Background: Hyperhomocysteinemia is a risk factor for vascular diseases. This study aimed to investigate the serum total homocysteine (tHcy) level and nutritional status in elderly inpatients and determine the relationship between tHcy level and nutritional status. Methods: This cross sectional study was carried out in the Tongji hospital, and 142 subjects were consecutively recruited. Fasting blood was collected, and the liver and kidney function, blood glucose, glycosylated hemoglobin (HbA1c), plasma protein, lipid profile, folic acid, vitamin B12 and serum total tHcy were measured. Anthropometric measurements, grip strength and the shortened MNA form (MNA-SF) were used to assess the nutritional status. Results: Undernutrition was common in this population. Based on MNA-SF scores, 34.2% of subjects were at risk of malnutrition, and malnourished subjects accounted for 4.9%. The mean tHcy was 14.10±5.46 μmol/l, and the prevalence of hyperhomocysteinemia was 32.4% (46/142). Hyperhomocysteinemia was a risk factor of cerebral infarction (RR=1.636, 95% CI: 1.169-2.288); Serum tHcy was negatively correlated with serum folic acid, vitamin B12 and MNA-SF score (r=-0.348,P=0.000; r=-0.236, P=0.005; r=-0.208, P=0.014), and positively with BMI within normal range (18.5-23.9; r=0.232, P=0.044). Serum tHcy was negatively correlated with HbA1c, (r=-0.196, P=0.021) and positively with serum creatinine (r=0.327, P=0.000), but unrelated to fasting blood glucose (r=-0.098, P=0.250). Multivariate stepwise regression analysis showed serum folic acid, serum creatinine, MNA-SF score and HbA1c were independent determinants of serum tHcy. Conclusion: Elderly subjects have higher serum tHcy level. Compromised renal function, poor nutritional status and lower blood glucose are likely to influence the serum tHcy level.