
and calf circumference. Weight was recorded using
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portable calibrated Wedderburn scales using standardised
procedures or from weights recorded in the participants’
clinical notes upon admission to the AT&R ward or
ARRC facility. Height was calculated from demi-span measured to the nearest 0.5 cm where height was not recorded
[19]. Calf circumference was measured in accordance with
the (MNAâ-SF) user guide [20].
Prescribed medications were recorded from the participants’
clinical notes. Participant dentition was recorded as dentate
(having one or more natural teeth) edentulous (no natural
teeth) or with use of a dental appliance (removable dental
prosthesis that substitutes for missing natural teeth) [21].
Psychological health
Cognition was assessed using the Montreal Cognitive
Assessment (MoCA) [22]. The MoCA assesses a variety of
cognitive domains including attention and concentration,
executive functions, memory, language, visuoconstructional
skills, conceptual thinking, calculations and orientation
[22]. The total score is 30 with scores > 26 indicative of
normal cognitive function.
Dysphagia risk
The validated Eating Assessment Tool (EAT-10) questionnaire was used to assess risk of dysphagia [23]. Points
are assigned for each of 10 items and are accumulative.
EAT-10 scores ≥3 are indicative of problems with swallowing.
Nutrition risk
The validated MNAâ-SF was used to assess nutrition risk
[24]. The MNAâ-SF comprises questionnaire items which
include food intake over the past three months, weight loss
over the past three months, weight loss, mobility, psychological stress or acute disease, neuropsychological problems
and body mass index (BMI). Calf circumference was used
in place of BMI if weight or height were not available. The
maximum score is 14 points. Scores of 12–14 indicate normal nutrition status; 8–11 points risk of malnutrition and
0–7 points malnourished.
Statistical analysis
All study data were entered into Microsoft Excel spreadsheets, with subjects only identified by their unique study
number. Statistical analyses were performed using SPSS
Version 23. Descriptive analyses were completed for sociodemographic, physical measures and nutrition risk.
Variables were tested for normality using the Kolmogorov–
Smirnov, Shapiro–Wilk tests and normality plots. Normally
distributed data are summarised as the mean (standard
deviation, SD), non-normally distributed data as median
(25th, 75th percentiles) and categorical data as frequencies.
Between-groups comparisons were made using one-way
ANOVA for normally distributed data, Kruskal–Wallis test
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for non-normally distributed data or Pearson’s chi-square
(v2) test for categorical data. Where significant effects were
found, post hoc tests (Tukey one-way ANOVA, Mann–
Whitney Kruskal–Wallis, and comparing cells by row,
using ɀ tests and a Bonferroni correction v2) were used to
identify where significant differences were. Differences were
considered significant at P < 0.05.

Results
There were 167 participants in the study (70 men) with the
mean age of 80 years (range 65–103). Community-living
participants tended to be younger (mean age 73 years) compared to those recently admitted to hospital (82 years) or
residential care (87 years) (P < 0.001). Most (120) of the
participants were NZ European, 10 identified as NZ M 
aori,
eight as Pacifica and 29 as of ‘other’ ethnicity. Nearly half
(44%) of the participants were married or partnered and
42% were widowed. There was a significant relationship
between education level and residential setting (P < 0.001),
with 49% of the participants recently admitted to hospital
receiving only a primary education compared to 14% of participants living in the community and 21% admitted to residential care. Participants living in the community had a
significantly higher BMI (P < 0.001) and were more likely to
have a BMI ≥ 25 (64%) than those recently admitted to hospital (44%) or residential care (15%).
There was a significant relationship between nutrition risk
status and residential setting (P < 0.001), with 5.3% of
community-living participants at nutrition risk (MNAâ-SF
scores 8–11) compared to participants newly admitted to
hospital (57.9%) or residential care (43.4%). Similarly
1.8% of community-living participants were malnourished
(MNAâ-SF scores 0–7) compared to those newly admitted
to hospital (22.8%) or residential care (47.2%) (Table 1).
Table 2 shows risk of dysphagia (EAT-10 score ≥3) was
significantly higher among participants recently admitted to
residential care (32.1%) compared to living in the community (3.5%). Participants recently admitted to residential
care or hospital were also significantly more likely to have
≥4 comorbidities and lower cognitive function scores than
those in a community setting. Participants recently admitted to hospital were significantly more likely to be taking
five or more medications, [median 25th, 75th percentiles]
10 (7, 13.5) than those admitted to residential care, 7 (7–
10) medicines or living in the community 3 (1–5) medicines
P < 0.001.
The MNAâ-SF nutrition risk factor items for participants
in community, hospital and residential care settings are
shown in Table 3. A significant relationship was found
between experiencing psychological distress or acute disease and residential setting (P < 0.001), with hospitalised
participants (78.9%) having a higher prevalence than residential care (56.6%) or community participants (10.5%).
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Table 1: Participant characteristics and nutrition risk status across Waitemata DHB community, hospital and residential care settings
Total, n = 167
Age (years)
Range (years)
Men
Women
Ethnicity, n (%)
NZ European
NZ Maori
Pacifica
Other
Marital status, n (%)
Married/partnered
Widowed
Divorced/separated
Never married
Education, n (%)
Primary
Secondary
Tertiary
Weight (kg), n = 164
Range (kg)
BMI (kg/m2), n = 163
Range (kg/m2)
BMI groups, n (%)‡
Underweight (<18.5)
Normal (18.5–24.99)
Overweight/obese (≥25.0)
Nutrition risk status, n (%)§
Normal nutrition status MNAâ SF (12–14)
At risk
MNAâ-SF (8–11)
Malnourished
MNAâ-SF (0–7)

80.4   8.70
65.0–103.0
77 (46.1)
90 (53.9)

Community, n = 57
73   6.36
65.0–93.0
31 (54.4)
26 (45.6)

a,b

Hospital, n = 57
82.07   6.92
66.0–95.0
23 (40.4)
34 (59.6)

a,c

Residential care, n = 53
86.6   6.65
65.0–103.0
23 (43.4)
30 (56.6)

b,c

P-value†
<0.0001
0.288

120
10
8
29

(71.9)
(6.0)
(4.8)
(17.4)

33
8
7
9

(57.9)
(14.0)
(12.3)
(15.8)

43
2
1
11

(75.4)
(3.5)
(1.8)
(19.3)

44 (83.0)
0
0
9 (17.0)

—

73
70
14
10

(43.7)
(41.9)
(8.4)
(6.0)

34
15
6
2

(59.6)
(26.3)
(10.5)
(3.5)

22
25
4
6

(47.4)
(43.9)
(7.0)
(10.5)

17
30
4
2

(32.1)
(56.6)
(7.5)
(3.8)

—

47 (28.1)
79 (47.3)
41 (24.6)
69.2   18.4
31.8–124.8
24.9   5.8
12.8–45.8

8 (14.0)a
33 (57.9)a
16 (28.1)
78.6   18.0a,b
41–124.8
28.0   5.52a,b
19.0–45.8

28 (49.1)a,c
19 (33.3)a
10 (17.5)
69.8   17.2a,c
35.0–104.9
25.2   5.70a,c
16.0–40.0

11 (20.8)b,c
27 (50.9)
15 (28.3)
58.8   14.4b,c
31.8–91.8
21.3   3.93b,c
12.8–30.7

18 (11.1)
77 (47.2)
68 (41.7)

0 (0)
20 (36.4)
35 (63.6)

6 (11.0)
25 (45.4)
24 (43.6)

12 (22.6)
33 (62.3)
8 (15.1)

69 (41.3)
59 (35.3)

53 (93.0)a,b
3 (5.3)a,b

11 (19.3)a
33 (57.9)a

5 (9.4)b
23 (43.4)b

39 (23.4)

1 (1.8)a,b

13 (22.8)a,c

25 (47.2)b,c

0.001
<0.0001
<0.0001

—

<0.0001

Data are presented as mean   SD unless otherwise indicated. †Significant differences between residential settings; one-way ANOVA for continuous variables; Pearson’s chi-square for
categorical variables where valid. ‡Recognised cut-offs for BMI [25]. §Cut-offs from MNAâ-SF [20]. aSignificant difference (P < 0.05) between community and hospital care. bSignificant
difference (P < 0.05) between community and residential care. cSignificant difference (P < 0.05) between hospital and residential care. –, not significant. BMI, body mass index; DHB,
district health board; MNAâ-SF, Mini-Nutritional Assessment – Short Form; NZ, New Zealand.

Table 2: Prevalence of dysphagia, comorbidities, medication use, cognition and dental status by setting
Dysphagia risk‡
Dysphagia risk
No risk (EAT-10 < 3)
At risk (EAT-10 ≥ 3)
Comorbidities
<4 comorbidities
≥4 comorbidities
Medication use
<5 medications
≥5 medications
Cognition (MOCA)§
Normal cognitive function (26–30)
Below normal cognitive function (<26)
Dental status¶
Dentate
Edentulous
Dental appliance

Total, n = 167
n (%)

Community, n = 57
n (%)

Hospital, n = 57
n (%)

Residential care, n = 53
n (%)

P-value†

139 (83.2)
28 (16.8)

55 (96.5)b
2 (3.5)b

48 (84.2)
9 (15.8)

36 (67.9)b
17 (32.1)b

<0.0001

58 (34.7)
109 (65.3)

44 (77.2)a,b
13 (22.8)a,b

7 (12.3)a
50 (87.7)a

7 (13.2)b
46 (86.8)b

<0.0001

55 (32.9)
112 (67.1)

40 (70.2)a,b
17 (29.8)a,b

4 (7.0)a
53 (93.0)a

11 (20.8)b
42 (79.2)b

<0.0001

24 (16.0)
126 (84.0)

17 (32.1)a,b
36 (67.9)a,b

5 (11.4)a
39 (88.6)a

2 (3.8)b
51 (96.2)b

<0.001

62 (37.1%)
5 (3.0%)
100 (59.9)

24 (42.1)
3 (5.3)
30 (52.6)

15 (26.3)
0
42 (73.7)

23 (43.4)
2 (3.8)
28 (52.8)

—

†Significant differences between residential settings; Pearson’s chi-square for categorical variables where valid. ‡Cut-offs from EAT-10 questionnaire [23]. §Cut-offs from MOCA
questionnaire [22]. ¶Dental status definitions [21]. aSignificant difference (P < 0.05) between community and hospital care. bSignificant difference (P < 0.05) between community and
residential care. cSignificant difference (P < 0.05) between hospital and residential care. –, not significant. EAT, Eating Assessment Tool questionnaire; MOCA, Montreal Cognitive
Assessment.

Discussion
Our findings demonstrate that malnutrition is higher among
new admissions to residential care versus hospital AT&R
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wards or among older people living in the community with
nearly half (47%) of residential care participants malnourished and 43% at high nutrition risk. Similarly malnutrition
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Table 3: Mini-Nutritional Assessment – Short Form nutrition risk across community, hospital and residential care settings

Food intake
Severe decrease
Moderate decrease
No decrease
Weight loss
Weight loss >3 kg
Does not know
Weight loss between 1–3 kg
No weight loss
Mobility
Bed or chair bound
Able to get out of bed/chair but does not go out
Goes out
Psychological stress or acute disease
Yes
No
Neuropsychological problem
Severe dementia or depression
Mild dementia
No psychological problems
BMI (n = 41)
BMI < 19
BMI 19 to < 21
BMI 21 to < 23
BMI 23 or >
Calf circumference (n = 16)
CC < 31 cm
CC 31 or >

Total, n = 167
n (%)

Community, n = 57
n (%)

Hospital, n = 57
n (%)

Residential care, n = 53
n (%)

14 (8.4)
45 (26.9)
108 (64.7)

1 (1.8)
5 (8.8)
51 (89.5)

1 (1.8)
19 (33.3)
37 (64.9)

12 (22.6)
21 (39.6)
20 (37.7)

2
1
3
51

10
1
17
29

17
5
15
16

29
7
35
96

(17.4)
(4.2)
(21.0)
(57.5)

(3.5)
(1.8)
(5.3)
(89.5)

(17.5)
(1.8)
(29.8)
(50.9)

(32.1)
(9.4)
(28.3)
(30.2)

6 (3.6)
80 (47.9)
82 (48.5)

0 (0)
5 (8.8)
52 (91.2)

1 (1.8)
57 (82.5)
9 (15.8)

5 (9.4)
28 (52.8)
20 (37.7)

81 (48.5)
86 (51.5)

6 (10.5)
51 (89.5)

45 (78.9)
12 (21.1)

30 (56.6)
23 (43.4)

12 (7.2)
38 (22.8)
117 (70.1)

3 (5.3)
4 (7.0)
50 (87.7)

1 (1.8)
10 (17.5)
46 (80.7)

8 (15.1)
24 (45.3)
21 (39.6)

1
3
4
35

7
3
10
35

12
7
10
14

20
13
24
84

(14.2)
(9.2)
(17.0)
(59.6)

5 (17.9)
23 (82.1)

(2.3)
(7.0)
(9.3)
(81.4)

0 (0)
16 (100)

(12.7)
(5.5)
(18.2)
(63.6)

0 (0)
2 (100)

(27.9)
(16.3)
(23.3)
(32.6)

5 (50)
5 (50)

BMI, body mass index; CC, calf circumference.

(MNA score <17) and risk of malnutrition (MNA score 17–
23.5) have been reported in 71% and 29%, respectively, of
Swedish nursing home residents [26] and in 29% and 60%
of 2114 eligible aged care residents in Finland [9]. Malnutrition has also been found to be present among 50% of more
than 800 aged care residents in QLD using the Subjective
Global Assessment tool [7]. The prevalence of malnutrition
increases as the length of stay increases [9]; hence, identification of those at risk on admission to residential care or hospital is imperative so that effective nutrition care plans can
be implemented.
Body mass index values <18.5 (underweight) were found in
nearly a quarter (22.6%) of the residential care participants
and in 11% of participants newly admitted to hospital. By
contrast, community participants were more likely to have a
higher body weight and BMI ≥25 than those recently admitted
to hospital or residential care. Increased body weight is associated with better health outcomes for older people and those
who are overweight may be at a healthy weight for their age
and have greater nutritional reserves to draw upon when they
become ill [27]. By contrast, among adults older than
70 years a very low BMI is associated with the highest mortality [28] suggestive of an increasingly U-shaped relationship
between BMI and mortality in advanced age.
The risk of dysphagia (EAT-10 score ≥3) was significantly
higher among participants recently admitted to residential
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care (32.1%) compared to living in the community (3.5%).
Disordered deglutition is an ageing concern [29,30]. Older
adults experience changes to the swallowing process
brought on by physiological changes with advancing age,
including reductions in muscle mass, muscle strength and
tissue elasticity, leading to slower bolus transit times from
mouth to the stomach. This may predispose older adults to
increased risk of developing dysphagia, and as a consequence, nutritional issues such as decreased food intake
leading up to malnutrition. In a population-based prevalence study of independently living older people over
70 years, dysphagia was more prevalent with increasing
age (36.4% in 80 year olds, compared to 21.7% in 70–
79 year olds) [29]. Furthermore, malnutrition or being at
risk of malnutrition was independently associated with
impaired efficacy of swallow. The finding of ‘malnourished’
participants being at a higher risk of dysphagia risk in the
current study is therefore not unexpected. Previous literature supports an association between increased dysphagia
risk and malnutrition [10,29,30]. Difficulty swallowing
reduces food volume intake and results in food avoidance
and anxiety over mealtimes. The three main swallowing
issues, assessed from the EAT-10, were as follows: ‘swallowing solids takes extra effort’; ‘swallowing pills takes
extra effort’; and ‘when I swallow food sticks to my
throat’. Although not further investigated in this study,
these unpleasant experiences would likely result in changes
in eating habits, most notably in the form of food
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restriction [10]. The extra effort in swallowing and poor
nutritional intake is a potential explanation for a malnourished or at risk of malnutrition state in patients at higher
risk of dysphagia. In the study by Mann et al. [10], those
with swallowing difficulties were found to be deficient in
fibre, calcium, magnesium, zinc, vitamins D, E and K and
folate. These deficiencies were on average 44.9% below
recommended dietary intakes [10].
Generalisability of these findings is limited by the small
sample. Community-living participants recruited into this
study were younger (mean age 73) compared to those
recently admitted to hospital (82 years) or residential care
(87 years). They had less comorbidity, took less medication, had better cognition and were more likely to be dentate; most (96.5%) had no risk of dysphagia. This study
needs to be repeated in a larger sample size sufficient
enough to ensure reliable conclusions. Body mass index is
an integral part of the MNA-SF tool. M aori and Pacifica
were younger than the NZ European participants and are
more likely to have a higher BMI as in general they have a
greater lean body mass compared to NZ European [31].
Although they compromised only a quarter (26.3%) of the
community and 4.4% of the hospital participants, the proportion of those with a normal BMI or overweight and
obese may have been altered. Hence, limitations should be
considered when interpreting these results.
Nonetheless there are marked differences in nutritional risk
and prevalence of dysphagia between older adults living in
different social settings. Independently living older adults
demonstrate the best nutritional profiles with nutrition risk
and prevalence of dysphagia ten times lower than those
admitted to either hospital or residential care facilities.
Intuitively, these results may be expected; however, these
data reveal the stark delineation between well older adults
and those experiencing a slide in their health status and
profile. With such clear differences in risk, we now need to
pinpoint factors that determine this paradigm shift in eating and nutrition. In this way, we will be able to intervene
prior to individuals experiencing irreversible decline in
health and well-being.

E ,

This is the first New Zealand study to describe the prevalence of malnutrition risk in early admission to residential
care and hospital AT&R wards. Malnutrition and swallowing difficulties significantly affect quality of life and are
costly to individuals, families and the community. Screening
for malnutrition risk needs to occur in all settings and the
reasons for weight loss investigated. Simple intervention
measures to manage undernutrition by an interdisciplinary
team are recommended by the Australian and New Zealand
Society for Geriatric Medicine [15], which can make a substantial difference to improve the nutritional health of older
6

J

e t a l .

people. However, given the differences that we have identified by setting, a more targeted approach should be used to
identify the optimum nutrition intervention for each setting,
so that the nutrition status of all older adults is improved.

Acknowledgements
We acknowledge all participants for their commitment to
this study and all of our Waitemata DHB partners that
facilitated the study (Nutrition Services, Dr Lannes Johnson
and Lynelle Dagley Waitemata PHO; Dr Cheryl Johnson,
Geriatrician; and Tanya Bish, Katrina Lenzie-Smith
ARRC). The authors declare no conflicts of interest.

References
1
2
3
4
5

6

7
8
9
10
11
12

Conclusion

B u h s - C a t t e r a l l

13
14
15
16

17

Statistics New Zealand. 2013 Census QuickStats About People Aged
65 and Over. New Zealand: Wellington, 2015.
Robson B, Harris R. Hauora: M a ori Standards of Health IV. A Study
of the Years 2000–2005. Dunedin: School of Medicine and Health
Sciences, University of Otago, 2007.
Donini L, Savina C, Rosano A, Cannella C. Systematic review of
nutritional status evaluation and screening tools in the elderly. Journal of Nutrition Health and Aging 2007; 11: 421–32.
Wham C, Carr R, Heller F. Country of origin predicts nutrition risk
among community living older people. The Journal of Nutrition,
Health and Aging 2011; 15: 253–258.
Wham C, Teh R, Moyes S et al. Health and social factors associated
with nutrition risk: Results from life and living in advanced age: A
cohort study in New Zealand (LILACS NZ). Journal of Nutrition Health
and Aging 2015; 19: 637–645.
Beck E, Patch C, Milosavljevic M et al. Implementation of malnutrition screening and assessment by dietitians: Malnutrition exists in
acute and rehabilitation settings. Nutrition and Dietetics 2001; 58:
92–97.
Banks M, Ash S, Bauer J, Gaskill D. Prevalence of malnutrition in
adults in Queensland public hospitals and residential aged care facilities. Nutrition and Dietetics 2007; 64: 172–178.
Visvanathan R, Penhall R, Chapman I. Nutritional screening of older
people in a sub-acute care facility in Australia and its relation to discharge outcomes. Age and Ageing 2004; 33: 260–265.
Suominen M, Muurinen S, Routasalo P et al. Malnutrition and associated factors among aged residents in all nursing homes in Helsinki.
European Journal of Clinical Nutrition 2005; 59: 578–583.
Mann T, Heuberger R, Wong H. The association between chewing
and swallowing difficulties and nutritional status in older adults.
Australian Dental Journal 2013; 58: 200–206.
Chen PH, Golub JS, Hapner ER, Johns MM 3rd. Prevalence of perceived dysphagia and quality-of-life impairment in a geriatric population. Dysphagia 2009; 24: 1–6.
Wolfe R, Miller S, Miller K. Optimal protein intake in the elderly. Clinical Nutrition 2008; 27: 675–684.
Neumayer LA, Smout RJ, Horn HG, Horn SD. Early and sufficient
feeding reduces length of stay and charges in surgical patients. Journal of Surgical Research 2001; 95: 73–77.
Middleton MH, Nazarenko G, Nivison-Smith I, Smerdely P. Prevalence
of malnutrition and 12-month incidence of mortality in two Sydney
teaching hospitals. Internal Medicine Journal 2001; 31: 455–461.
Australian and New Zealand Society for Geriatric Medicine. Position
Statement – Undernutrition and the Older Person. Sydney: The
Society, 2015.
National Institute for Health and Care Excellence. Nutrition Support in
Adults: Oral Nutrition Support, Enteral Tube Feeding and Parenteral
Nutrition. Screening for the Risk of Malnutrition. London: The Institute,
2006. Clinical Guideline No.: 32.
Mueller C, Compher C, Ellen DM. A.S.P.E.N. Clinical guidelines. Journal of Parenteral and Enteral Nutrition 2011; 35: 16–24.

Australasian Journal on Ageing, Vol    No       2017   –  
© 2017 AJA Inc.

 N u t r i t i o n

18
19

20

21
22

23
24

Joint Commission on Accreditation of Healthcare Organizations. Comprehensive Accreditation Manual for Hospitals. Chicago, IL: The
Commission, 2007.
Hirani V, Mindell J. A comparison of measured height and demi-span
equivalent height in the assessment of body mass index among people aged 65 years and over in England. Age and Ageing 2008; 37:
311–317.
Nestle Nutrition Institute. A Guide to Completing the Mini Nutritional
Assessment – Short Form (MNAâ-SF). [Cited 16 November 2014.]
Available from URL: http://www.mna-elderly.com/forms/mna_guide_e
nglish_sf.pdf
Ministry of Health. Our Oral Health: Key Findings of the 2009 Oral
Health Survey. Wellington: Ministry of Health, 2010.
Nasreddine Z, Phillips N, Bedirian V et al. The Montreal Cognitive
Assessment, MoCA: A brief screening tool for mild cognitive
impairment. Journal of the American Geriatrics Society 2005; 53:
695–699.
Schindler A, Mozzanica F, Monzani A et al. Reliability and validity of
the Italian eating assessment tool. Annals of Otology, Rhinology and
Laryngology 2013; 122: 717–724.
Rubenstein L, Harker J, Salva A, Guigoz Y, Vellas B. Screening for
undernutrition in geriatric practice: Developing the short-form mininutritional assessment (MNA-SF). The Journals of Gerontology Series
2001; 56: 366–372.

Australasian Journal on Ageing, Vol    No       2017   –  
© 2017 AJA Inc.

25
26
27

28

29

30

31

r i s k

o f

o l d e r

p e o p l e

World Health Organization. World Health Statistics. Geneva: The
Organization, 2007.
Saletti A, Lindgren EY, Johansson L, Cederholm T. Nutritional status
according to mini nutritional assessment in an institutionalized elderly
population in Sweden. Gerontology 2000; 46: 139–145.
Locher JL, Roth DL, Ritchie CS et al. Body mass index, weight loss,
and mortality in community-dwelling older adults. The Journals of
Gerontology Series A: Biological Sciences and Medical Sciences
2007; 62: 1389–1392.
Thinggaard M, Jacobsen R, Jeune B, Martinussen T, Christensen K.
Is the relationship between BMI and mortality increasingly U-shaped
with advancing age? A 10-year follow-up of persons aged 70–95
years. The Journals of Gerontology Series A: Biological Sciences and
Medical Sciences 2010; 65A: 526–531.
Serra-Prat M, Hinojosa G, Lopez D et al. Prevalence of oropharyngeal
dysphagia and impaired safety and efficacy of swallow in independently living older persons. Journal of the American Geriatrics Society
2011; 59: 186–187.
Wakabayashi H, Matsushima M. Dysphagia assessed by the 10-item
Eating Assessment Tool is associated with nutritional status and
activities of daily living in elderly individuals requiring long-term care.
The Journal of Nutrition, Health and Aging 2015; 1–6.
Ministry of Health. The Health of New Zealand Adults 2011/12: Key Findings
of the New Zealand Health Survey. Wellington: Ministry of Health, 2012.

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