ReviewMalnutrition in the elderly: A narrative review
Introduction
The world's population is rapidly ageing with estimates that in the first five decades of the 21st century the proportion of the world's population over 60 years will double from 11% to 22%. The expected increase in the absolute number of older adults will triple from 605 million to 2 billion over this period [1]. As the number of older people continues to rise, provision of improved healthcare to the elderly – both in hospital and in the community – is imperative. Often, the focus of nutrition in older adults is a healthy diet and exercise to minimise the risk of developing lifestyle diseases (such as cardiovascular disease, Type 2 diabetes mellitus). However, there is a large body of evidence to indicate that protein-energy malnutrition (PEM) is a common problem in this age group, including in the hospital, nursing home and community setting. Therefore, the purpose of this paper is to summarise the current literature regarding:
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the prevalence,
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aetiology,
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identification, and
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effective nutritional management
of PEM in the elderly.
Section snippets
Causes of general malnutrition – starvation (PEM), sarcopenia, and cachexia
While there is no universally accepted definition of malnutrition, one of the most commonly used identifies malnutrition as “a state of nutrition in which a deficiency, or excess, of energy, protein and micronutrients causes measurable adverse effects on tissue/body form (body shape, size and composition) and function, and clinical outcome” [2]. However, in relation to under-nutrition, this definition does not take into account the aetiology of unintentional weight loss. Recent literature
Prevalence of PEM in the elderly
Multicentre studies that have evaluated PEM prevalence in the acute care setting report that 23–60% of elderly patients are malnourished and an estimated 22–28% are at nutritional risk (Table 1).
In comparison to other healthcare settings, there is limited literature on the prevalence of PEM in community-dwelling older adults. However, the reported prevalence indicates a range of 5–30% [27], [28], [29]. In the residential aged care setting, the reported PEM prevalence ranges from 16% to 70%
Risk factors of PEM in the elderly
The aetiology of PEM in the elderly is multifactorial and consists of physiological, social and economic parameters, often referred to as the “nine d's” (dementia, dysgeusia, dysphagia, diarrhoea, depression, disease, poor dentition, dysfunction, and drugs) [34]. The physiological parameters also affect food consumption in the elderly (Fig. 1); thereby further exacerbating the problem of PEM.
Identifying PEM
Malnutrition screening is the recommended first step in the nutrition care process as it allows the early identification of nutritional concerns [35], [36], [37]. Given the multifactorial nature of PEM in the elderly, and in the absence of a single objective measure or “gold standard”, a number of nutrition screening tools specific to the older adult population have been developed. Each tool is unique as they include a range of different parameters [38]:
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Biochemical and clinical indices:
Consequences of PEM
PEM can affect almost every function, organ and/or system of the human body [49] and therefore has been associated with a range of outcomes with implications for health and recovery from illness/surgery [50]. Although the onset of PEM depends on the body's nutritional reserves (independent of the disease state) [50], a connection between PEM and disease exists, whereby disease may influence PEM, or PEM may have a negative effect on disease [49]. Therefore, PEM is often referred to as “a cause
Management of PEM
In addition to the pathophysiological, social and behavioural factors that play a role in the development of PEM amongst older adults, illness and hospitalisation have also been implicated in the development (or worsening of PEM) in elderly patients. A large number of barriers adversely affecting food intake in elderly patients have been identified in the literature. These include self-limiting factors (loss of appetite, acute illness, oral issues, low mood, dysphagia, confusion, isolation),
Implications for practice
Validated nutrition screening tools and monitoring weight (and body composition) are important to identify older adults at nutritional risk. Geriatricians should continue to identify and manage nutritional issues as part of a comprehensive geriatric assessment. General practitioners often have the primary role of monitoring the nutritional status of patients who are discharged from acute or rehabilitation settings, the residential aged care setting and in the community. Strategies to identify
Conclusion
Malnutrition risk increases with age and level of care. Muscle wasting related to ageing (sarcopenia) is more evident in advanced years and can be masked by fat mass. Cachexia is mediated by proinflammatory cytokines and occurs with particular conditions like cancer but may also occur with ageing. The prevalence of PEM in older adults due to reduced dietary intake remains unacceptably high. Several valid malnutrition screening tools, e.g. MST, MNA-SF and MUST are available to identify
Contributors
All coauthors have contributed and agree to the content of the paper.
Competing interest
None declared.
Funding
No funding was received for this manuscript. Co-authors contributed during their academic activities from the University of Queensland, Queensland University of Technology and Flinders University. CIA Isenring also works for Queensland Health.
Provenance and peer review
Commissioned and externally peer reviewed.
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