East Asian Arch Psychiatry 2024;34:65-9 | https://doi.org/10.12809/eaap2417

ORIGINAL ARTICLE

pdf Full Paper in PDF

Sirinapa Aphisitphinyo, Department of Psychiatry, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
Chaikrit Archaaphisit, Department of Psychiatry, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
Poonsri Rangseekajee, Department of Psychiatry, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
Pattharee Paholpak, Department of Psychiatry, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
Veeradej Pisprasert, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
Papan Vadhanavikkit, Department of Psychiatry, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
Nawanant Piyavhatkul, Department of Psychiatry, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
Pongsatorn Paholpak, Department of Psychiatry, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand

Address for correspondence: Dr Pongsatorn Paholpak, Department of Psychiatry, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand, Email: ppaholpak@kku.ac.th

Submitted: 9 April 2024; Accepted: 24 July 2024

Malnutrition is characterised by deficiencies, excesses, or imbalances in the intake of energy and/or nutrients.¹

Individuals with deteriorations in physical, psychosocial, and cognitive functions are susceptible to malnutrition.

Malnutrition is a common geriatric problem, and ageing can be an aggravating factor. Interactions between malnutrition and health outcomes are complex. Factors associated with malnutrition in older adults include socioeconomic status, limited transportation, social isolation, impaired cognitive function, diminished senses of smell and taste, dental problems, swallowing problems, and decreased functioning of the digestive or absorption systems.^2-4 These usually result in decreased appetite, limited food intake, restricted diet, and ineffective absorption, thereby leading to weight loss, loss of muscle mass, increased risk of falls, frailty, increased institutionalisation, poor quality of life, increased morbidity and mortality, and increased caregiver burden.^5-11

Psychosocial and cognitive issues also play key roles in nutritional status, especially in patients with dementia. Psychosocial factors associated with malnutritional in the geriatric population include depression, anxiety, loneliness, emotionally stressful life events, and the nutrition and mental health status of caregivers.^3,4,12-16 Declining nutritional status can both cause and be caused by cognitive impairment in patients with dementia.^17-21 Malnutrition is a risk factor for cognitive decline and can worsen neuropsychiatric symptoms.¹⁹ Patients with dementia may have disturbances in eating or swallowing that affect their nutritional condition.²² Nutritional problems in people with dementia can manifest differently depending on the stage of the condition. Changes in food preferences, eating habits, and appetite are common causes of eating disturbance in patients in milder stages of dementia, whereas swallowing disturbance is a major problem in patients with advanced dementia.²²

Malnutrition can aggravate cognitive decline²⁰ and is associated with behavioural and psychological symptoms of dementia (BPSD).^13,18,19,23 Some clusters of BPSD (wandering, agitation, and repetitive behaviours) are associated with increased psychomotor activity and can lead to malnutrition from increased energy expenditure,²⁴ whereas apathy, which predominantly presents with psychomotor hypoactivation, may cause a decrease in appetite and dietary intake.²³ Eating problems in people with BPSD are common and usually manifest as hyperphagia, hyporexia, sweet cravings, restricted choices of food, food refusal, severe feeding difficulties, and nutritional problems.¹⁹

Among geriatric patients with dementia, the rate of malnutrition ranges from 4.9% to 32.9%,^{6,14,23,25-27} whereas the rate of being at risk of malnutrition ranges from 31.1% to 58.9%.^{6,14,15,25-27} The difference in rates is due to differences in types and severity of dementia, clinical settings, demographics, and nutritional assessments. Malnutrition among people with mild cognitive impairment in Thailand has been studied.²⁸ We aimed to determine the rate and predictive factors of malnutrition in people with dementia in Thailand.

Methods

This cross-sectional study was conducted at the outpatient dementia clinic of Srinagarind Hospital, Khon Kaen, Thailand. Patients aged ≥60 years with a diagnosis of major neurocognitive disorder (according to DSM-5 criteria) and their primary caregivers were invited to participate. If there were multiple caregivers, the person who spent the most time with the patient during the previous week was selected. Patients were excluded if they were unable to eat, were bedbound, had post-stroke hemiparesis (motor power weaker than grade IV on any limb), were undergoing chemotherapy or radiotherapy, or had Parkinson disease. Both older adults with dementia and their caregivers were interviewed separately by trained professionals.

Nutritional status of both patients and their caregivers was assessed using the Thai version of the Mini-Nutritional Assessment (MNA),²⁹ which comprises 18 items in four domains: anthropometry, dietary recall, clinical assessment, and self-assessment. Total scores range from 0 to 30; scores of 24 to 30 indicate normal nutrition, whereas scores of 17 to 23.5 indicate being at risk of malnutrition and scores of <17 indicate malnutrition.^29,30

Cognitive function of patients was assessed using the Thai version of the Mini-Mental State Examination,³¹ which comprises six domains. Total scores range from 0 to 30; scores of ≥24 indicate normal cognition, whereas scores of 19 to 23, 10 to 18, and ≤9 indicate mild, moderate, and severe cognitive impairment, respectively.

Functional status of patients was assessed using the Barthel Index for activities of daily living³² and Lawton Instrumental Activities of Daily Living Scale.³³

Overall dementia symptom severity of patients was assessed using the Clinical Global Impression – severity scale. The profile of BPSD of patients was assessed using the Neuropsychiatric Inventory (NPI),³⁴ which is a caregiver-rated questionnaire to capture frequency, severity, and caregiver distress of 12 problematic behaviours in dementia. The frequency scores range from 0 (none) to 4 (every day), whereas severity scores range from 0 (no disturbance) to 3 (severe disturbance). The frequency × severity score from each domain represents the degree of disturbance for each behaviour ranging from 0 to 12; total NPI scores range from 0 to 144. The caregiver distress score from each domain ranges from 0 (no distress) to 5 (severe distress); total scores range from 0 to 60.

The required sample size was 59, which was calculated based on a malnutrition rate of 4% in a previous study using the Taro Yamane formula, with a confidence interval of 95% and a precision of 5%. Bivariate regression analysis was performed using the nutritional status as a dependent variable. Variables with a p value <0.2 were entered into ordinal linear regression analysis using the stepwise backward technique to determine predictors for nutritional status.³⁵ A p value of <0.05 was considered statistically significant. Statistical analyses were performed using Stata (version 10, StataCorp).

Results

In total, 61 pairs of older adults with dementia and their caregivers were included (Table 1). The 30 male and 31 female patients (mean age, 74 years) had a mean duration of dementia diagnosis of 5.7 years; 45.9% of patients were diagnosed with Alzheimer disease dementia; 52.5% of patients had mild dementia symptoms. The three most common BPSD were apathy (45.61%), irritability (40.5%), and eating problems (38.6%). Regarding caregivers, the mean age was 56.6 years, 80.3% were female, and 95.1% were relatives of patients. The mean hours of caregiving per day were 19.0.

Of the 61 patients with dementia, 4.9% had malnutrition and 34.4% were at risk of malnutrition. Regarding caregivers, 93.4% were of normal nutritional status and the remaining 6.6% were at risk of malnutrition. BPSD severity scores of patients and caregiver distress scores are shown in Table 2.

Six variables were significant after bivariate regression analysis: patient age, Clinical Global Impression – severity scale score, Mini-Mental State Examination score, NPI apathy subscale score, NPI aberrant motor behaviour subscale score, and caregiver MNA score. In the ordinal regression analysis, the predictors for the nutritional status of patients with dementia were caregiver MNA score (odds ratio = 0.72, p = 0.03) and patient NPI apathy subscale score (odds ratio = 1.26, p = 0.05) [Table 3]. The predicting model had the highest R²value of 0.22.

Discussion

In Khon Kaen, Thailand, among patients with dementia, the rate of malnutrition was 4.9% and the rate of being at risk of malnutrition was 34.4%, consistent with studies that reported 4.9% to 32.9%^{6,14,23,26,27} and 31.1%,²⁵ respectively. Regarding caregivers, 6.6% were at risk of malnutrition, which was lower than the 23.1% to 41.1% reported in the literature.^15,16,36

Higher rate of malnutrition is associated with worsened cognitive and functional impairment.^14,18,19 In the present study, most patients had mild cognitive and functional impairments and dementia symptoms. In studies reporting higher rates of malnutrition, most patients had moderate cognitive and functional impairments.^6,15 Nutritional problems are associated with BPSD, especially verbal aggression, emotional disinhibition, apathy, aberrant motor behaviour, and nighttime disturbances.^18,19,23,37 The most common BPSD in our patients were apathy, irritability, eating problems, and aberrant motor behaviour, consistent with findings of other studies. However, the eating problem subscale of the NPI, as perceived by caregivers, may not fully illustrate eating problems in patients with dementia. Therefore, comprehensive nutritional assessments on both macro- and micro-nutrient intakes may give a clearer picture of nutritional status.

The nutritional status of caregivers is a predictor for the nutritional status of the patients they care for.^15,16 Most caregivers were family members and relatives; we speculated that this relationship often results in good- quality care. Furthermore, the median caregiver distress score of the NPI was relatively low, which may result in the low rate of being at risk of malnutrition among caregivers. Nevertheless, psychological problems (such as depression and anxiety) among caregivers may affect patient malnutrition status,^13,17  but these were not assessed. In addition, our patients were recruited from a university hospital with provision of multidisciplinary care. Therefore, patients probably received early detection and appropriate interventions for malnutrition issues.

In the present study, predictors for nutritional status of patients with dementia were the patient NPI apathy subscale score and caregiver MNA score. Poorer MNA scores are associated with more severe apathy symptoms.^15,19 Apathy is a disorder of motivation. Older adults with dementia who have apathy are usually less motivated to initiate purposeful behaviours by themselves,³⁸ which can influence eating behaviour and food selection,³⁹ and tend to have dependent eating skills and decreased dietary intake.³⁶ People with apathy are not concerned about food selection and preference. In addition, decreased physical activity and less affective response may also affect nutritional status.³ As a result, apathy is a potential risk factor for malnutrition in older adults with dementia.¹⁹

In the present study, caregiver MNA scores were associated with patient MNA scores, consistent with findings of previous studies.^15,16 Good nutritional status of caregivers may be a protective factor of malnutrition in patients with dementia. Caregiver psychological distress is also correlated with malnutrition in older adults with dementia.^13,14

Limitations of this study include a lack of assessments of biological parameters (such as routine laboratory tests, proteins, and micronutrient data), the single-centre study design, and the small sample size.

Conclusion

Apathy level of patients and nutritional status of caregivers were predictors of nutritional status in patients with dementia. Regular monitoring of BPSD in older adults with dementia and the nutritional status of their caregivers should be included in comprehensive nutritional assessment.

Contributors

All authors designed the study, acquired the data, analysed the data, drafted the manuscript, and critically revised the manuscript for important intellectual content. All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

Conflicts of interest

All authors have disclosed no conflicts of interest.

Funding/support

This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

All data generated or analysed during the present study are available from the corresponding author on reasonable request.

Ethics approval

This study was approved by the ethics committee of Khon Kaen University (reference: HE611108). The participants provided written informed consent for all treatments and procedures and for publication.

Acknowledgement

The authors thank Kanokarn Kongpitee, Kanthapitcha

Sutchantho, and Kitima Sangtong for their support.

References

1. World Health Organization. Malnutrition. Accessed April 2024. Available from: https://www.who.int/news-room/questions-and-answers/item/malnutrition.
2. Mangels AR. CE: Malnutrition in older adults. Am J Nurs 2018;118:34-41. ^Crossref
3. Evans C. Malnutrition in the elderly: a multifactorial failure to thrive. Perm J 2005;9:38-41. ^Crossref
4. Hickson M. Malnutrition and ageing. Postgrad Med J 2006;82:2-8^Crossref
5. Volkert D, Chourdakis M, Faxen-Irving G, et al. ESPEN guidelines on nutrition in dementia. Clin Nutr 2015;34:1052-73. ^Crossref
6. Yildiz D, Büyükkoyuncu Pekel N, Kiliç AK, Tolgay EN, Tufan F. Malnutrition is associated with dementia severity and geriatric syndromes in patients with Alzheimer disease. Turk J Med Sci 2015;45:1078-81. ^Crossref
7. Tana C, Lauretani F, Ticinesi A, et al. Impact of nutritional status on caregiver burden of elderly outpatients. A cross-sectional study. Nutrients 2019;11:281. ^Crossref
8. Rasheed S, Woods RT. Malnutrition and quality of life in older people: a systematic review and meta-analysis. Ageing Res Rev 2013;12:561-6. ^Crossref
9. Norman K, Haß U, Pirlich M. Malnutrition in older adults: recent advances and remaining challenges. Nutrients 2021;13:2764. ^Crossref
10. Kupisz-Urbanska M, Marcinowska-Suchowierska E. Malnutrition in older adults: effect on falls and fractures: a narrative review. Nutrients 2022;14:3123. ^Crossref
11. Söderström L, Rosenblad A, Thors Adolfsson E, Bergkvist L. Malnutrition is associated with increased mortality in older adults regardless of the cause of death. Br J Nutr 2017;117:532-40. ^Crossref
12. Chen CC, Schilling LS, Lyder CH. A concept analysis of malnutrition in the elderly. J Adv Nurs 2001;36:131-42. ^Crossref
13. Brocker P, Benhamidat T, Benoit M, et al. Nutritional status and Alzheimer’s disease: preliminary results of the REAL.FR study [in French]. Rev Med Interne 2003;24(Suppl 3):314s-318s. ^Crossref
14. Roqué M, Salvà A, Vellas B. Malnutrition in community-dwelling adults with dementia (NutriAlz Trial). J Nutr Health Aging 2013;17:295-9. ^Crossref
15. Rullier L, Lagarde A, Bouisson J, Bergua V, Barberger-Gateau P. Nutritional status of community-dwelling older people with dementia: associations with individual and family caregivers’ characteristics. Int J Geriatr Psychiatry 2013;28:580-8. ^Crossref
16. Tombini M, Sicari M, Pellegrino G, Ursini F, Insardá P, Di Lazzaro V. Nutritional status of patients with Alzheimer’s disease and their caregivers. J Alzheimers Dis 2016;54:1619-27. ^Crossref
17. Vellas B, Lauque S, Gillette-Guyonnet S, et al. Impact of nutritional status on the evolution of Alzheimer’s disease and on response to acetylcholinesterase inhibitor treatment. J Nutr Health Aging 2005;9:75-80.
18. Guerin O, Soto ME, Brocker P, et al. Nutritional status assessment during Alzheimer’s disease: results after one year (the REAL French Study Group). J Nutr Health Aging 2005;9:81-4.
19. Spaccavento S, Del Prete M, Craca A, Fiore P. Influence of nutritional status on cognitive, functional and neuropsychiatric deficits in Alzheimer’s disease. Arch Gerontol Geriatr 2009;48:356-60. ^Crossref
20. Sanders C, Behrens S, Schwartz S, et al. Nutritional status is associated with faster cognitive decline and worse functional impairment in the progression of dementia: the Cache County Dementia Progression Study 1. J Alzheimers Dis 2016;52:33-42. ^Crossref
21. Koyama A, Hashimoto M, Tanaka H, et al. Malnutrition in Alzheimer’s disease, dementia with Lewy bodies, and frontotemporal lobar degeneration: comparison using serum albumin, total protein, and hemoglobin level. PLoS One 2016;11:e0157053. ^Crossref
22. Kai K, Hashimoto M, Amano K, Tanaka H, Fukuhara R, Ikeda M. Relationship between eating disturbance and dementia severity in patients with Alzheimer’s disease. PLoS One 2015;10:e0133666. ^Crossref
23. Kimura A, Sugimoto T, Kitamori K, et al. Malnutrition is associated with behavioral and psychiatric symptoms of dementia in older women with mild cognitive impairment and early-stage Alzheimer’s disease. Nutrients 2019;11:1951. ^Crossref
24. Sergi G, De Rui M, Coin A, Inelmen EM, Manzato E. Weight loss and Alzheimer’s disease: temporal and aetiologic connections. Proc Nutr Soc 2013;72:160-5. ^Crossref
25. Cereda E, Pedrolli C, Klersy C, et al. Nutritional status in older persons according to healthcare setting: a systematic review and meta-analysis of prevalence data using MNA. Clin Nutr 2016;35:1282-90. ^Crossref
26. Marino LV, Ramos LF, Chiarello PG. Nutritional status according to the stages of Alzheimer’s disease. Aging Clin Exp Res 2015;27:507-13. ^Crossref
27. Soysal P, Dokuzlar O, Erken N, Dost Günay FS, Isik AT. The relationship between dementia subtypes and nutritional parameters in older adults. J Am Med Dir Assoc 2020;21:1430-5. ^Crossref
28. Seesen M, Sirikul W, Ruangsuriya J, Griffiths J, Siviroj P. Cognitive frailty in Thai community-dwelling elderly: prevalence and its association with malnutrition. Nutrients 2021;13:4239. ^Crossref
29. Vellas B, Villars H, Abellan G, et al. Overview of the MNA: its history and challenges. J Nutr Health Aging 2006;10:456-65.
30. Guigoz Y. The Mini Nutritional Assessment (MNA) review of the literature: what does it tell us? J Nutr Health Aging 2006;10:466-87.
31. Train the Brain Forum Committee. Thai mental state examination (TMSE). Siriraj Hospital Gazette 1993;45:661-74.
32. Mahoney FI, Barthel DW. Functional evaluation: the Barthel Index. Md State Med J 1965;14:61-5. ^Crossref
33. Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist 1969;9:179-86. ^Crossref
34. Cummings JL, Mega M, Gray K, Rosenberg-Thompson S, Carusi DA, Gornbein J. The Neuropsychiatric Inventory: comprehensive assessment of psychopathology in dementia. Neurology 1994;44:2308-14. ^Crossref
35. Bursac Z, Gauss CH, Williams DK, Hosmer DW. Purposeful selection of variables in logistic regression. Source Code Biol Med 2008;3:17. ^Crossref
36. Beattie E, McCrow JM, Dyce C, Fielding E, Isenring E. Nutritional challenges for the family caregiver and person with dementia dyad. J Aging Res Clin Pract 2014;3:41-6.
37. Kishino Y, Sugimoto T, Kimura A, et al. Longitudinal association between nutritional status and behavioral and psychological symptoms of dementia in older women with mild cognitive impairment and early- stage Alzheimer’s disease. Clin Nutr 2022;41:1906-12. ^Crossref
38. Pagonabarraga J, Kulisevsky J, Strafella AP, Krack P. Apathy in Parkinson’s disease: clinical features, neural substrates, diagnosis, and treatment. Lancet Neurol 2015;14:518-31. ^Crossref
39. Fostinelli S, De Amicis R, Leone A, et al. Eating behavior in aging and dementia: the need for a comprehensive assessment. Front Nutr 2020;7:604488. ^Crossref