International Journal of Gerontology 11 (2017) 215e219

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International Journal of Gerontology

journal homepage: www.ijge-online.com

Original Article

Association Between Nutrition Status and Cognitive Impairment

Among Chinese Nonagenarians and Centenarians
Shan Hai, Li Cao, Xue Yang, Hui Wang, Ping Liu, Qiukui Hao, Birong Dong*
Department of Geriatrics, West China Hospital, Sichuan University, Chengdu 610041, China

a r t i c l e i n f o s u m m a r y

Article history: Background: The association of nutrition status with cognitive impairment has been confirmed by
Received 23 August 2016 previous studies. However, there are no relevant data from a Chinese oldest old population.
Received in revised form Method: Five hundred eighty elderly residents aged 90 years or more were investigated. Socio-
9 November 2016
demographic characteristics and lifestyle habits were collected by using a general questionnaire.
Accepted 9 December 2016
Available online 23 October 2017
Nutritional state was assessed with the Mini Nutritional Assessment (MNA) and biochemical pa-
rameters, whereas cognitive performance was evaluated by the Mini-Mental State Examination
(MMSE). Multiple Logistic regression was used to analyze the association between cognitive impair-
Keywords:
Chinese population,
ment and nutrition status.
cognitive impairment, Results: The total prevalence rate of cognitive impairment was 55.5%, 67 (35.1%) men and 255 (65.6%)
nonagenarians and centenarians, women were classified as cognitive impairment. Compared with cognitively impaired subjects, those
nutrition with normal cognition had a higher MNA score (14.28 ± 1.89 vs.13.51 ± 1.75, p < 0.05), a higher level of
hemoglobin (116.53 ± 16.74 vs.112.62 ± 13.82, p < 0.05) and body mass index (BMI) (19.63 ± 3.8 vs.
18.96 ± 3.59, p < 0.05). Pearson correlation analysis showed a significant correlation between MMSE with
MNA (p < 0.05), the level of HGB (p < 0.05) and BMI (p < 0.05). In the multivariate model, malnutrition
(OR ¼ 4.24, 95% CI: 1.89e9.52) was the risk factor for cognitive impairment.
Conclusion: Among Chinese nonagenarians and centenarians, there were significant associations be-
tween nutrition status and cognitive impairment. Further studies should evaluation if maintaining a
good nutritional status or nutritional intervention may be effective in the management and prevention of
cognitive impairment.
Copyright © 2017, Taiwan Society of Geriatric Emergency & Critical Care Medicine. Published by Elsevier
Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).

1. Introduction individual nutritional status influences cognitive function4,5.

By 2050, 115 million people worldwide are expected to have
some form of cognitive impairment, including mild cognitive
impairment and dementia, with the increase of the aging popula-
tion1. Many studies have suggested that demographic factors, life-
style, functionality status, and chronic diseases (e.g. hypertension,
cardiovascular disease, and diabetes mellitus) are associated with
cognitive impairment1e3. Proper nutrition is also important for
cognitive function. Recently several epidemiological and observa-
tional studies demonstrated the relationship of nutrition status
with cognitive impairment, although it remains unclear how
* Corresponding author. Department of Geriatrics, West China Hospital, Sichuan
University West China Hospital, Sichuan University, Chengdu 610041, China.
E-mail address: dongbirong33@163.com (B. Dong).
Changes of nutrition status, specifically the risk of malnutrition
may play an important role in the progression of cognitive loss in
hospital and the community-dwelling elderly population6,7. In
parallel, another study reported cognitive impairment might result
in nutritional risk, in this study, there was a significantly higher
frequency of malnutrition or nutritional risk among older adults
with cognitive impairment compared with those with normal
cognition8.
As the older population increases, the number of cognitively
impaired older individuals can be expected to rise. However, most
of the studies on nutrition and cognitive decline commonly include
only a small proportion of people over 80 years of age. There still
have been no relevant data for a Chinese oldest old population. In
the present study, we observed the association of nutrition status
with cognitive impairment among very old people using data from
the Project of Longevity and Aging in Dujiangyan.

https://doi.org/10.1016/j.ijge.2016.12.002
1873-9598/Copyright © 2017, Taiwan Society of Geriatric Emergency & Critical Care Medicine. Published by Elsevier Taiwan LLC. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
216
2. Materials and methods
2.1. Participants and data collection
The present study is part of the Project of Longevity and Aging in
Dujiangyan (PLAD).Dujiangyan is a city near Chengdu, the capital of
Sichuan province in southwest China. The PLAD study was per-
formed by researchers from Sichuan University in conjunction with
local officials and hospitals or clinics on 870 Chinese elderly aged 90
years and older in April 2005. The participants were recruited from
a government registry and the Bureau of Statistics at the
Dujiangyan City government has registered each person. Twenty-
one men and 26 women were not eligible for the study because
they died or moved away from the area. Of the 262 men and 561
women interviewed, we excluded 102 persons who did not com-
plete the MMSE test and 141 persons without an MNA score. Finally,
580 participants (191 men and 389 women) were included in our
study and their data were analyzed.
Data were collected by trained personnel who visited all the
participants face to face. Socio-demographic characteristics and
lifestyle habits were recorded using a general questionnaire. We
collected data on age, gender, education level, MMSE and MNA
scores, weight (kilograms), height (centimeters), tea and alcohol
consumption, smoking history, exercise, disease history, and other
items. Habits of smoking, alcohol consumption, tea consumption,
and exercise, which included former and current were collected by
using a general questionnaire. In the questionnaire, every item had
2 options (yes or no). The subjects, who did almost every day during
the recent 1 year, were classified as those with these habits current,
otherwise as without. The subjects, who had did almost every day
for more than 2 years as of a year before, were classified as those
with these habits previously, otherwise as without. Alcohol con-
sumption included spirits, liqueurs, wine, sherry, martini, beer,
lager, cider, stout, and so on. Tea consumption included all types of
tea. Right arm blood pressure (BP) was measured twice to the
nearest 2 mmHg using a standard mercury sphygmomanometer
(phases I and V of Korotkoff) by trained nurses or physicians. The
mean value of two measurements was used to calculate systolic BP
(SBP) and diastolic BP (DBP). Blood samples were collected after an
overnight fast (at least 8 h) for measurement of plasma glucose,
serum albumin, hemoglobin (Hgb), serum total cholesterol (TC),
triglycerides (TG), low-density lipoprotein (LDL), cholesterol, high-
density lipoprotein (HDL), and other biochemistry indicators by
standard laboratory techniques (performed by a technician in the
biochemistry laboratory of Sichuan University). Subjects were
considered to be hypertensive if 3 or more repeated blood pressure
readings were above 140 mmHg (SBP) and/or 90 mmHg (DBP), or if
they were taking antihypertensive drugs. Subjects were considered
to be diabetic if they were treated for diabetes or had a fasting
blood glucose of >110 mg/dL.
2.2. Assessment of cognitive function
Cognitive function was measured with the 30-item MMSE, a
global test with the following components: attention, orientation,
language, calculation, and recall. Cognitive impairment was defined
as a score below 24 on the MMSE (sensitivity 80e90%, specificity
80e100%)9. Subjects were categorized as follows: possible de-
mentia (scores between 0 and 18), mild cognitive impairment
(scores between 19 and 24) and normal (scores between 25 and
30)10. Increasing studies suggest that MMSE scores may be affected
by many other factors, including visual, education, and auditory
abilities, especially in advanced age.11 At age 95, the range of MMSE
was 10 (10th percentile) to 27 (90th percentile). Previous findings
provided different norms for MMSE scores in very old subjects12. In
S. Hai et al.
the oldest-old sample, only 38 subjects (32 men, 6 women) had
scores higher than 24; Therefore, we refered to some previous
studies10,13. and merged those with mild cognitive impairment and
normal cognitive function together as the cognitive non-
impairment group for data analysis.
2.3. Evaluation of nutritional status
MNA was used because it is an instrument especially designed to
assess the nutritional status of older persons. Participants are
classified by MNA scores as follows: normal nutritional state (score
of 24e30); at risk of malnutrition (score of 17e23.5); and malnu-
trition (score of <17). Other nutritional state indicators evaluated
included BMI and several serum biochemical values: albumin (g/L),
cholesterol (mg/dL), and Hgb (g/L). BMI was calculated as weight in
kilograms divided by height in meters-squared (kg/m2). We cate-
gorized underweight (BMI<18.5) using the BMI cutoffs for Asian
populations recommended by the WHO15. Abnormal levels of
serum lipid/lipoprotein were defined according to the 2004 criteria
provided by the Chinese Medical Association. Normal criteria were:
TC<5.18 mmol/l, TG<1.7 mmol/l, LDL<3.37 mmol/l, and
HDL>1.04 mmol/l. Normal level of hemoglobin was: Hgb120 g/L
for men and 110 g/L for women.
2.4. Statistical analysis
SPSS18.0 was used in our statistical analysis. Continuous vari-
ables are presented as means ± standard deviation (M±SD). Sig-
nificance testing of the difference between the two groups was
conducted using the independent-samples t-test for continuous
variables, and the Chi-square test or Fisher's exact test for cate-
gorical variables. The association between the indicators of nutri-
tional state and MMSE was assessed using Pearson correlation
analysis. Multiple logistic regression analysis was used to evaluate
the association between risk factors and cognitive impairment. We
calculated the 95% confidence interval (CI) for each odds ratio
(OR).All p values were two-sided and p < 0.05 was considered to be
statistically significant.
2.5. Ethical considerations
The study protocol was approved by the Research Ethics Com-
mittee of Sichuan University. All participants provided written
informed consent.
3. Results
3.1. Baseline characteristics according to cognitive function and
prevalence of cognitive impairment
Among the 580 subjects, the mean age was 93.2 ± 3.1 years
(ranging from 90 to 105 years) and 389 (67.0%) were women,
including 17 centenarians. Most (90%) of the subjects lived in the
countryside. Only 24 subjects had scores higher than 24, so we
defined subjects with an MMSE score lower than 18 as having a
cognitive impairment. In the oldest group, the total prevalence rate
of cognitive impairment was 55.5%. Subjects were divided into two
groups: cognitive impairment group (n ¼ 322) and normal group
(n ¼ 258). The M±SD MMSE score was 11.64 ± 3.48 in the cognitive
impairment group and 20.39 ± 2.80 in the normal group
(p < 0.001).The prevalence rate of cognitive impairment was 35.1%
among males and 65.6% among females. Women had a significantly
higher prevalence of cognitive impairment than men (255/389 vs.
67/191 p < 0.05).The total prevalence rate of malnutrition was
83.8%. The prevalence rate was 81.2% (n ¼ 155) among males and
Association Between Nutrition Status and Cognitive Impairment 217

85.1% (n ¼ 331) among females. Compared with cognitively Table 2

impaired subjects, those with normal cognition had a higher MNA Pearson correlation analysis for cognitive function and nutritional indicators.

score (14.28 ± 1.89 vs.13.51 ± 1.75, p < 0.001; Table 1) and a higher Variable MMSE scores correlation p value
level of Hgb (116.53 ± 16.74 vs.112.62 ± 13.82, p < 0.05) and BMI coefficient
(19.63 ± 3.8 vs. 18.96 ± 3.59, p < 0.05).There was no statistical MNA scores 0.24 <0.001a
difference for lifestyle (smoking habits, alcoholic and tea con- BMI 0.09 0.042a
sumption, exercise habits) between subjects of normal and Hgb 0.17 <0.001a
TG 0.02 0.564
impaired cognition. Demographic and clinical characteristics of the
TC 0.07 0.114
580 subjects, grouped by normal and impaired cognition, are Alb 0.03 0.509
shown in Table 1. LDL-C 0.02 0.649
HDL-C 0.06 0.155
a
3.2. Correlations between cognitive function and indicators of p < 0.05.
nutrition

levels, smoking habits, alcohol and tea consumption, exercise, hy-

Correlations between cognitive function and indicators of
pertension, cardiac disease, diabetes and stroke, malnutrition
nutrition status are shown in Table 2. MMSE scores significantly
(OR ¼ 4.24, 95% CI: 1.89e9.52) was the risk factor for cognitive
correlated with MNA scores (p < 0.001), Hgb levels (p < 0.001) and
impairment. The other indicators (such as underweight and ane-
BMI (p < 0.05). We did not find a correlation with the other
mia) did not reach statistical significance in this model (Table 3).
indicators.

3.3. Multivariate logistic regression for subjects with cognitive 4. Discussion

impairment and those without at baseline
As the elderly population increases, so does the prevalence of
We assessed whether the indicators of nutrition status were cognitive impairment14,15. In our cross-sectional observations of
associated with an increased risk of cognitive impairment. In the Chinese nonagenarians and centenarians, the high prevalence of
multivariate model, after adjustment for gender, ages, educational cognitive impairment (above 55.5%) was greater than that seen in

Table 1
Baseline characteristics according to cognitive function (n ¼ 580).

Cognitive impairment n ¼ 322 Normal cognitive function n ¼ 258 p value

Gender, n (%)
men 67 (20.8) 124 (48.1)
women 255 (79.2) 134 (51.9) <0.001*
Age,years 93.62 ± 3.11 93.03 ± 3.07 0.522
MMSE scores 11.64 ± 3.48 20.39 ± 2.80 <0.001*
MNA scores 13.51 ± 1.75 14.28 ± 1.89 <0.001*
SBP (mm Hg) 140.80 ± 23.58 141.68 ± 22.34 0.649
DBP (mm Hg) 72.36 ± 11.36 72.89 ± 11.83 0.581
BMI (Kg/m2) 18.96 ± 3.59 19.63 ± 3.8 0.027*
FPG (mmol/L) 4.47 ± 1.41 4.40 ± 1.47 0.560
TG (mmol/L) 1.27 ± 0.68 1.25 ± 0.73 0.810
TC (mmol/L) 5.11 ± 1.79 4.14 ± 0.77 0.358
LDL-C (mmol/L) 2.26 ± 0.61 2.25 ± 0.63 0.815
HDL-C (mmol/L) 1.58 ± 0.60 1.64 ± 0.97 0.362
Hgb g/L 112.62 ± 13.82 116.53 ± 16.74 0.002*
Alb g/L 42.74 ± 3.08 42.51 ± 3.39 0.404
Diseases, n (%)
Hypertension 60 (18.6) 106 (41.1) 0.803
Cardiac disease 24 (7.5) 42 (16.3) 0.826
Stroke history 56 (17.4) 64 (24.8) 0.237
Diabetes 73 (22.7) 78 (30.2) 0.628
Smoking, n (%)
Former 188 (58.4) 164 (63.6) 0.333
Current 138 (42.9) 122 (47.3) 0.286
Alcoholic, n (%)
Former 121 (37.6) 112 (43.4) 0.173
Current 73 (22.7) 78 (30.2) 0.267
Tea habits
Former 125 (38.8) 136 (52.8) 0.154
Current 158 (49.1) 131 (50.8) 0.181
Exercise, n (%)
Former 110 (34.2) 89 (34.5) 0.617
Current 137 (42.5) 112 (43.3) 0.933
Education, n (%)
Illiteracy 295 (91.6) 227 (88.0)
Primary school 18 (5.6) 20 (7.8)
Secondary school 6 (1.9) 8 (3.1)
College and postgraduate 3 (0.9) 3 (1.1) 0.521

Abbreviations: SBP, systolic blood pressure; DBP, diastolic blood pressure; FPG, fasting plasma glucose; Mean ± s.d. *p < 0.05; vs. cognitive impairment group using the Chi-
square or Fisher's exact test for categorical variables and Independent-Samples t-test for continuous variables. P value < 0.05 was considered to be statistically significant.
218
Table 3
Multivariate logistic regression for subjects with cognitive impairment and those
without at baseline.
Risk factor Unadjusted Adjusted
Malnutrition OR (95%CI) 3.95 (1.89e8.27)* 4.24 (1.89e9.52)*
Underweight OR (95%CI) 1.15 (0.82e1.59) 0.92 (0.64e1.33)
Anemia OR (95%CI) 1.03 (0.74e1.43) 1.21 (0.84e1.75)
Adjusted for gender, ages, educational levels, smoking habits, alcohol and tea con-
sumption, exercise, hypertension, cardiac disease, diabetes and stroke. *: P < 0.05.
other large surveys16,17 with a very low average score of cognitive
function (lower than 18 on the MMSE). Several possible reasons
may account for these findings. First, although most subjects in
other studies were older than 65 years, few were older than 90
years. Second, our participants differed from those of previous
studies because they were mostly from rural areas and had a lower
education level.Several studies have shown that the prevalence of
cognitive impairment increases with age18,19. In China, therefore,
very old people may be becoming an important population for the
prevention of cognitive impairment.
The elderly are particularly vulnerable to nutritional deficits. In
our study, we assessed the nutrition status of the nonagenarians
and centenarians. We found that the prevalence rate of malnutri-
tion was 83.8% among the 580 subject. Some studies have shown
the prevalence of malnutrition to be 3%e5% among free-living older
adults and 21.3% among home care patients20. In Europe21, preva-
lence of malnutrition is 10%e80%, while in long-term-care (LTC)
settings and in nursing homes, the average prevalence is 30%. In the
present study, the subjects were all over 90 years old, and the
prevalence was very high than other previous studies22. Previous
studies have reported that dietary intake patterns, daily activity and
residential status influenced nutritional status. In the study, most
(90%) of the participants were countryside residents with limited
food and nourishment, which may be the primary reason causing
the high prevalence of malnutrition.
The present study confirmed that subjects with cognitive
impairment have lower MNA scores, Hgb levels and BMI levels than
those with normal cognition. The Pearson correlation showed a
significant correlation between MMSE scores and MNA scores
(p < 0.05), HGB levels (p < 0.05) and BMI (p < 0.05). In our study, the
nutritional state of the subjects with cognitive impairment was
worse than that of those with normal cognition. Several research
studies have reported cognitive impairment as an important risk
factor for malnutrition. Patients with serious cognitive impairment
are characterized by a poor nutritional state, serious functional
impairment, and increased mortality23,24. It was reported that
assessment with the MNA scale among patients with mild to
moderate dementia showed that 9% belonged to the malnutrition
group and 34% were at in the risk of malnutrition group25. Malara
et al. also reported that 42% of patients with severe cognitive
impairment had malnutrition, but only 4% of malnourished pa-
tients showed a moderate cognitive deficit6. Cognitive impairment
is also a risk factor for weight loss in the elderly. Zhou et al.
analyzed data from a survey that was conducted on all residents
aged 90 years and reported an association between BMI and
cognitive function13. White et al. explored the association between
Alzheimer's disease (AD) and weight changes. They found that
almost twice as many patients with AD lost more than 5% of their
total body weight compared to controls, and that patients with
more severe forms of AD were 6e7 times more likely to suffer
progressive weight loss progressive weight loss26.
Several studies have demonstrated the risk of malnutrition may
play an important role in the progression of cognitive loss in hos-
pital and the community-dwelling elderly population6,7. However,
S. Hai et al.
most of the previous studies commonly include only a small pro-
portion of people over 80 years of age. At present, the oldest old are
among the fastest growing segment of the population in China. The
population of the nonagenarians/centenarians (>90 years old)
reached a high of 1 million in 2011, so we need to give more
attention to the increasing population cognitive health. Proper
nutrition is important for cognitive function. In the present study,
multiple logistic regression analysis confirmed that malnutrition
was the risk factors for cognitive impairment among Chinese no-
nagenarians and centenarians (Table 3). Despite using different
methods to assess nutritional status and cognitive performance, the
results of the present study are consistent with those of previous
research.
Cognitive impairment has several negative consequences on the
health of the elderly; it can influence the prognosis of various
conditions, reduce quality of life, and increase morbidity/mortality
and hospital admissions. Good nutrition status is important in
maintaining cognitive performance, and altered nutrition status
appears to predict the severity and progression of cognitive
impairment.
Our study had limitations that deserved mention. First, we did
not analyze the different subtypes of cognitive impairment. Second,
we did not adjust for other potential confounding factors, such as
socio-economic status, the APOE genotype or family history of
cognitive impairment. Most (90%) of the participants in the present
study were countryside residents, Thus, our results might not be
generalizable to the urban population. In this study, there was high
dropout rate because there was the high prevalence of visual or
hearing impairment in nonagenarians and centenarians who could
not complete the MMSE and MNA, which may cause selection bias.
In addition, the assessment of cognitive impairment and nutritional
status was based on cross-sectional measures, so it was not possible
to determine causal relationships.
5. Conclusion
We found the prevalence of cognitive impairment and malnu-
trition to be high among Chinese nonagenarians and centenarians.
There were significant associations between nutrition status and
cognitive performance. Prevention and early treatment of malnu-
trition may be effective in lowering the risk of cognitive impair-
ment, but this needs to be confirmed by larger studies.
Conflicts of Interest
None.
Acknowledgements
This work was supported by the Discipline Construction Foun-
dation of Sichuan University (XK05001) and by grants from the
Project of Science and Technology Bureau of Sichuan Province
(2006Z09-006-4).The authors thank the staff of the Department of
Geriatrics, West China Hospital and Dujiangyan Hospital, and all
participants for their great contribution.
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