Malnutrition in the elderly: A narrative review

doi:10.1016/j.maturitas.2013.07.013

Maturitas

Volume 76, Issue 4, December 2013, Pages 296-302

https://doi.org/10.1016/j.maturitas.2013.07.013 Get rights and content

Abstract

The focus of nutrition is often on healthy diets and exercise to minimise the risk of developing lifestyle diseases such as cancer, diabetes and cardiovascular disease. However, during the shift into older years often the nutrition priorities change towards meeting increased nutrient needs with less energy requirements, and minimising lean muscle loss. There are several causes of general malnutrition in the elderly that lead to depletion of muscle including starvation (protein-energy malnutrition), sarcopenia and cachexia. The prevalence of protein-energy malnutrition increases with age and the number of comorbidities. A range of simple and validated screening tools can be used to identify malnutrition in older adults, e.g. MST, MNA-SF and ‘MUST’. Older adults should be screened for nutritional issues at diagnosis, on admission to hospitals or care homes and during follow up at outpatient or General Practitioner clinics, at regular intervals depending on clinical status. Early identification and treatment of nutrition problems can lead to improved outcomes and better quality of life.

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:

•
the prevalence,
•
aetiology,
•
identification, and
•
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]:

•
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.

References (85)

I. Chapman
Weight loss in older persons
Medical Clinics of North America
(2011)
D. Thomas
Loss of skeletal muscle mass in aging: examining the relationship of starvation, sarcopenia and cachexia
Clinical Nutrition
(2007)
D. Thomas
Distinguishing starvation from cachexia
Clinics in Geriatric Medicine
(2002)
R. Fielding et al.
Sarcopenia: an undiagnosed condition in older adults. current consensus definition: prevalence, etiology, and consequences
International Working Group on Sarcopenia, Journal of the American Medical Directors Association
(2011)
M. Muscaritoli et al.
Consensus definition of sarcopenia, cachexia and pre-cachexia: joint document elaborated by Special Interest Groups (SIG) “cachexia-anorexia in chronic wasting diseases” and “nutrition in geriatrics”
Clinical Nutrition
(2010)
B. Messinger-Rapport et al.
Clinical update on nursing home medicine: 2009
Journal of the American Medical Directors Association
(2009)
Y. Rolland et al.
Treatment strategies for sarcopenia and frailty
Medical Clinics of North America
(2011)
Y. Rolland et al.
Current and future pharmacologic treatment of sarcopenia
Clinics in Geriatric Medicine
(2011)
W. Evans et al.
Cachexia: a new definition
Clinical Nutrition
(2008)
K. Fearon et al.
Definition and classification of cancer cachexia: an international consensus
The Lancet Oncology
(2011)

J.E. Morley et al.

Cachexia: pathophysiology and clinical relevance

American Journal of Clinical Nutrition

(2006)

A. Yaxley et al.

Pharmacological interventions for geriatric cachexia: a narrative review of the literature

Journal of Nutrition Health and Aging

(2012)

E. Agarwal et al.

Nutritional status and dietary intake of acute care patients: results from the Nutrition Care Day Survey 2010

Clinical Nutrition

(2012)

M. Pirlich et al.

The German hospital malnutrition study

Clinical Nutrition

(2006)

M.I.T.D. Correia et al.

Prevalence of hospital malnutrition in Latin America: the multicenter ELAN study

Nutrition

(2003)

D.L. Waitzberg et al.

Hospital malnutrition: the Brazilian national survey (IBRANUTRI): a study of 4000 patients

Nutrition

(2001)

J. Kondrup et al.

An ad hoc ESPEN Working Group. Nutritional Risk Screening (NRS 2002): a new method based on analysis of controlled clinical trials

Clinical Nutrition

(2003)

L. Valentini et al.

The first nutrition day in nursing homes: participation may improve malnutrition awareness

Clinical Nutrition

(2009)

J.M.M. Meijers et al.

Malnutrition in Dutch health care: prevalence, prevention, treatment, and quality indicators

Nutrition

(2009)

J. Edington et al.

Prevalence of malnutrition on admission to four hospitals in England. The malnutrition prevalence group

Clinical Nutrition

(2000)

J. Kondrup et al.

ESPEN guidelines for nutrition screening 2002

Clinical Nutrition

(2003)

K. Poulia et al.

Evaluation of the efficacy of six nutritional screening tools to predict malnutrition in the elderly

Clinical Nutrition

(2012)

F. Wolinsky et al.

Progress in the development of a nutritional risk index

The Journal of Nutrition

(1990)

M. Elia et al.

An analytical appraisal of nutrition screening tools supported by original data with particular reference to age

Nutrition

(2012)

L. Donini et al.

A systematic review of the literature concerning the relationship between obesity and mortality in the elderly

The Journal of Nutrition, Health and Aging

(2012)

A.M. Young et al.

Malnutrition screening tools: comparison against two validated nutrition assessment methods in older medical inpatients

Nutrition

(2013)

C. Kubrak et al.

Malnutrition in acute care patients: a narrative review

International Journal of Nursing Studies

(2007)

K. Jeejeebhoy

Nutritional Assessment

Nutrition

(2000)

M. Ferguson et al.

Development of a valid and reliable malnutrition screening tool for adult acute hospital patients

Nutrition

(1999)

A.M. Mudge et al.

Helping understand nutritional gaps in the elderly (HUNGER): a prospective study of patient factors associated with inadequate nutritional intake in older medical inpatients

Clinical Nutrition

(2011)

F. Neelemaat et al.

Oral nutritional support in malnourished elderly decreases functional limitations with no extra costs

Clinical Nutrition

(2012)

A. Cawood et al.

Systematic review and meta-analysis of the effects of high protein oral nutritional supplements

Ageing Research Reviews

(2012)

C. Baldwin et al.

Dietary advice and nutritional supplements in the management of illness-related malnutrition: systematic review

Clinical Nutrition

(2004)

H. Lochs et al.

Evidence supports nutritional support

Clinical Nutrition

(2006)

Z. Stanga

Basics in clinical nutrition: nutrition in the elderly

e-SPEN, the European e-Journal of Clinical Nutrition and Metabolism

(2009)

W. Nieuwenhuizen et al.

Older adults and patients in need of nutritional support: review of current treatment options and factors influencing nutritional intake

Clinical Nutrition

(2010)

M. Patel et al.

Why don’t elderly hospital inpatients eat adequately

Journal of Nutrition Health and Aging

(2008)

WHO Interesting facts about ageing. Available from: www.who.int_ageing_about_facts_en_index.html.pdf; 2012 [cited...

R. Stratton et al.

Scientific criteria for defining malnutrition. Disease related malnutrition: an evidence-based approach to treatment

(2003)

A. Yaxley et al.

The complexity of treating wasting in ambulatory rehabilitation: is it starvation, sarcopenia, cachexia or a combination of these conditions?

Asia Pacific Journal of Clinical Nutrition

(2012)

A. Yaxley et al.

The challenge of appropriate identification and treatment of starvation, sarcopenia, and cachexia: a survey of Australian dietitians

Journal of Nutrition and Metabolism

(2011)

A. Cruz-Jentoft et al.

Sarcopenia: European consensus on definition and diagnosis report of the European Working Group on sarcopenia in older people

Age and Ageing

(2010)

Cited by (356)

Parenteral nutrition consensus report from KEPAN
2024, Nutrition
Medical nutrition therapy is one of the core components of patient management, although its implication is still limited in Daily practice globally. Clinicians are in need of guidance that will ease the application of medical nutrition therapy. The pre- and post-graduate curriculum for medical nutrition therapy is limited in most regions, worldwide. A report that is short, clear, and having clear-cut recommendations that will guide the primary healthcare professionals in indications, choice, practical application, follow-up, and stopping parenteral nutrition (PN) would facilitate the application and success of medical nutrition therapy. KEPAN is the Clinical Enteral and Parenteral Nutrition Society of Turkey and is an active member of the European Society for Clinical Nutrition and Metabolism (ESPEN).
In this study, we present the KEPAN PN consensus report on optimal PN use in medical nutrition therapy as outlined by the works of academicians experienced in the clinical application of PN (nine working group academicians and 10 expert group academicians).
This report provides 22 clear-cut recommendations in a question-answer format.
We believe that this report could have a significant impact on the optimum use of PN in the context of medical nutrition therapy when clinicians manage everyday patients.
Nutritional risk predicts readmission within 30 and 180 days after discharge among older adult patients across a broad spectrum of diagnoses
2024, Clinical Nutrition ESPEN
Hospital readmissions can have negative consequences for older adult patients, their relatives, the hospital, and society. Previous studies indicate that older adult patients who are at nutritional risk during hospital admission are at higher risk of readmission. There is a lack of studies investigating this relationship across different older adult patient groups while using recommended instruments and adjusting for relevant confounders. Thus, the aim of the present study was to investigate whether nutritional status according to the Nutrition Risk Screening 2002 during hospitalization predicted readmission among older adult patients within 30 and 180 days across a broad spectrum of wards and diagnoses when adjusting for age, sex, length-of-stay, diagnosis, and discharge destination.
The present study is a retrospective cohort study based on registry data and included 21,807 older adult patients (≥65 years) hospitalized during a 5-year period. In order to investigate the relationship between nutritional risk and readmission, hierarchical logistic regression analyses with readmission within 30 days (n = 8371) and 180 days (n = 7981) as the dependent variable were performed.
Older adult patients at nutritional risk during the index admission were 1.44 times more likely to be readmitted within 30 days after discharge (P < 0.001), and 1.47 times more likely to be readmitted within 180 days after discharge (P < 0.001), compared to older adult patients who were not at nutritional risk during index admission when adjusting for age, sex, discharge destination, diagnosis group, and length-of-stay.
Our results highlight the importance of focusing on nutritional status in older adults as a factor in the prevention of readmissions, including ensuring that practices, resources, and guidelines support appropriate screening procedures. Because nutritional risk predicts readmission both in a 30-days and 180-days perspective, the results point to the importance of ensuring follow-up on the screening result, both in the hospital context and after discharge.
The risk of rehospitalization within 30 days of discharge in older adults with malnutrition: A meta-analysis
2024, Archives of Gerontology and Geriatrics
Malnutrition is a global health problem associated with higher rehospitalization risk, subsequently increasing the risks of adverse complications, and mortality in older individuals. Nevertheless, studies investigating this are still scarce, and even fewer reviewed and aggregated. A number of studies have recently assessed the correlation of malnourishment with rehospitalization among older adults.
This systematic review and meta-analysis aimed to elaborate the correlation between malnutrition and 30-day rehospitalization in older adults.
Systematic review was conducted on literatures from Cochrane, ScienceDirect, SpringerLink, Oxford Academic, and MEDLINE according to PRISMA Guideline, investigating the correlation of malnutrition in older adults with rehospitalization, using Malnutrition, Older Adults, and Rehospitalization as keywords. Meta-analysis was done using RevMan, with random-effect analysis model. P values of ≤0.05 were considered statistically significant with results reported as risk ratios (RR), mean differences (MD), 95 % confidence intervals (CI) and I² statistics.
Seven literatures were analysed, consisting of 19,340 patients aged 65 or older undergoing hospitalization. Subjects were assessed with screening tools to identify malnutrition. Malnourished subjects are compared to others with normal nutrition; in cohort studies with follow-up period ranging from 3 to 16 months. Malnutrition significantly increased the risks of rehospitalization within 30 days (RR 1.73 [95 % CI 1.10–2.72], p = 0.02, I² = 56 %), overall rehospitalization at all times (RR 1.33 [95 % CI 1.16–1.52], p < 0.0001, I² = 75 %), and overall mortality (RR 2.66 [95 % CI 1.09–6.50], p = 0.03, I² = 94 %).
Malnutrition exhibited significant consequences in older patients regarding the rate of rehospitalization and mortality based on this meta-analysis. Further research is highly encouraged to verify this finding.
Enteral nutrition consensus report from KEPAN: Indications, choice, practical application, and follow-up
2024, Nutrition
Clinicians are in need of guidance that will ease the application of medical nutrition therapy. In order to facilitate the application and success of medical nutrition therapy, the Turkish Clinical Enteral & Parenteral Nutrition Society (KEPAN) planned a report that is short, is clear, and has clear-cut recommendations that will guide health care professionals in the indications, choice, practical application, follow-up, and stopping of enteral nutrition.
The enteral nutrition consensus report on enteral nutrition use in medical nutrition therapy was developed by a study group (12 working group academicians and 17 expert group academicians) under the organization of KEPAN. The enteral nutrition consensus report was generated in 5 online and face-to-face phases from December 2019 through October 2022. At the end (Delphi rounds), a total of 24 questions and subjects, recommendations, and comments were sent to the enteral nutrition working group and the expert group via e-mail. They were asked to score the criteria by using the Likert scale.
The first round of the study resulted in acceptance of all 24 recommendations. None of the criteria was rejected. Only some minor editing for wording was recommended by the panelists during the first and second rounds of the Delphi study. The final report was sent to all 29 panelists and was approved without any revision suggestions.
This report provides 24 clear-cut recommendations in a question-answer format. We believe that this report could have a significant effect on the optimum use of enteral nutrition in the context of medical nutrition therapy when clinicians manage everyday patients.
Steering protein and carbohydrate digestibility by food design to address elderly needs: The case of pea protein enriched bread
2023, LWT
A “source of protein” and a “high protein” bread intended for the elderly were obtained by replacing wheat flour in bread dough with 50 and 165 g/kg pea protein concentrate. Carbohydrate and protein digestibility was evaluated in vitro by mimicking adult and elderly digestive conditions. Protein digestibility was measured by the OPA assay. Carbohydrate digestibility was assessed by determining the incremental area under the glucose curve during the intestinal phase to estimate the glycaemic index (GI_e). Pea proteins negatively affected some key features accounting for elderly acceptability of bread, mainly the textural ones, with firmness increasing from 1.2 to 3.3 N. Proteolysis was not affected by physiological conditions but by reformulation, with “high protein” bread presenting the highest proteolysis, followed by “source of protein” and soft wheat bread (around 110, 80 and 70 mmol free NH₂/g_dw, respectively). Conversely, carbohydrate digestibility was restrained in elderly settings compared to adult ones, with glucose concentration during digestion reaching maximum values of 0.5 and 0.8 respectively, with no differences between enriched bread. Results may contribute to a better understanding of food digestibility under different gastrointestinal conditions and of its dependence on technological factors and would help to design age-tailored foods.
Associations between cooking self-efficacy, attitude, and behaviors among people living alone: A cross-sectional survey analysis
2023, Appetite
Cooking-related literacy and attitudes may play important roles in preventing and reducing diet-related chronic diseases and nutrition disparities. People living alone are an under-researched but growing population who face above average food insecurity rates. This study's objectives were to 1) test how cooking self-efficacy and attitude are stratified demographically among a sample of people living alone, focusing on variations across gender, age, and food security, and 2) examine how cooking self-efficacy and attitude are associated with two indicators of cooking behavior – cooking frequency and convenience orientation. We draw from a cross-sectional survey analysis of 493 adults living alone in Illinois, USA with validated measures for cooking self-efficacy, attitude, frequency, convenience orientation, and demographic characteristics. Hierarchical linear regression models were used to examine demographic factors explaining variation in self-efficacy and attitude, with attention to interactions between gender, food insecurity, and age. Poisson and OLS linear regression models were used to examine associations between self-efficacy and attitude and cooking frequency and convenience orientation. We find cooking-related self-efficacy and attitude showed strong but distinct associations with cooking frequency and convenience orientation. Overall, food insecure groups had lower self-efficacy than those who were food secure; however, food insecure women had higher self-efficacy than men in similar positions, apart from older-adult women who held particularly low efficacy. Cooking attitudes varied in small ways, notably with food insecure younger and older women possessing more negative cooking attitudes than middle-aged women. This research highlights the importance of understanding the cooking-related orientations of single-living people, while demonstrating that this group's ability to prevent and manage food insecurity is not uniform. These results can inform targeted interventions around food and nutrition insecurity, cooking attitudes, and self-efficacy among single-living populations.

View all citing articles on Scopus

View full text

ReviewMalnutrition in the elderly: A narrative review

Abstract

Introduction

Section snippets

Causes of general malnutrition – starvation (PEM), sarcopenia, and cachexia

Prevalence of PEM in the elderly

Risk factors of PEM in the elderly

Identifying PEM

Consequences of PEM

Management of PEM

Implications for practice

Conclusion

Contributors

Competing interest

Funding

Provenance and peer review

Medical Clinics of North America

Clinical Nutrition

Clinics in Geriatric Medicine

International Working Group on Sarcopenia, Journal of the American Medical Directors Association

Clinical Nutrition

Journal of the American Medical Directors Association

Medical Clinics of North America

Clinics in Geriatric Medicine

Clinical Nutrition

The Lancet Oncology

American Journal of Clinical Nutrition

Journal of Nutrition Health and Aging

Clinical Nutrition

Clinical Nutrition

Nutrition

Nutrition

Clinical Nutrition

Clinical Nutrition

Nutrition

Clinical Nutrition

Clinical Nutrition

Clinical Nutrition

The Journal of Nutrition

Nutrition

The Journal of Nutrition, Health and Aging

Nutrition

International Journal of Nursing Studies

Nutrition

Nutrition

Clinical Nutrition

Clinical Nutrition

Ageing Research Reviews

Clinical Nutrition

Clinical Nutrition

e-SPEN, the European e-Journal of Clinical Nutrition and Metabolism

Clinical Nutrition

Journal of Nutrition Health and Aging

Scientific criteria for defining malnutrition. Disease related malnutrition: an evidence-based approach to treatment

The complexity of treating wasting in ambulatory rehabilitation: is it starvation, sarcopenia, cachexia or a combination of these conditions?

Asia Pacific Journal of Clinical Nutrition

The challenge of appropriate identification and treatment of starvation, sarcopenia, and cachexia: a survey of Australian dietitians

Journal of Nutrition and Metabolism

Sarcopenia: European consensus on definition and diagnosis report of the European Working Group on sarcopenia in older people

Age and Ageing

Review
Malnutrition in the elderly: A narrative review