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PREDICTORS OF MALNUTRITION AMONG HOSPITALIZED ADULTS WITH 

PNEUMONIA AT THE 37 MILITARY HOSPITAL IN ACCRA, GHANA 

 

 

 

 

 

BY THERESA ANDOH 

ID 10876819 

 

 

THIS THESIS IS SUBMITTED TO UNIVERSITY OF GHANA, LEGON IN PARTIAL 

FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MPHIL 

NUTRITION DEGREE 

JUNE, 2023

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DECLARATION 

I, Theresa Andoh, author of this thesis ― Predictors of malnutrition among hospitalized adults 

with pneumonia at the 37 military hospital; do hereby declare that this thesis is the result of my        

own work carried out at the Department of Nutrition and Food Science, College of Basic and 

Applied Sciences, University of Ghana, under the supervision Dr. Justina Serwaah Owusu and Dr. 

Mohammed Husein. All references to other works have been duly acknowledged. 

 

 

Theresa Andoh  

(Student) 

 

 

…………………… 

 

Date 8th June 2023 

 

 

 

 

……………………………………… …………………………………………. 

Dr. Justina Serwaah Owusu Dr. Husein Mohamed 

(Main supervisor) (Supervisor) 

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DEDICATION 

I dedicate this work to God Almighty for His benevolence and graciousness throughout this 

project. Warm regards to my parents Mr. Peter Andoh and Sarah Paintsil for their tremendous 

support financially, encouragement and prayers throughout the execution of this project. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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ACKNOWLEDGEMENT 

My sincere gratitude to God Almighty for His Grace, protection, and guidance throughout my stay 

in school, especially during the research. My deepest appreciation goes to the Department of 

Nutrition and Food Science for accepting me to read my master's program, without which I would 

not have had the opportunity to do this research. I am indebted to my supervisors, Dr. Justina 

Serwaah Owusu and Dr. Mohammed Hussein, for their tutelage, modelling my research 

knowledge, and the love they showed me throughout the study. It would have been impossible to 

complete this course without the immense support of all the lecturers and staff of the Nutrition and 

Food Science Department. To all, I say God bless you. I appreciate the PAR Foundation 

(Preventing Antibiotic Resistance) for funding this project through the Noguchi Memorial Institute 

of Medical Research. It was only possible to undertake this research with their funds. My gratitude 

to the nurses and doctors at the 37 Military Hospital for their support in identifying the participant 

during data collection. God richly bless you all. 

I am grateful to Dr. Agustina Frimpong, Dr. Eliza Mari Kwesi-Maliepaard, Mr. Israel Mensah 

Attipoe, Goerge Opoku, Emmanuel Ackon, and Eunice A. Boafo for their assistance during the 

data collection. I am grateful for the participants who, through their willingness, made this project 

a success. I say God bless them. 

Lastly, I deeply appreciate my family and friends’ invaluable support throughout this course. 

 

 

 

 

 

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TABLE OF CONTENT 

DECLARATION............................................................................................................................. ii 

DEDICATION ............................................................................................................................... iii 

ACKNOWLEDGEMENT ............................................................................................................. iv 

ACRONYMS ................................................................................................................................ xii 

ABSTRACT ................................................................................................................................. xiv 

1.0 INTRODUCTION .................................................................................................................... 1 

1.1 BACKGROUND ...................................................................................................................... 1 

1.2 PROBLEM STATEMENT ........................................................................................................ 3 

1.3 RATIONALE ............................................................................................................................ 4 

Research question ....................................................................................................................... 5 

1.4 AIMS AND OBJECTIVES. ...................................................................................................... 5 

1.4.1 Main aim ............................................................................................................................ 5 

1.4.2 Specific objectives ............................................................................................................. 5 

1.5 SIGNIFICANT OF STUDY ..................................................................................................... 5 

CHAPTER TWO ............................................................................................................................ 7 

2.0 LITERATURE REVIEW .......................................................................................................... 7 

2.1 PREVALENCE OF AGEING ON THE POPULATION .......................................................... 7 

2.1.1 Dynamics and prevalence of malnutrition among the elderly ........................................... 7 

2.2 TYPES OF MALNUTRITION AMONG THE ELDERLY ................................................... 10 

2.2.1 Sarcopenia ........................................................................................................................ 10 

2.2.2 Anorexia ............................................................................................................................11 

2.2.3 Wasting ............................................................................................................................. 12 

2.2.4 Cachexia ........................................................................................................................... 12 

2.3.0 MALNUTRITION SCREENING TOOLS FOR THE ELDERLY ..................................... 13 

2.3.1 Subjective Global Assessment (SGA) ........................................................................ 13 

2.3.2 Nutrition screening initiative (NSI) ............................................................................ 13 

2.3.3 Malnutrition Screening tool ........................................................................................ 15 

2.3.4 Nutrition Risk Screening -2002 .................................................................................. 15 

2.3.5 Geriatric Nutritional Risk Index ................................................................................. 15 

2.3.6 Mini-Nutrition Assessment .............................................................................................. 16 

2.4 NUTRITION RELATED ISSUES OF MALNUTRITION IN THE ELDERLY ................... 17 

2.4.1 DIET- RELATED ISSUES AMONG THE ELDERLY ................................................... 17 

2.4.1.1 Poor Appetite ....................................................................................................... 17 

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2.4.1.2 Oral cavity ........................................................................................................... 18 

2.4.1.2 Oesophagus ............................................................................................................... 18 

2.4.1.3 Decreased sensory functions. .............................................................................. 18 

2.5 GASTROINTETINAL CHANGES DURING AGEING ....................................................... 19 

2.5.1 The stomach ................................................................................................................ 20 

2.5.2 The small intestine ........................................................................................................... 20 

2.5.3 Large intestine .................................................................................................................. 20 

2.5.3 Health -related issues of malnutrition in the elderly ........................................................ 21 

2.5.4 Gastroesophageal Reflux Disease .................................................................................... 21 

2.5.5 Oropharyngeal dysphagia ................................................................................................ 21 

2.5.6 Depression and other psychological problems ................................................................ 22 

2.5.7 Comorbidity ..................................................................................................................... 22 

2.6 SOCIO-ECONOMIC RELATED FACTORS TO MALNUTRITION ................................... 22 

2.7 EFFECTS OF MALNUTRITION ON THE ELDERLY ........................................................ 24 

2.7.1 Immune dysfunction ........................................................................................................ 24 

2.7.2 Nutrient deficiency........................................................................................................... 25 

2.7.3 Folate deficiency .............................................................................................................. 25 

2.7.4 Vitamins D and calcium deficiency ................................................................................. 25 

2.7.5 Iron deficiency anaemia ................................................................................................... 26 

2.7.6 Diseased and disabilities .................................................................................................. 26 

2.8 PNEUMONIA INFECTION AND UNDERNUTRITION IN THE GHANAIAN ELDERLY 

POPULATION .............................................................................................................................. 27 

2.8.1 Classification of pneumonia ....................................................................................... 28 

2.8.2 Risk factors of community-acquired pneumonia among the elderly. .............................. 28 

2.8.3 Lifestyle activities ............................................................................................................ 29 

2.8.4 Comorbidities ................................................................................................................... 29 

2.8.5 Nutritional status .............................................................................................................. 29 

2.8.6 Age and Poor dental care ................................................................................................. 29 

CHAPTER THREE ...................................................................................................................... 30 

3.0 METHODOLOGY ................................................................................................................. 30 

3.1 STUDY SITE .......................................................................................................................... 30 

3.1.1 Study design ..................................................................................................................... 30 

3.2 STUDY POPULATION, SAMPLE SIZE DETERMINATION AND SAMPLING 

TECHNIQUE ................................................................................................................................ 30 

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3.2.1 Study population .............................................................................................................. 30 

3.2.2 Sample Size Determination.............................................................................................. 30 

3.2.3 Population Sampling ........................................................................................................ 31 

3.2.4 Inclusion Criteria and Exclusion Criteria ........................................................................ 31 

3.3 DATA COLLECTION ............................................................................................................ 32 

3.3.1 Questionnaire Survey ....................................................................................................... 32 

3.3.2 Anthropometry and Biochemical Assessment ................................................................. 32 

3.3.2.1 Anthropometric Assessment...................................................................................... 32 

3.3.2.2 Weight Measurement ................................................................................................ 32 

3.3.2.3. Height measurement ................................................................................................ 33 

3.3.2.4 Body Mass Index ................................................................................................. 33 

Table 3.1 Body Mass Index Classification for the elderly .................................................... 33 

3.3.2.5 Mid Upper Arm Circumference .......................................................................... 33 

3.3.2.6 Calf circumference .............................................................................................. 34 

3.3.2.7 Biochemical Assessment ........................................................................................... 34 

3.3.4 Dietary Assessment ...................................................................................................... 34 

3.3.5 Mini Nutritional Assessment tool (MNA) ....................................................................... 34 

3.4 DATA ANALYSIS .................................................................................................................. 35 

3.4.1 Questionnaire Survey ....................................................................................................... 35 

3.4.2 Anthropometric data ......................................................................................................... 35 

3.4.2.1 The mid-upper arm circumference (MUAC) and calf measurements ...................... 35 

3.4.3 Dietary diversity Assessment. .......................................................................................... 36 

3.4.4 Anaemia Data ................................................................................................................... 36 

3.4.5 Health status data ............................................................................................................. 36 

3.5 ETHICAL ISSUES ................................................................................................................. 37 

3.5.1 Participants consent. ........................................................................................................ 37 

CHAPTER FOUR ......................................................................................................................... 38 

4.0 RESULTS ................................................................................................................................ 38 

4.1 BACKGROUND CHARACTERISTICS OF PARTICIPANTS ............................................ 38 

4.1 HEALTH – RELATED INFORMATION OF PARTICIPANTS ............................................ 39 

4.1.1 Prevalence of anaemia among hospitalized adults with pneumonia ............................ 39 

4.1.2 Health related characteristics of study participants (N= 54) ........................................ 40 

4.2 NUTRITIONAL STATUS OF PARTICIPANTS .................................................................... 41 

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4.2.1 Prevalence of malnutrition among participants using the Mini Nutrition Assessment tool

................................................................................................................................................... 42 

4.2.3 Malnutrition indicators and its association with the malnutrition screening tool (MNA 

score) and the body mass index (BMI). .................................................................................... 43 

4.3 NUTRIENT INTAKE OF STUDY PARTICIPANTS ............................................................ 45 

4.3.1 Nutrient intake, dietary diversity, and its association with malnutrition ......................... 47 

4.3.2 Association between nutrient intake, dietary diversity, and body mass index (BMI) ...... 47 

4.4 HEALTH CONDITIONS AND IT ASSOCIATION WITH MALNUTRITION ................... 50 

4.5 COMORBIDITY AND ITS ASSOCIATION WITH MALNUTRITION .............................. 55 

4.6 PREDICTORS OF MALNUTRITION .................................................................................. 55 

4.6.1 Predicator and its association with malnutrition indicators ............................................. 57 

4.7 SOCIO- DEMOGRAPHIC CHARACTERISTICS AND ITS ASSOCIATION WITH 

MALNUTRITION ........................................................................................................................ 60 

4.7.1 Predictors of malnutrition among participants ................................................................. 63 

CHAPTER FIVE .......................................................................................................................... 64 

5.0 DISCUSSION ......................................................................................................................... 64 

5.1 SOCIO- DEMOGRAPHIC CHARACTERISTICS ............................................................... 64 

5.2 LIFESTYLE PATTERN AND HEALTH STATUS OF STUDY PARTICIPANTS ............... 65 

5.4 SOCIO-DEMOGRAPHIC CHARACTERISTICS AND THEIR ASSOCIATION WITH 

MALNUTRITION. ....................................................................................................................... 69 

5.5 PREDICTOR VARIABLES AND ITS ASSOCIATION WITH MALNUTRITION ............. 69 

5.6 HEALTH CONDITIONS AND ITS ASSOCIATION WITH MALNUTRITION ................. 70 

5.7 LIMITATION OF THE STUDY ............................................................................................. 72 

CHAPTER SIX ............................................................................................................................. 73 

6.0 CONCLUSION AND RECOMMENDATION ...................................................................... 73 

6.1 Conclusion .......................................................................................................................... 73 

6.2 Recommendation ................................................................................................................ 73 

REFERENCES ............................................................................................................................. 75 

APPENDIX I- QUESTIONNAIRE .............................................................................................. 92 

APPENDIX 11-ETHICAL CLEARANCE ................................................................................. 100 

 

 

 

 

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LIST OF TABLES 

Table 3.1 Body Mass Index Classification for the elderly ............................................................ 33 

Table 4.2 Health information of participants (N=54) ................................................................... 39 

Table 4.3 Health related information of participant (N=54) ......................................................... 41 

Table 4.4 Nutritional status study of participants (N=54) ............................................................. 42 

Malnutrition can be assessed using several indicators; therefore, tables 4.5 and 6 show the 

association between the indicator of malnutrition and its association with the screening tool 

(MNA scores) and the body mass index. There was a statistical significance in mid-upper arm 

circumference and calf circumference (P< 0.05) for both the malnutrition screening tool and the 

body mass index. Table 4.5 Malnutrition indicators and its association with the MNA score 

(N=54). .......................................................................................................................................... 43 

Table 4. 5 Nutritional status of participants .................................................................................. 44 

Table 4. 6 Malnutrition indicators and its association with body mass index .............................. 44 

Table 4.7 Nutrient intake of participants ....................................................................................... 45 

Table 4.8 Recommended Dietary Intake by gender. ..................................................................... 46 

A chi-square analysis was conducted to determine the association between nutrient intake and 

malnutrition using malnutrition indicator scores from the malnutrition- screening tool. There was 

no significant difference between nutrient intake and malnutrition except for carbohydrate intake, 

with a P <0.05. Table 4.7 show that all the nutrients relevant in the ageing population have a P > 

0.05................................................................................................................................................ 47 

Table 4.9 Nutrient intake, dietary diversity and its association with malnutrition based on MNA 

screening tool. ............................................................................................................................... 47 

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Table 4.10 Association between nutrient intake, dietary diversity and malnutrition based on body 

mass index (BMI) ......................................................................................................................... 49 

Table 4.11 Health condition and its association with malnutrition base on MNA screening tool. 51 

Table 4.12 Health conditions and its association with Mid upper arm circumference ................. 52 

Table 4.13 Health conditions and its association with Body Mass Index (BMI) ......................... 53 

Table 4.14 Health condition and its association with Calf Circumference ................................... 54 

Table 4.15 Bivariate analysis of co-morbidity and malnutrition .................................................. 55 

Table 16 Predicators of malnutrition and its association with Mini Nutritional Assessment tool 

(MNA)........................................................................................................................................... 56 

Table 4.18 Predicators and its association with Body mass Index (BMI) .................................... 58 

Table 4.19 Predicators and its association with malnutrition based on Calf circumference. ........ 59 

Table 4.20 Binary logistic regression of sociodemographic characteristics and its association with 

malnutrition. .................................................................................................................................. 61 

Table 4.21 Bivariate analysis of predictors and its association with malnutrition ........................ 62 

 

 

 

 

 

 

 

 

 

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LIST OF FIGURES  

Figure 2.1 Cause and effect relation with sarcopenia and malnutrition (Roubenoff, 2000). .........11 

Figure 2.2 Effects of ageing on nutrition ...................................................................................... 24 

Figure 4.1 Prevalence of anaemia among study participants ........................................................ 40 

Figure 4.2 Prevalence of malnutrition based on the Mini nutritional assessment screening tool. 43 

Figure 4.3 Prevalence of Co-morbidity among study participants ............................................... 54 

 

 

 

 

 

 

 

 

 

 

 

 

 

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ACRONYMS 

BMI Body Mass Index 

MNA Mini Nutritional Assessment Tool 

DDS Dietary Diversity Score 

MUCA Mid- Upper Arm Circumference 

CC Calf circumference 

FAO Food and Agriculture Organization 

WHO World Health Organization 

RDA Recommended Dietary Allowance 

UN United Nations 

GLIM Global Leadership Initiative on Malnutrition 

ICD International Classification of Diseases 

NHANES National Health and Nutrition Examination Survey 

NSI Nutrition Screening Initiative 

SGA Subjective Global Assessment 

MST Malnutrition Screening Tool 

GNRI Geriatric nutrition Risk index 

CCK Cholecystokinin 

GIT Gastrointestinal tract 

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CI Confident Level 

OR Odds Ratio 

ASPEN American Society for Parenteral and Enteral Nutrition 

MNA Mini Nutritional Assessment  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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ABSTRACT 

Introduction: The aging population is the world’s most pressing medical and socio demographic 

challenge, and addressing this issue is a key concern. In Sub-Saharan Africa and Ghana, 

undernutrition among older people is high. There is limited information on the malnutrition 

situation among the hospitalized older adults in Ghana. This study was undertaken to identify 

malnutrition cases and the determinants of malnutrition among hospitalized adults with pneumonia 

at the 37 Military Hospital in Accra. 

Methodology: A cross-sectional survey was conducted with 54 hospitalized adults aged 60 and 

above infected with pneumonia at the 37 Military Hospital. Data were collected on socio- 

demographics, health status, lifestyle factors, and dietary intakes (a 24-hour dietary recall). 

Anthropometric data and the Mini Nutritional Assessment Tool (MNA) were used to determine 

the prevalence of malnutrition among the study group. Chi-square and regression analysis were 

used to determine the association between malnutrition and comorbidity among hospitalized adults 

with pneumonia. 

Results: This study revealed that 85.2% of the study population were malnourished based on their 

Body Mass Index (BMI). Based on MNA scores, 50.0% and 40% of the participants were at risk 

of malnutrition and malnourished respectively. There was no significant association between 

dietary diversity, nutrient intake, and malnutrition using BMI and MNA-Score (P > 0.05), 

respectively. Predictors such as marital status, feeding mode, morbidity, and taking more than 3 

prescriptions per day were independently associated with malnutrition with a (P > 0.05). The 

prevalence of comorbidity among the study population was (61.1%) as participants with 

comorbidity had higher odds for malnutrition than those who are morbid (OR =2.58: CI=0.394 

16.94). Study participants with health conditions such as neuropsychological problems 

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had 4 times higher odds (OR 4.52:CI= 0.004-2.177) for malnutrition than those who had no 

neuropsychological problems. Lastly, the prevalence of anaemia among hospitalized a with 

pneumonia was 40.7%. 

 

Conclusion: The prevalence of malnutrition in adult with pneumonia was high using both the 

MNA and the body mass index. Almost all participants had inadequacies for calcium and fibre 

intake while there was no association between dietary and malnutrition however carbohydrate was 

the only nutrient that was associated with MNA. Predictors such as marital status, taking more 

than 3 prescriptions per day, feeding mode, living independently, and mobility were associated 

with malnutrition

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CHAPTER ONE 

1.0 INTRODUCTION 

1.1 BACKGROUND 

The human health revolution is a global success story that represents the triumph of medical 

progress, public health, and economic development over infectious diseases and injuries which has 

resulted in decreased life expectancy. This health revolution has moved the human survival curve 

upwards, improving survival at all ages but the aging population has created some current concerns 

about economic growth and social support networks. In Ghana, old age is characterized by a 

person’s ability to work as well as social characteristics such as experience and leadership. As a 

result, a person is regarded old if he or she is unable to work due to the aging process, diminished 

physical strength, or health problems (WHO, 2001). Aging is mostly associated with decreased 

physical activity and dietary intake which may result in poor nutritional status making nutrition a 

crucial component of the health and functional ability of the aged, primarily affecting their physical 

and psychological well-being. 

Undernutrition in the aging population is prevalent in hospitals and care homes. Malnutrition is an 

acute, subacute, or chronic state of nutrition with or without inflammation defined by (ASPEN). It 

can be caused by varying degrees of over-nutrition or under-nutrition (Rajendramet al., 2015). 

Healthy diets and exercise are frequently emphasized in nutrition to reduce the risk of lifestyle 

diseases. However, the nutritional need of the elderly is meet through consumption-nutrient- dense 

foods. Malnutrition in the elderly is linked to increased mortality and morbidity. Healthy Aging is 

a chosen priority of the World Health Organization on aging between 2016 and 2030. This program 

aims to help the elderly develop and preserve functional abilities for health, well- being and 

participation in society (Rudnicka et al., 2020b). Undernutrition is associated with decreased 

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functional ability, impaired muscle function, lower bone mass, reduced immunity, impaired 

cognitive function, delayed wound healing, higher hospital readmission, and mortality (Ahmed & 

Haboubi, 2010). The aged are more susceptible to poor nutritional status and are at risk of 

nutritional deficiencies than infants although, it is mostly underreported and undiagnosed (Pirlich 

& Lochs, 2001). Aging causes malabsorption and malnutrition, which can result from chewing and 

swallowing disorders, atrophic gastric disease, social deprivation, financial issues, and loneliness, 

which influence their nutritional status. 

Persons over 60 years are disproportionally burdened with various infectious diseases and 

experience disease severity and mortality as these infections include Pneumonia is an 

inflammatory reaction of the lungs, specifically the alveoli mostly caused by a bacterium or virus, 

but the etiological agent is rarely identified, particularly in the aging population (Chebibet al., 

2021). According to the World Health Organization, 450 million people are infected with 

pneumonia yearly with four million deaths accounting for 7% of the world’s population (World 

Health Organization, 2002). In 2015, pneumonia caused 6.8 million hospitalizations worldwide 

with 4 million people dying and 1.1 million in-hospital deaths (World Health Organization, 2022). 

The rate of hospital admissions rises with age, and men have a higher rate than women. Pneumonia 

is prevalent in the elderly because of the physiological changes in the respiratory tree and a 

decreased immune response. Comorbidity, such as neurodegenerative disease, 

immunosuppression, poor nutritional status, cardiovascular and chronic respiratory diseases, and 

cerebrovascular diseases increase the risk of pneumonia in the elderly. Pneumonia and malnutrition 

have a synergic relationship as pneumonia increase the risk of becoming malnourished through the 

effect of the condition such as difficulty breathing, chest pain, fever, weight loss, and severe 

impaired respiratory strength also malnutrition and micro-nutrient deficiencies is associated with 

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decreased immune function as people age resulting in an increased risk of infectious disease (Yang 

et al., 2019). 

 

1.2 PROBLEM STATEMENT 

Globally, there is an unprecedented and continual change in the age structure, which is driven by 

increased life expectancy and decreased fertility among the population. According to 

Rafalimanana, (2020) the prevalence of the elderly population will double to over 1.5 million in 

decades three decades with the highest in developing countries however, the Ghanaian population 

of the elderly has increased rapidly from 0.3 million to 1.4 million persons in 1976 and 2006 

respectively (Mba, 2010). The proportions of older people are expected to rise dramatically. The 

global proportion of people aged 65 and more is predicted to more than double between 2000 and 

2050, from 6.9% to 16.4%. The share of the oldest-old (those aged 80 and up) will rise from 1.9 

to 4.2 percent during this period. It is estimated that by 2030,” one in every six people in the world 

will be 60 or older (World Health Organization, 2022). 

The absolute number of elderly people in Ghana has increased, as it has in other African countries. 

The Population and Housing Census, (2010), indicates that the adult population in Ghana has 

increased sevenfold: from 215,258 in 1960 to 1,643,978 in 2010 and it is projected to rise to 2.3 

million in 2025 and 5.6 million by 2050 (Ghana Statistical Service, 2010). The African population 

of the aged has doubled between 1990 and 2015, rising from 23 million to46 million. (United 

Nations, 2016). Malnutrition prevalent in the aged in the community ranges between 1.3% and 

47.8% (Takedaet al., 2020) and it is higher in developing countries than in developed countries, 

according to studies. Evidence shows that 23% to 62% of hospitalized aged are malnourished while 

85% are residents of a nursing home (Donini et al., 2013). The elderly is more susceptible to poor 

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nutritional status and are at risk of nutritional deficiencies than the younger population. 

Malnutrition is autonomously linked with 30-day mortality in hospital- acquired pneumonia and 

nursing home-acquired pneumonia (Falcone et al., 2018). This is due to the aging process which 

causes malabsorption because of chewing and swallowing disorders, atrophic gastric disease, 

social deprivation, financial issues, and loneliness, which influence the nutrition and health status 

of the aged. Pneumonia is the most common cause of infection-related morbidity and mortality 

among the elderly (Troeger et al., 2017a). Hospital- acquired pneumonia has caused 6.8 million 

hospitalizations worldwide in 2015, with 1.1 million deaths. 

1.3 RATIONALE 

Globally the aging population has the most important medical and socio-demographic problem 

worldwide (Rudnicka et al., 2020b). Ghana’s National Institute of Ageing, (2004) has presented 

challenges in the health, social well-being, and economic status of older adults. Ghana has 

instituted livelihood empowerment against poverty cash transfer programs that target households 

with older adults as eligible beneficiaries but there has not been a holistic assessment of the 

situation for older adults in the country. 

In Sub-Saharan Africa, undernutrition among older people ranges from 6 to 54% and is as high as 

28.4% in countries with low socioeconomic status (Obeng et al., 2022). The prevalence of 

undernutrition among older adults in Ghana is 48% (Flegal et al., 2014). Pneumonia is one of the 

primary causes of infection-related morbidity and mortality in the elderly (Troeger et al., 2017a) 

and has caused 6.8 million hospitalizations worldwide in 2015;450 million people develop 

pneumonia each year and 1.1 million in-hospital deaths. Healthy Aging is a decade program by 

the World Health Organization (WHO) and other organizations to promote healthy aging of the 

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aged with a policy framework to highlight the need for action across all sectors. Healthy aging 

seeks to develop and preserve the functional abilities of the elderly for health well-being and 

participation in society (Norman et al., 2021b). 

Research question  

What is the prevalence of malnutrition among hospitalized older adults with pneumonia at the 37 

Military Hospital in Accra? 

1.4 AIMS AND OBJECTIVES.  

1.4.1 Main aim  

To identify malnutrition cases and the predicators of malnutrition among hospitalized adults with 

pneumonia at the 37 Military Hospital in Accra. 

1.4.2 Specific objectives 

 To determine the prevalence of malnutrition and anaemia among hospitalized adults with 

pneumonia. 

 To assess dietary diversity and nutrient intake among hospitalized adults with pneumonia 

and its association with malnutrition. 

 To assess gender differences in health characteristics, nutritional assessment, and nutrient 

intake of study participants. 

 To assess the predictors (socio demographics, dietary intake, and health status) of 

malnutrition among hospitalized adults with pneumonia. 

1.5 SIGNIFICANCE OF STUDY  

The rise in the older population in sub-Saharan Africa (Ghana) is accompanied by increasing 

pressure on health facilities due to their higher risk of malnutrition leading to increased 

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susceptibility to diseases; however, there is insufficient information on geriatric nutrition in 

Ghana. 

 This study sought to fill this gap by identifying the population of the aged who are at 

risk of being malnourished or are malnourished. 

 This study will help identify nutritional problems that are of public health importance, 

as knowledge from the study will help influence nutrition intervention in the aged. 

 The findings of this study will provide information on geriatric nutrition, which will 

be relevant to stakeholders. 

 Contribute to achieving the action plan by WHO on healthy aging. 

 

 

 

 

 

 

 

 

 

 

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CHAPTER TWO 

2.0 LITERATURE REVIEW 

 

2.1 PREVALENCE OF AGEING ON THE POPULATION 

The ageing population is part of an ever-widening spectrum, ranging from healthy octogenarians 

to those suffering from chronic disease and disability. The elderly occupies more than two-thirds 

of general and acute hospital beds, and those 75years and above have longer hospital stays. Life 

expectancy has increased in the twenty-first century, and the population is expected to grow by 

56% between 2015 and 2030 (Nations, 2010; United Nations, 2016). The elderly population in the 

world is set to increase dramatically, by 2050; the aging population will have increased to two 

billion worldwide, with 400 million people aged 80, and 80% of the elderly in developing countries 

(World Health Organization, 2022). Aging is a global phenomenon, but as life expectancy rises 

and fertility rates fall, the world’s demographic structure has shifted leading to an increase in the 

aged population. In Ghana, the prevalence of adults 65years and older has increased with time, 

from 4.0% in 1984 to 5.3% in 2000, according to the Population and Housing Census Report which 

is anticipated to increase from 327,594 in the 1960 population census to 1,902,200 according to 

National Population Council, (2014) Ghana’s life expectancy increased from 45.5 years in the 

1960s to 67 years as of 2018 (Nationset al., n.d.). 

2.1.1 Dynamics and prevalence of malnutrition among the elderly 

There is no unified definition for the term malnutrition. It describes the lack of, excess of, or 

deficiency of nutrients, which has a detectable negative impact on body composition, function, 

and health outcomes. Undernutrition is a grave issue among the elderly, especially the sick, and it 

can be observed in hospitals, nursing homes, and communities. Undernutrition prevalence among 

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the elderly in the community ranges from 1.3% to 47.8% by the World Health Organization 

(ICOPE) and it is higher in developing countries than in developed countries, Research indicates 

15% of the aged malnourished with 85% of nursing home patients are severely underweight and 

up to 62% of hospitalized participants and 23% of those in nursing homes are overweight (Donini 

et al., 2013). In Sub-Saharan Africa, undernutrition among older people ranges from 6 to 54% and 

is as high as 28.4% in countries with low socioeconomic status (Obeng et al., 2022). However, in 

Ghana, the prevalence of undernutrition among older adult’s accounts for about 48% (Flegal et al., 

2014). Malnutrition in the elderly is particularly common in hospitals and nursing homes (Streicher 

et al., 2018). Malnutrition is a public health concern characterized by reduced fat and muscle mass 

because of a lack of food intake or absorption. Nutrition is a critical component of the elderly’s 

health and functional abilities, affecting their physical and psychological well-being (Norman et 

al., 2021a). The American Society for Parenteral and Enteral Nutrition (ASPEN) defines 

malnutrition as an acute, subacute, or chronic nutritional state with varying degrees of over- 

nutrition or under- nutrition. It is combined with or without inflammatory activity that results in 

changes in body fat composition and function. Nutrition transition in developing countries has 

increased prevalence rates of over-nutrition however undernutrition remains a public health 

concern (AbdAziz et al., 2017). Healthy diets and exercise are frequently emphasized in nutrition 

to prevent lifestyle diseases such as cardiovascular diseases, and diabetes. Malnutrition increases 

with age, which is mostly undiagnosed and untreated, malnutrition among the elderly is caused by 

complex factors such as polypharmacy, paleopathology, socioeconomic factors such as poor 

education, and poor financial status therefore the nutritional goals for the elderly including meeting 

greater nutrient needs with less energy and preventing lean muscle loss (Streicher et al., 2018). 

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The American Society for Parenteral and enteral Nutrition (ASPEN) and the Academy of Dietetics 

and Nutrition use two out of six criteria to assess malnutrition.” These criteria include low energy 

intake, weight loss, loss of muscle mass, fluid accumulation, and handgrip strength. while the 

Global Leadership Initiative on Malnutrition (GLIM) states that malnutrition is associated with 

one of the following: weight loss, low body mass index (BMI>20kg/m2), or reduced muscle mass 

(Agarwal et al., 2013). The elderly are more susceptible to poor nutritional status and are at risk of 

most nutritional deficiencies than younger people because malnutrition in the elderly is associated 

with reduced functional ability, impaired muscle function, low bone mass, micro-nutrient 

deficiencies, delayed wound healing, increased hospitalization and readmission rates, and 

mortality which results from chewing and swallowing disorders, atrophic gastric disease, social 

deprivation, financial issues, and loneliness (Ahmed & Haboubi., 2010). 

Malnutrition is also associated with physiological, environmental, social, and lifestyle factors such 

as loneliness, marital status, level of education, socio-economic status, and place of residence The 

elderly population is more prone to developing poor nutritional status due to tooth loss, reduced 

sense of taste, poor mobility, and these influence their dietary intake (Besora- Morenoet al., 2020). 

The consensus is that body fat mass increases until around the age of 75years when it begins to 

decline or remains stable, Evidence suggests that as fat mass decline in the central fat storage of 

the elderly increases which result in an increased risk of cardiovascular and another non-

communicable disease (Kyle et al., 2001).  

 

 

 

 

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2.2 TYPES OF MALNUTRITION AMONG THE ELDERLY 

2.2.1 Sarcopenia  

Sarcopenia is a syndrome described as a gradual and universal reduction of skeletal muscle mass, 

strength, and or physical performance, admittedly as a disease and assigned an international 

Classification of Diseases (ICD) code (Anker et al., 2016). Insufficient protein and calorie intake 

results in a reduction in muscle-building hormones such as insulin-like growth factor-1, 

Dehydroepiandrosterone sulphate, testosterone, and oestrogen (Hickson,2006). Alteration of 

inflammatory pathway activation and reduced physical activities also contributes to sarcopenia (Jo 

et al., 2012).  Aging is associated with 8% decrease in muscle mass between 40 and 70 years, 

 which increases to 15% per decade after a reduction in physical activity. Muscle loss can occur 

because of injury, disease, excess fat, lack of exercise, or simply poor diet and lifestyle factors 

such as stress and obesity (Dupont et al., 2019). The cause and effects of sarcopenia a summarized 

in figure 2.1. 

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Figure 2.1 Cause and effect relation with sarcopenia and malnutrition (Roubenoff, 2000). 

2.2.2 Anorexia  

Anorexia of aging is an age-related change such as a decrease in energy intake and an increased 

risk of malnutrition as people get older, Age-related anorexia is caused by decreased 

chemosensory functions, reduced psychological functions, environmental changes, and 

reduced hormone secretions that control appetite (di Francesco et al., 2007; Malafarina et al., 

2013). Daily food intake reduces by 30% between the ages of 20 and 80years, this is an age-

related physiological decrease in appetite and calorie intake (Giezenaar et al., 2016) the ages 

of 20–29 and 70–79 years, men's daily energy intake decreased by 38% (1138 kcal) and 

women's daily energy intake decreased by 27% (522 kcal), according to the American National 

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Health and Nutrition Examination Survey (NHANES) III. Reduction in energy expenditure is 

responsible for most of the energy loss during aging, however, calorie intake is lower than 

energy expended, resulting in weight loss (Morley, 1997) Anorexia of aging is linked with 

cachexia, sarcopenia, poor endurance, and impaired mobility in older persons and 

autonomously envisages morbidity and mortality in a variety of clinical situations 

(Tsutsumimoto et al., 2018). 

2.2.3 Wasting  

Wasting necessitates a negative energy balance throughout the body, which is induced mostly 

by a reduced dietary intake. The mechanism involved in wasting is loss of appetite. Wasting is 

a type of unintentional weight loss induced by a lack of nourishment. This can occur in the 

setting of cachexia, sarcopenia, or both, and can be caused by sickness or psychological factors 

(Saunders, 2010). 

2.2.4 Cachexia  

Cachexia is a metabolic disorder characterized by muscle loss and fat accumulation (or both). 

Cachexia is defined by weight loss, a lower BMI, decreased muscle mass function, and illness 

with persistently high inflammatory activity (Aoyagi et al., 2015). Pro-inflammatory cytokines 

are thought to be important in the metabolic inflammatory process or stress. They have a 

significant impact on hormone balance, metabolic regulation, and direct tissue effects. These 

cytokines have been linked to cancer, heart failure, HIV/AIDS, and COPD (Evans et al., 2008). 

The immediate immune reaction releases pro-inflammatory cytokines that disrupt hormone 

synthesis and metabolism resulting in cachexia (Corcoran et al., 2019). The aging population 

has a higher risk of cachexia due to their increased risk of malnutrition, and sarcopenia. 

Cachexia treatment options include better food, appetite stimulants, combination 

pharmaceutical therapy, and exercise (Ali & Garcia, 2014; Cederholm et al., 2015) 

 

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2.3.0 MALNUTRITION SCREENING TOOLS FOR THE ELDERLY  

The World Health Organization (WHO) has identified the importance of early detection of 

malnutrition and the provision of effective intervention to reduce the prevalence and risk of 

malnutrition in the elderly worldwide (Volkert et al., 2019). The ability to accurately identify 

malnourished individuals is dependent on the screening tool used by the researcher therefore, 

there are several malnutrition-screening tools based on their validity and the type to be used 

which include: 

2.3.1 Subjective Global Assessment (SGA) 

The Subjective Global Assessment is the benchmark for identifying malnutrition. It has been 

validated in a diverse patient population, to classify those who would benefit from intervention 

by taking a history of recent dietary intake, weight change, gastrointestinal symptoms, and a 

clinical evaluation (Prasad & Sinha, 2018). 

2.3.2 Nutrition screening initiative (NSI) 

The Nutrition Screening Initiative is a community-based program aimed at identifying and 

treating nutritional issues in the elderly. It is a questionnaire that estimates your nutritional risk 

by using typical warning indicators of malnutrition. The original nutrition-screening project 

was published in the American Journal of Clinical Nutrition (Anon., 1991). With a 

“DETERMINE” checklist which includes 

Disease: any existing chronic disease that can influence the dietary intake of the elderly non-

communicable diseases such as diabetes, hypertension, and cognitive problems can result in 

poor nutritional status of the aged. 

Eating Poorly: excess or/ and inadequate consumption of nutrients can result in malnutrition 

as most elderly turn to have a less diverse diet due to a lack of financial support and are not 

able to meet their dietary requirement. 

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Tooth loss and mouth pain: Ageing is associated with tooth loss and dry mouth, which 

influence their protein intake because they cannot the most of the animal-rich - protein-rich 

foods that makes eating difficult. 

Economic Hardship: Most of the elderly are dependent on their children for financial support 

since they are on retirement, and this can influence their dietary intake because they cannot 

consume their preferred foods and they are living below the standard resulting in malnutrition. 

Reduced Social Contacts: with the empty net stage, most elderly live alone resulting in 

depression and loneliness, which affect their dietary intake and health. 

Multiple Medication: Ageing is associated with most chronic diseases; therefore, older adults 

are on medications to manage such health problems however, these medications have several 

side effects such as loss of appetite, change in taste, drowsiness, and constipation, which 

influence the dietary intake of the elderly. 

Involuntary weight Loss or Gain: older adults are at risk of involuntary weight loss that is 

mostly classified as wasting and this is due to poor dietary intake and depression. 

Need Assistance in self-care: older adults need assistance with shopping, prescriptions, and 

cooking this is due to the reduction in bone density and vision loss of all older adult's needs 

and assistance for their daily activities. 

Elderly 80years and above; this stage of life is mostly associated with a higher risk of frailty 

and health problems there optimal is key.  

NSI also consists of ten questions on meal frequency, food preference, weight, meal 

preparation, and alcohol consumption. A total score of 0 to 2 by circling "Yes" next to each 

question indicates that you are well nourished while 3 to 5; you are at moderate risk of 

malnutrition, and above six means high-risk malnutrition (Posner et al., 1993). 

 

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2.3.3 Malnutrition Screening tool 

Malnutrition Screening Instrument (MST) is a straightforward two-way question-screening 

tool designed for volunteers and staff who work with senior adults. MST assigns a five-point 

scale to reflect the seriousness of the risk of malnutrition (Wu et al., 2012). Ferguson et al 

developed MST in 1999; this is a quick and easy screening test that includes questions 

regarding appetite, nutritional intake, and recent weight loss. A score of equal to or more than 

2, out of a total of 7, shows the need for a nutritional assessment and/or intervention. It is 

recommended for hospitalized, outpatient and institutionalized adult patients. To identify how 

to best assist an elderly person and what kind of follow-up is required (Serón-Arbeloa et al., 

2022). 

2.3.4 Nutrition Risk Screening -2002 

This is a malnutrition screening tool that considers a person's recent BMI (20.5kg/m2), current 

weight loss, poor dietary intake, and severity of the disease. The score ranges from 0 to 7, with 

0 indicating no risk of malnutrition, 1-2 indicating a lower risk, and 3-4 indicating a medium 

risk (Koren-Hakim et al., 2016). Its nutritional risk-screening tool is widely used in hospitals 

around the world. 

2.3.5 Geriatric Nutritional Risk Index 

The nutrition risk index was used to develop the GNRI, which is used for the development of 

nutrition related health problems in the elderly. The serum albumin level test, recent body 

weight, and ideal body weight are used to assess the nutritional status of the aged. A lower 

serum albumin level and weight loss indicate a greater likelihood of malnutrition-related health 

problems (Abd-El-Gawad et al., 2014). This formula can be used to calculate” GNRI values: 

[1.489serum albumin (g/l) +41. 7current body weight /ideal weight] “. An index of 98 or higher 

indicates no risk, 92-98 indicates lower risk, and 82 indicates a higher risk of malnutrition-

related health problems (Koren-Hakim et al., 2016; Stoffel et al., 2018). 

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2.3.6 Mini-Nutrition Assessment 

This is the commonest nutrition screening and assessment tool for the elderly. It has been 

approved for clinical use more than twenty years ago but has recently received additional 

attention and has been the subject of reappraisals to expand the practice of a full nutritional 

assessment of the elderly patient. MNA® has gone through three revisions since its inception 

in the 1990s. Geriatricians in the United States and Europe created the first MNA®. Which 

was a simple and reliable way of assessing the nutritional health of people over the age of 

65years and including a nutrition component in the Comprehensive Geriatric Assessment. The 

entire MNA® comprises 18 elements to determine nourished, malnourished, or at risk of 

malnutrition elderly. It has been used in hundreds of research and translated into more than 

twenty languages since its certification in 1994. It is a tried-and-true instrument with high 

sensitivity, specificity, and consistency. Patients with a score greater than or equal to 24 have 

excellent nutritional status, whereas individuals at risk of malnutrition have a score between 17 

and 23.5 (Vellas et al., 2006). “The Mini Nutrition Assessment short form (MNA-SF) originates 

from the MNA full questionnaire which has eighteen questions however, MNA- SF which was 

produced by Rubenstein and his colleagues is a complete version of the MNA full questionnaire 

but with six questions that can be completed within 10-15 minutes. MNA-SF is a quick 

nutrition assessment tool designed for the elderly, whether they are hospitalized, or not. 

Questions include nutritional status, health problems, motility, quality of life, cognition, 

mobility, and subjective health. The European Society for Clinical Nutrition and Metabolism 

has recommended this tool as a sensitive, specific, and accurate diagnostic rapid nutrition 

assessment tool for the elderly. It classifies the elderly into well nourished, malnourished, and 

at risk of malnutrition (Langkamp-Henken et al., 2005). 

In elderly patients who are bedridden and immobile, anthropometric measurements of BMI can 

take a long time; however, calf circumference (CC) and mid-arm circumference can be 

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measured quickly, on the other hand, are two simple tape measure alternatives to BMI due to 

its correlation with serum albumin, calf circumference is a specific biomarker for sarcopenia 

(Kaiser et al., 2009). Each question has a score that is used to determine whether the person is 

malnourished: 12-14 indicates well nourished, 8-11 indicates malnourished, and 0-7 indicates 

malnourished (Koren- Hakim et al., 2016; Slee et al., 2015). 

2.4 NUTRITION RELATED ISSUES OF MALNUTRITION IN THE ELDERLY 

Determinants of malnutrition are classified into medical, social, and psychological. Dentition, 

dysgeusia, dysphagia, diarrhoea, depression, disease, dementia, dysfunction, and medications 

are elements that influence the elderly's diet, and these issues can harm the senior population's 

environment, which has been associated to poor nutrition (Poulia et al., 2012). According to 

studies, older individuals who live in hospitals or care homes are more likely to be 

malnourished than those who reside in the community (Kucukerdonmez et al., 2017). The aging 

process is a leading cause of malnutrition among the elderly, while there are common problems 

such as sarcopenia, cachexia, diminished sensory function, social and economic deprivation, 

existing comorbidity, and gastrointestinal changes that influence the nutritional status of the 

aged. 

2.4.1 DIET- RELATED ISSUES AMONG THE ELDERLY 

2.4.1.1 Poor Appetite 

The most prevalent cause of malnutrition is anorexia, or a lack of appetite, caused by a variety 

of circumstances. It is an established knowledge that as people age, their energy intake 

decreases, resulting in nutritional deficits. The lack of appetite that occurs during the elderly is 

attributed to gastrointestinal-related changes and changes in the central nervous system. Aging 

influences the full function of the gastrointestinal tract as it affects motility, enzyme, hormone 

secretions, digestion, and absorption. Making it difficult to rule out pathological conditions like 

diabetes, pancreatitis, liver disease, and cancer. 

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2.4.1.2 Oral cavity 

Oral health and dentition also effects food intake, which deteriorate as people age. The survey 

of oral health in the National Diet and Nutrition Survey reveals chewing and mouth dryness 

conditions such as oral candidiasis, aphthous stomatitis, and dry mouth are high among aged 

65years and above, which explains the decrease in salivary quality and quantity in the elderly 

(D'Souza, 2007b). Chewing problems have been related to poor health and reduced quality of 

life. According to dietary statistics from the National Institutes of Health, edentate people had 

decreased energy consumption, as well as micronutrient deficiencies such as calcium, iron, 

vitamins A, B, C, and E, fibre, and protein. 

2.4.1.2 Oesophagus 

Changes in the oesophagus of the elderly have evolved over the years from pre-by- oesophagus 

which describes the physiologic changes in swallowing associated with aging currently, 

oesophageal changes in the elderly are associated with their co-morbidity which results in the 

decrease in oesophageal peristalsis and emptying (Robbins et al., 2006), causing oesophageal 

dysphagia which is food being a stick in the chest caused by the obstruction of the oesophagus 

or the compression of the tissue the oesophagus which increases the risk of aspiration among 

the elderly(Durazzo et al., 2017). According to studies, a third of the elderly has reduced saliva 

production, which slows peristalsis and increases the risk of constipation, slower peristalsis can 

potentially contribute to early satiety by delaying oesophageal emptying and early satiety is a 

major factor in the aged population's lower food intake (Pilgrim et al., 2015) 

 

2.4.1.3 Decreased sensory functions. 

The aged population’s sensory function deteriorates as they age, reducing their enjoyment of 

eating. This is the alteration of taste or an impaired sense of taste that occur during aging, it is 

associated with the side effects of certain medication and the lack of zinc among malnourished 

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aged. Dysgeusia and ageusia are linked with diseased of the nervous system (Jain & 

Pitchumoni, 2009). Taste and smell are associated with appetite loss due to a perceived decrease 

in food pleasantness; however, the loss of taste and smell is common, and it is worsened by 

illness and medications. Some elderly people have multiple health conditions that require at 

least three medications to maintain a balanced diet. The body's response to food is affected by 

the cephalic phase response, which prepares the body for digestion. The elderly's taste and scent 

are influenced by polypharmacy, resulting in a lack of appetite also, the loss of taste and smell 

can be attributed to the decreased receptors functioning in cell membranes involved in the taste 

sensation. Appetite and thirst will be dysregulated because of sensory alterations. Food may 

lose its attraction due to sensory changes, and the elderly may find it difficult to cook and eat 

normally when their vision deteriorates (Amarya et al., 2015). According to Siddique et al., 

(2017) about 74% of the elderly population experience taste impairment while more than 60% 

of the elderly subject in a study conducted by Ahmed& Haboubi, (2010) also had reduced sense 

of taste and smell and this may also be because of certain medications. These changes and other 

factors such as poor dietary intake, loneliness, and physiological, and health changes influence 

their nutritional status. 

2.5 GASTROINTETINAL CHANGES DURING AGEING 

The elderly is 85% more likely to become malnourished due to changes in the gastrointestinal 

tract. A combination of stomach wall relaxation and the hormone cholecystokinin determines 

satiety. As people get older, their CCK levels rise, and their stomach emptying slows. TNFa, 

IL1, IL6, and serotonin are all known to cause anorexia and may contribute to accelerated 

muscle breakdown and nitrogen losses. These chemicals are also known for appetite regulation, 

causing loss of appetite in the elderly. 

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2.5.1 The stomach 

Ageing is associated with the alteration of the gastric microbat, reduced mucosal protective 

mechanism, and decreased gastric blood flow. There is a reduction in the secretion of gastric 

acid and pepsin as people age, which limit the digestion and absorption of nutrients such as 

vitamin B12, iron, and protein (Corcoran et al., 2019). The decline in gastric acid secretion is 

associated with a high prevalence of helicobacter pylori infection, atrophic gastritis, and peptic 

and gastric ulcers in the elderly. Sensitive changes in the gastrointestinal tract are linked with 

a decline in gastric fundus receptive relaxation, resulting in faster antral filling of the stomach, 

slower peristalsis, and constipation (D’Souza, 2007a). Insulin levels are higher in the elderly, 

which enhances satiety by increasing leptin while blocking ghrelin, the hormone that promotes 

appetite (Ahmed & Haboubi, 2010). 

2.5.2 The small intestine 

Hormone secretion and absorption in the small intestine are not significantly altered in the 

elderly compared to their younger counterparts (D’Souza, 2007b). In the absence of a 

concurrent illness, minor abnormalities in the small intestine such as abnormal mucosal 

immunity and motility are found, but these are clinically insignificant. A study on humans 

found that while certain morphologic changes may occur, they are typically not significant 

enough to result in malabsorption (Drozdowski & Thomson, 2006). 

2.5.3 Large intestine 

It has been investigated to determine if the aging process affects gastrointestinal motility and 

lengthens colon transit time. It is still unclear whether age is a risk factor for issues with large 

intestine motility because the results of this research were conflicting. While Metcalf et al., 

(1987) discovered that aging did not affect colon transit time, Madsen & Graff, (2004) 

discovered the opposite, that aging increased colon transit time in those aged 80 and up. 

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However, there is a change in human gut microbiota that occurs in the large intestine because 

Bifidobacterium and an adult dominate an infant’s microbiota however in the elderly these 

Bacteroidetes and firmicutes can result in inflammatory bowel disease and metabolic 

abnormalities (Magrone & Jirillo, 2013). 

2.5.3 Health -related issues of malnutrition in the elderly 

The Central Nervous System is also involved in food intake regulation, as are numerous 

neurotransmitters. Nitric oxide may be important in appetite regulation coordination. Opioids 

are thought to increase food consumption in young adults, and the loss of opioid receptors and 

lower levels of endogenous opioids in the brain is linked to aging, which influences food intake 

(Chapman, 2004). 

2.5.4 Gastroesophageal Reflux Disease 

This is the commonest condition associated with aging affecting about 23% of the elderly in 

the nursing home according to (Moore et al., 2012). GERD occurs after eating as the reflux of 

the stomach context results in complications. This may be due to motility disorder, decreased 

saliva, and cause heart burns. Changes in the oesophageal can also result in odynophagia and 

community- acquired pneumonia. Poly-pharmacology can also result in the inflammation of 

the oesophagus and ulceration affecting the dietary intake of this group thereby increasing their 

risk of malnutrition (Wilcox, 2013). 

2.5.5 Oropharyngeal dysphagia 

This is the sensational difficulty in chewing and swallowing caused by the neuromuscular 

mechanism that regulates the throat, tongue, pharynx, and upper oesophageal sphincter 

(Durazzo et al., 2017), this is common in the elderly with neuromotor disorders. About 50% of 

aged in nursing homes have this condition and are not aware until it gets complicated which 

results in aspiration pneumonia, malnutrition, and dehydration. Symptoms include cough with 

swallowing, food sticking in the throat, and nasal regurgitation (Cabre et al., 2010). 

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2.5.6 Depression and other psychological problems 

Alzheimer's disease can lead to weight loss and changes in eating and drinking patterns. 50% 

of patients with Alzheimer's disease lose their capacity to eat, drink, and smell which is a key 

component of taste. Weight loss and changing eating patterns are well-known indicators of 

advanced psychological diseases. This could have an impact on the eating patterns and food 

consumption of these patients (Gilbert et al., 2022). Poor dietary intake is a hallmark of 

depression, and research has shown that bereavement is a common determinant of weight loss 

and malnutrition among the aged. 

2.5.7 Comorbidity 

The coexistence of two or more related medical conditions in the elderly also affects their 

nutritional status because these conditions such as hypertension, diabetes, and metabolic 

syndrome increase their risk of malnutrition, as all these conditions results in multiple 

medications and dietary modifications that prevent the aged from consuming their preferred 

food choices, and with their decreased appetite, these conditions affect their dietary intake 

resulting in malnutrition. 

2.6 SOCIO-ECONOMIC RELATED FACTORS TO MALNUTRITION 

The health and nutrition status of people relates to demographic features, socioeconomic status, 

adequate and proper nutrition, and access to essential social amenities such as food, water, and 

electricity. Age, gender, township status, and ethnicity, are all key factors in demography that 

affects the elderly's quality of life and nutritional health. Ghana, like other African countries in 

similar socioeconomic situations, is no exception when it comes to the poor health of the 

elderly. The elderly is on retirement making them less active and lonely which makes them 

more dependent on others and this affects their health and financial status. Loneliness and 

isolation from society and children have a profound influence on nutrition as it limits their 

functional capabilities and social status and difficult in accessing social services, however, 

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loneliness has been associated with depression and poor dietary intake increasing their risk of 

malnutrition as the Chinese proverbs state that elderly death does not come with age but with 

abandonment. A study by Pranjic et al., (2011) reported that loneliness is a predictor of anorexia 

nervosa and increased the risk of malnutrition affecting their quality of life, information on 

isolation and income from the “National Diet and Nutrition Survey” for the elderly indicates 

that aged who lived alone consumed less energy than those who lived with others. Lower-

income people consumed much less energy, protein, fibre, and a variety of micronutrients. 

Social factors such as poverty and low levels of education among the aged can result in 

inadequate knowledge about nutrition resulting in a monotonous diet that predisposes them to 

malnutrition and affects food availability and nutritional status through their inability to shop 

and cook (Donini et al., 2013). Economic hardship during this stage affects the elderly 

population on their food and nutrition security as they turn to consume energy-dense food 

which is less nutritive resulting in poor nutritional status moreover poverty is associated with 

lower educational level because most elderly who were not enrolled in government work is not 

entitled to a pension fee, therefore, they will rely on older children for financial support. The 

most indigent elderly group must choose between buying prescribed drugs and healthy food 

(Besora-Moreno et al., 2020). Figure 2.2 show the effects ageing on nutrition. 

 

 

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Figure 2.2 Effects of ageing on nutrition 

2.7 EFFECTS OF MALNUTRITION ON THE ELDERLY 

2.7.1 Immune dysfunction 

Immune senescence, or the aging of the immune system, has long been connected to negative 

alterations in the immune system. Malnutrition has a substantial effect on the immunity of the 

elderly, raising the risk of sepsis. As we age, the body amasses damage to molecules, cells, and 

organs, resulting in weak immunity and an increased risk of disease (Pae et al., 2012), the 

immune system is affected by aging, the impact is not equal; certain immune system 

components are more dramatically damaged than others as they grow older (Amarya et al., 

2015). The elderly has a weakened immune system and are more prone to disease, which is 

influenced by inadequate diet. Nutrients such as zinc, vitamin E, and vitamin D stand out as 

nutritional components recognized to be significantly crucial for healthy immunity, however, 

the elderly are lacking in these micronutrients, resulting in immune system dysregulation. (Pae 

& Wu, 2017) Even while low zinc serum levels and vitamin E levels are common in the elderly, 

zinc deficiency can cause immune system abnormalities such as impaired T-cell response, 

decreased lymphocyte proliferation, and a diminished delayed-hypersensitivity response. 

However, appropriate micronutrient consumption at daily-recommended levels has been found 

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to help the elderly regain their immune systems and lower the risk of respiratory infections. 

Vitamin D is necessary for bone metabolism, and insufficiency is significantly more common 

among the elderly, leading to an increased risk of infection (Pae & Wu, 2017). 

2.7.2 Nutrient deficiency 

Decreased appetite among the elderly is associated with reduced nutrient intake while the 

changes in the GIT are also associated with decreased absorption resulting in nutrient 

deficiencies that can influence the nutritional status of the aged (Ahmed & Haboubi, 2010), 

due to the age-related decrease in the production of an intrinsic factor for the absorption of 

vitamins B12 in the gut and this is associated with impaired cognitive development, increased 

levels of homocysteine and macrocytic anaemia (Wells & Dumbrell, 2006). 

2.7.3 Folate deficiency 

Folate absorption decreases with aging with about 50% of the hospitalized elderly deficient in 

vitamin B9. Folate deficiency is associated with an increase risked of cardiovascular disease, 

colorectal cancer, dementia, and depression in the elderly (Ahmed & Haboubi, 2010; Reynolds, 

2002) 

2.7.4 Vitamins D and calcium deficiency 

The aging process is linked with the wear and tear of bones de Vries et al., (2013) and the 

decrease in food intake during this process can result in inefficient levels of vitamins D and 

calcium that are needed for bone mineralization. This decline in vitamins D and calcium may 

result in reduced mobility and increased risk of fractures, especially among elderly women 

resulting in osteoporosis, this is high in women because of the lack of testosterone due to 

menopause therefore supplementation and dietary modification are key at this stage to prevent 

hip fractures (Ahmed & Haboubi, 2010; Wells & Dumbrell, 2006). 

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2.7.5 Iron deficiency anaemia 

Hospitalization, disability, mortality, a deterioration in physical performance, reduced quality 

of life, and diminished muscle strength are all associated with anaemia, which is one of the 

most prevalent micronutrient deficiencies among the elderly (Penninx et al., 2003). According 

to the World Health Organization (WHO), anaemia is defined as a drop in haemoglobin 

concentration of more than 13 g/dL in men and more than 12 g/dL in women, with mild grade 

anaemia defined as Hb concentration of 10.0 to 11.9 g/dL in women and 10.0 to 12.9 g/dL in 

men. Approximately 3 million older adults are anaemic, with more than 20% between the ages 

of 85 and above, and 11 percent and 10.2 percent for men and women 65 and older, respectively. 

Two-thirds of the elderly who are anaemic have two or more associated diseases. (Guralnik et 

al., 2004). The commonest form of anaemia among the elderly is iron deficiency anaemia; 

however, there are four main types of anaemia in the elderly, depending on the causes of 

anaemia: nutrient deficiencies, chronic kidney disease, chronic disease, or inflammation (ACI) 

or chronic renal disease, and unexplained anaemia (UA) (Bianchi, 2016). 

2.7.6 Diseased and disabilities 

Malnutrition may result in increased hospitalization and all forms of infection resulting in high 

dependence and increased cost. The elderly is prone to several diseases due to poor nutritional 

status as the high risk of malnutrition worsens illness among this group resulting in disabilities 

or morbidities or even death. 

To conclude malnutrition is more common in the aged as body composition and energy storage 

change with age, making it a public health concern. Because malnutrition among the elderly is 

so complex, several extra aspects must be addressed to build effective treatment regimens. 

Although providing adequate dietary intake and nutrients is critical in the treatment of 

malnutrition, an intervention will not be effective if it is not combined with lifestyle and 

socioeconomic factors. 

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2.8 PNEUMONIA INFECTION AND UNDERNUTRITION IN THE GHANAIAN 

ELDERLY POPULATION 

Pneumonia consistently is the leading cause of morbidity and mortality worldwide (Lozanoet 

al., 2012). It is defined as an inflammatory condition of the lung primarily the alveoli mostly 

caused by a variety of microorganisms such as bacteria, viruses, and fungi. Pneumonia is one 

of the leading causes of infection-related morbidity and mortality in elderly patients (Troeger 

et al., 2017b). In 2015, pneumonia was the 4th cause of death in low- and middle- income 

countries however community-acquired pneumonia is underestimated because a patient with 

mild infection does not seek medical attention therefore CAP is underreported (Heron, 2017). 

Pneumonia is one of the most common and fatal infectious diseases worldwide. It is a bigger 

issue among the aging population as there is an increase in the number of cases and deaths 

every decade. The elderly and younger patients have different clinical presentations of 

pneumonia due to multiple factors, including functional status (self-reliance and immobility), 

comorbidities, nutritional status, and swallowing difficulties among the elderly. Pneumonia in 

the elderly is distinguished by where it is acquired (Mandell et al., 2007). 

The prevalence of community-acquired pneumonia (CAP) is approximately 3 episodes/per 

1000 persons in those aged between 65 and 69 years and increases to 22/1000 persons between 

the ages of 85 and 89 years (Millett et al., 2013). Clinical pneumonia caused 6.8 million 

hospitalizations worldwide in 2015, with approximately 1.1 million deaths. Hospital admission 

of pneumonia increases with age and is prevalent in men. The increased prevalence of 

pneumonia among the aged is attributed to the physiological changes associated with the aging 

process of the respiratory tree and reduced immunity. Streptococcus pneumonia is the 

commonest pathogen that causes CAP it enters the lower respiratory through aspiration of the 

oropharyngeal section progressing to cause pneumonia, however, this progression is dependent 

on the virulence of the pathogen to the host immune system, the volume of aspiration, 

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frequency of the aspiration and the inoculum of the pathogen (Torres et al., 2013a). 

Streptococcus pneumonia is a bacterial pathogen that colonizes the host's nasopharynx and 

upper airway mucosal surfaces (Willis et al., 2009). These organisms can travel from the upper 

respiratory tract to the sterile parts of the lower respiratory tract by a combination of virulence- 

factor activity and the capacity to elude the early components of the host immunity, resulting 

in pneumonia (Kadioglu et al., 2008). 

2.8.1 Classification of pneumonia 

 Community-acquired pneumonia (CAP); is an infection acquired outside of the 

hospital setting. 

 Nursing home-acquired pneumonia (NHAP); infection acquired over a stay within 

the nursing home. 

 Hospital-acquired pneumonia (HAP) or ventilator-associated pneumonia is defined 

as pneumonia that occurs 48 hours or more after hospitalization, whereas VAP 

usually occurs more than 48–72 hours after endotracheal intubation. 

 Healthcare-acquired pneumonia (HCAP) occurs in patients with frequent contact 

with the health system, numerous antibiotic intakes, and/or a functional state of 

frailty. 

 

2.8.2 Risk factors of community-acquired pneumonia among the elderly. 

Everyone is at risk of acquiring pneumonia however studies shows that the aged and infants 

are at more increased risk of acquiring pneumonia because the infant has an underdeveloped 

immune system with makes them more vulnerable to most infection while the aged are at risk 

because of lifestyle activities, nutritional status, comorbidity, overcrowded household, poor 

dental care, and age. 

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2.8.3 Lifestyle activities 

Lifestyle activities such as high alcohol intake, smoking, and regular contact with children are 

linked with an increased risk of Community-Acquired Pneumonia. These lifestyle activities 

such as smoking and alcoholism have harmful to the respiratory epithelial tissue and the 

clearance of pathogens from the respiratory tract while alcohol is associated with a negative 

impact on the immune system resulting in an increased risk of CAP (Nelson & Kolls, 2002) 

and frequent contact with children can also result in CAP among the elderly (Schnoor et 

al.,2007). 

2.8.4 Comorbidities 

Several comorbidities are associated with CAP and these include cardiovascular disease, 

COPD, history of respiratory diseases, patients with cerebrovascular and neurological disorders 

are twice at risk of CAP because these conditions are associated with swallowing problems, 

aspiration, and the use of sedative drugs for comorbidity is such as diabetes, chronic renal 

failure and cancer are associated with impaired immunity which will result in ahigh risk of 

CAP (Schlienger et al., 2007; Torres et al., 2013b). 

2.8.5 Nutritional status 

The nutritional status of an individual can also increase the risk of pneumonia because a 

person's nutritional status affects his/her immune system and increases nutritional deficiencies 

thereby the pathogen can easily progress in the host. Under-nourished individuals are at a 

higher risk of acquiring pneumonia and an individual with normal bodyweight. 

2.8.6 Age and Poor dental care 

Age increases the risk of acquiring pneumonia due to the changes that occur during aging and 

the decreased immune function (Cillóniz et al., 2013). Poor dental care can also increase the 

risk of CAP due to the formation of cavities, which are caused by bacteria and these bacteria 

can travel into the respiratory tract and then progresses to pneumonia. 

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CHAPTER THREE 

3.0 METHODOLOGY 

3.1 STUDY SITE  

This study was conducted at the Public Health department of the 37 Military Hospitals in the 

Greater Accra region of Ghana. The 37 Military hospital is the largest military hospital in 

Ghana; it is a specialist hospital in Greater Accra located between Airport Road and Accra 

central. It is about five (5) miles from the University of Ghana. This hospital is a referral and 

tertiary hospital in Greater Accra with Public Health Unit that caters for infectious diseases and 

has the capacity as well as medical expertise to manage bacterial infections. 

3.1.1 Study design  

This study was cross-sectional that involves a one-time data collection; this study design allows 

research to be conducted on an entire population or subgroup to establish an association 

between an exposure and an outcome in a population at a specific time. This design is used to 

ascertain the prevalence and generate hypotheses, which serve as a ground for future research 

(Olsen et al., 2004; Gordis 2009). This study uses a quantitative research method. 

3.2 STUDY POPULATION, SAMPLE SIZE DETERMINATION AND SAMPLING 

TECHNIQUE 

3.2.1 Study population 

This study was conducted among the elderly 60years and above who has been diagnosed with 

pneumonia at the 37 Military Hospital, Participants who qualified for the study were provide 

with an informed consent and then recruited from each hospital after they have been suspected 

or diagnosed with pneumonia infection through a rapid test for pneumonia. 

3.2.2 Sample Size Determination 

The carriage of pneumonia in the elderly in Ghana is not known however, the prevalence of 

influenza and pneumonia in Ghana is 9.29% (Influenza and Pneumonia in Ghana, n.d.). 

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 Therefore, the sample size determination was based on a formula quoted by Metcalfe, (2001) 

n= Z P (1− P) ÷ 𝐝2 

Where n = sample size; Z = Z statistic for a level of confidence; P = expected prevalence or 

proportion; d = precision. 

Where Z=1.96 (for 95% confidence interval), P=9.29% = 0.926 (prevalence of pneumonia 

among adults in Ghana) and d=5% = 0.05, the formula gives a sample size of 54 participants 

thus, 54 pneumoniae infected patients from 37 Military hospital. Using the G-power post hoc 

analysis, the sample size of 54 participants used in this study had a power (1- β) of 99.7%. 

3.2.3 Population Sampling 

Convenience sampling was used to recruit it study participants who meet the inclusion criteria, 

which are patients 60years and above, who have tested positive for pneumonia and has not 

been in the hospital for more than 72hours. 

3.2.4 Inclusion Criteria and Exclusion Criteria 

Patients were included in the study if they were: 

• Aged 60 years and above. 

 

• Infected with pneumonia. 

 

• Hospitalized for less than 72 hours. 

 

• Willingness to participate. 

 

Patient were excluded from the study if they were: 

• Presence of lung malignancies 

• Presence of upper respiratory tract infections at the time of sample collection 

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3.3 DATA COLLECTION 

A semi-structured questionnaire was pre-tested among five (5) participants at the Mother Love 

clinic. This made it easier for the investigator to assess the validity, dependability, and accuracy 

of the instrument before the start of data collection. Pre-testing was done to estimate the time 

for each interview and the number of interviews the researcher would be able to conduct per 

day. 

3.3.1 Questionnaire Survey 

The information from patients who volunteered to take part in the study were gathered using 

semi-structured questionnaires. To compare the participants' backgrounds, socio- demographic 

information was obtained through interviews with the participants. This data contained 

information on age, marital status, education level, and occupation. Details about their health 

status, including comorbidities, polypharmacy, exposures, and antibiotic use were also 

obtained. 

3.3.2 Anthropometry and Biochemical Assessment 

3.3.2.1 Anthropometric Assessment 

A weighing scale, a stadiometer, a measuring tape, a board maker, and a mid-upper arm 

circumference tape (MUAC) tape were used to evaluate anthropometric data. 

3.3.2.2 Weight Measurement 

A weighing scale was used to measure the weight of the elderly. They were weighed without 

jewellery, bulky clothing, shoes, or slippers. The shoeless adults were told to stand with their 

heads held high in the centre of the scale. The scale was placed on a level, solid surface, and it 

was tarred. Measurements were done twice and recorded to the nearest 0.1 kilograms (de Onis 

et al., 2004). The scale was tarred after each weighing to ensure accuracy. The pre- recoded 

weight of the immobile patient was taken from their file. 

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3.3.2.3. Height measurement 

Each respondent's height was determined using a stadiometer. Without shoes or slippers, 

respondents' height was measured with their heads, ankles, and legs against the wall as they 

stood tall and straight on a smooth, flat surface (On the stadiometer). Women were advised to 

lower their ponytails and take off their hair accessories. Measurements were obtained twice 

and reported to the nearest 0.5 cm (de Onis et al., 2004). Participants, who could not stand, 

were measured with a tape while lying down to take their recumbent length. 

3.3.2.4 Body Mass Index 

Body mass index (BMI) classifications were developed based on associations between BMI 

and chronic disease and mortality risk in unhealthy populations. The BMI of adults considering 

unintentional weight loss, maintenance of lean mass, and the presence of co-morbidities that 

would influence the nutritional status of the elderly according to Winter et al. (2014), therefore, 

the body mass index of participants was categorized using this formula: 

BMI (kg/m²) = Weight (kg) / Height (m²) 

Table 3.1 Body Mass Index Classification for the elderly 

BMI NUTRITIONAL STATUS  

≤ 23 kg/m2 Under-weight  

24 – 30 kg/m2 Healthy weight  

>30 kg/ m2 Overweight  

Source :( Winter et al., 2014) 

 

3.3.2.5 Mid Upper Arm Circumference 

MUAC measurement was done on the left arm of the participants. The elbow of the arm was 

bent at a right angle. The olecranon process and the acromion were found and designated as 

the midpoint between the shoulder tip and the elbow tip. The tape was wrapped around the 

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designated location after straightening the arm. To obtain an average, two readings were 

collected. (WHO; UNICEF, 2009) 

3.3.2.6 Calf circumference 

Measurement was done with the participant sitting and the foot on the ground folded at 90 

degrees, trousers and dresses were pulled up to expose the bare leg. The tape measure was 

wrapped on the widest part of the calf and to obtain an average, the reading was obtained twice. 

3.3.2.7 Biochemical Assessment 

Biochemical information was assessed using, a haemoglobin meter (URIT-12), cotton wool, 

strips, lancets, and 70% alcohol were utilized. The participants' haemoglobin concentrations 

were measured using the haemoglobin meter (URIT-12). The thump was used to obtain blood 

samples. To avoid contamination, the thump was wiped with cotton wool and 70% alcohol 

while wearing a disposable hand glove. A lancet was used to pierce the finger, and a drop of 

blood was then taken and placed on (URIT-12) haemoglobin meter strips then strips were put 

into the haemoglobin meter right away for reading and value were recorded. Participants who 

had recent laboratory reports on their HB levels had their values reported in g/dL. 

3.3.4 Dietary Assessment 

Participants and their guides were asked to provide detailed information about each food or 

drinks, such as its preparation technique and other properties, as well as an estimate of the 

portion size consumed the previous day before the interview day using a 24-hour dietary recall. 

With the aid of the UNICEF food models, the estimated portion sizes of the foods were 

recorded for dietary intake estimation. A single 24-hour dietary recall was used to assess the 

participants' dietary patterns. 

3.3.5 Mini Nutritional Assessment tool (MNA) 

The MNA® is a validated geriatric screening tool for the elderly that determines the nutritional 

status of participants. MNA is used to identify malnourished participants or those at risk of 

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malnutrition. It comprises eighteen elements divided into four categories: anthropometry, 

general health, dietary habits, and self-perceived health and nutrition. It is a tried-and-true 

method with high sensitivity, specificity, and consistency. Patients with an MNA score of > or 

= 24 have excellent nutritional status, patients at risk of malnutrition have a score between 17 

and 23.5, and patients with MNA > 17 are malnourished" (Vellas et al., 2006). 

3.4 DATA ANALYSIS 

3.4.1 Questionnaire Survey 

SPSS version 26 (statistical program for social science) was used for data management and 

analysis. Continuous values were reported as mean and standard deviation, whereas categorical 

variables were represented as frequencies and percentages. 

3.4.2 Anthropometric data 

Weight and height anthropometric data were converted to the body mass index (BMI). The 

body mass index of the participants was analysed by creating three categories, namely 

underweight, healthy weight, and overweight, by Winter et al. (2014), with a cut-off of 23.9 

kg/m2 for underweight, 24kg/m2- 29.9kg/m2 for a healthy weight, and 30 kg/m2 for 

overweight. The formula below was used to determine the BMI cut-off values and assess the 

women’s nutritional status in the study population. Formula for BMI (kg/m²) = Weight 

(kg)/Height (m²) 

3.4.2.1 The mid-upper arm circumference (MUAC) and calf measurements 

The mid-upper arm and calf circumference were classified by the MNA screening tool cut-off 

points, which were categorized into malnourished ˂  21 cm, at risk of malnutrition 21cm- 22cm, 

and well-nourished ˃22cm, while calf measurement indicator was categorized according to the 

MNA screening tool cut-off-point as is <31 cm malnourished and is >31 well-nourished. 

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3.4.3 Dietary diversity assessment 

The Food and Agriculture Organization (FAO) guideline was also used to assess dietary 

diversity scores (DDS) (Kennedy et al., 2011). The dietary diversity score was categorized into 

low, medium, and high. If participants consume less or equal to three food groups were 

classified as Low dietary diversity while those who consume more than six food groups has 

High dietary diversity and those in the Medium dietary diversity category consume between 

four and five food groups. The Dietary Diversity Score was therefore categorized into adequate 

and inadequate dietary diversity, where <5 food groups inadequate, and >5 food groups are 

adequate. The Ghana Foods Nutrients Database was used to analyse the nutrient intake of the 

individual meals and snacks consumed by the participants, using the Ghana Foods Database, 

the individual meals were used to calculate the daily caloric intake and the recommended 

dietary intake for macronutrients, vitamins, and micronutrients. The total caloric intake for 

adults 60 years and above is 1600-2000kcal for women and 2000-2800kcal for men, while the 

dietary reference intake of the macro and micronutrients were also established (IOM, 2006). 

3.4.4 Anaemia data 

According to World Health Organization guidelines, anaemia is classified into four categories: 

normal, mild, moderate, and severe. Non-pregnant women: 12.0 g/dL or higher, 11.0 g/dL-11.9 

g/dL, 8.0 g/dL-10.9 g/dL and 8.0g/dL." Men: 13.0 g/dL or higher, 12.0 g/dl-11.9 g/dL, 10.9 

g/dL-9.0 g/dL, and 8.0 g/dL; thus, participants' haemoglobin levels were classified by anaemia 

status (anaemic vs. non-anaemic) using WHO cut-offs (WHO, 2011). Frequencies and 

percentages were generated for each category. 

3.4.5 Health status data 

Participants' health status was evaluated using self-reported and diagnosed conditions from the 

folders. The temperature and pulse of the participants were measured using a pulse meter and 

a thermometer, while a sphygmomanometer was used to measure their blood pressure results 

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were expressed as means and standard deviation.  Comorbidity was classified as participants 

with more than one medical condition aside having pneumonia. Participants who were 

hypertensive, diabetic, or had stroke, cancer, and had coronary heart disease from the semi- 

structure questionnaire were classified as comorbid. A chi square analysis was done and those 

variables that where statistically significant were added into a regression model for further 

analysis to assess the relationship between comorbidity and malnutrition. 

3.5 ETHICAL ISSUES 

Ethical clearance was obtained from the Noguchi Memorial Institute of Medical Research 

institutional review board (NMIMR- IRB 006/21-22) and the Ethics and Protocol Review 

Committee of the 37 Military Hospital (37MH- IRB/MAS/IPN/538/21). 

 3.5.1 Participants consent 

All study participants gave written informed consent in person, in the presence of a witness, 

confirming that they understood the purpose of the study and gave their consent to participate 

in it. The issues of obscurity, confidentiality, benefits, risks, and freedom to participate or 

withdraw from the study were fully explained to the participants. 

 

 

 

 

 

 

 

 

 

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CHAPTER FOUR 

4.0 RESULTS 

4.1 BACKGROUND CHARACTERISTICS OF PARTICIPANTS 

A total of 54 pneumonia-infected individuals were involved in this study. The minimum age of 

participants was 60 years, with the oldest being 99 years. The mean and standard deviation of 

participant age is shown in Table 4.1. The majority (63.75%) of the participants were women, 

with more than half (64.0%) of the males being married and while (55.2%) of the females 

widowed. A little over half (58.6%) of the female participants were 75 years old or older, while 

most (68.0%) of the males were between 60 and 74 years old. Males had the tertiary education 

(40.0%), while most (34.5%) females had secondary and primary education. Most (92.0%) and 

(93.1%) of males and females had no occupation. Table 4.1 shows no significant association 

between demographic characteristics and gender. 

Table 4.1 Socio-Demographic characteristics of participants (N=54) 

              Gender 

Variables  Total  

(N=54) 

Male  

(N=25) 

n (%) 

Female  

(N=29) 

n (%) 

Age 

   Adults (60-74yrs) 

   Older Adults (75 and above) 

 

29(53.7) 

25(46.7) 

 

17(68.0) 

8(32.0) 

 

12(41.4) 

17(58.6) 

Marital Status 

   Married  

   Divorce  

   Widowed  

 

28(51.9) 

3(5.6) 

23(42.6) 

 

16(64.0) 

2(8.0) 

7(28.0) 

 

12(41.4) 

1(3.4) 

16(55.2) 

Level of Education 

   No Formal Education   

   Primary  

   Secondary  

   Tertiary   

 

14(25.9) 

9(16.0) 

18(33.3) 

13(24.1) 

 

4(12.0) 

3(12.0) 

8(32.0) 

10940.0) 

 

10(34.5) 

6(20.7) 

10(34.5) 

3(10.3) 

Occupation  

   Not- working  

   Working  

 

50(92.6) 

4(7.4) 

 

23(92.0) 

2(3.7) 

 

27(93.1) 

2(3.7) 

 

 

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4.1 HEALTH – RELATED INFORMATION OF PARTICIPANTS 

Study participants had a mean temperature of 36.2 °C and a mean pulse of 82.8 m/min. Systolic 

and diastolic blood pressures of 135.8 mm Hg and 76.7 mm Hg, respectively, and a 

haemoglobin level of 11.0 g/dL. The participants' mean weight was 64.4 kg, and their mean 

height was 164.3. In addition, the mean mini malnutrition score was 17.91, with a mean dietary 

diversity score of 4.59, as shown in Table 4. 2. There was a significant difference in the BMI 

and height of the participants. Table 4.2 Health -related information of participants (N=54) 

Table 4.2 Health information of participants (N=54) 

Variables Total (N=54) 

Mean ± SD 

Males (N=25) 

Mean ± SD 

Females (N=29)  

Mean ± SD 

P- value 

Body temperature (ºC) 36.2 ± 0.58 36.2 ± 0.69 36.3 ± 0.47 0.69 

Age 71.9 ± 13.3 71.1 ± 9.2 72.4 ± 16.3 0.73 

Blood pressure Systolic 

(mm Hg) 

Diastolic (mm Hg) 

 
135.8± 26.6 

79.7±19.6 

 
141.2 ± 26.5 

79.9 ± 23.9 

 
131.1 ± 26.1 

79.4 ± 14.2 

 

0.17 

0.94 

Pulse (min) 82.8 ± 15.4 82.4 ± 15.4 83.1 ± 15.6 0.86 

Weight (kg) 64.4 ± 11.1 65.8 ± 10.4 63.2 ± 11.7 0.38 

Height (m) 

 BMI (kg/m2) 

164.3 ± 7.9 

20.59 ± 3.29 

168.8 ± 6.61 

19.8 ± 2.8 

160.4 ± 6.8 

21.2± 3.5 
0.01 

0.04 

Hemoglobin level (g/dL) 

MNA- Score 

Dietary Diversity Score 

11.0 ± 2.0 

17.91 ± 4.38 

4.59 ± 1.60 

10.9 ± 2.3 

18.5 ± 4.1 

4.6 ± 0