Malnutrition in the Elderly: Causes, Costs and Consequences

Malnutrition in the Elderly: Causes, Costs and Consequences

Put simply, malnutrition is a state of nutrition (under or overnutrition) in which a lack of protein, energy and other nutrients causes measurable adverse effects on tissue and/or body form, composition, function or clinical outcome.  In this section, we will focus on undernutrition as a nutritional concern.
Malnutrition can be significant if a person has:
a BMI of less than 18.5 kg/m2   
a BMI less than 20kg/m2 and has had unintentional weight loss greater than 5% within the last 3-6 months 
had unintentional weight loss greater than 10% within the last 3-6 months
    People are also at risk of becoming malnourished if they have eaten very little or nothing for more than 5 days and/or this pattern is likely to continue. Malnutrition is, and continues to be, a serious problem in the UK.  Worryingly, more than 1 in 4 of all adults admitted for a hospital stay, to a mental unit or a care home is at risk of malnutrition, which is a staggering statistic.  It is a well-documented fact that worldwide, the elderly population is increasing, and with it, the incidence of malnutrition.  Malnutrition is associated with significantly increased morbidity and mortality in independently living older people, as well as in nursing home residents and hospitalised patients. [5,6]
    BAPEN NSW 2007 revealed a high prevalence of malnutrition amongst our elderly population: 
    • 35% in adults over 80 years of age
    • 25 – 35% in adults 60 – 80 years
    • 25% in adults less than 60 years of age
    Causes of Malnutrition
    There are many causes of malnutrition. These can include:
    • Reduced intake: Poor appetite due to illness, food aversion, nausea or pain when eating, depression, anxiety, side effects of medication or drug addiction

    • Inability to eat: This can be due to investigations or being held nil by mouth, reduced levels of consciousness; confusion; difficulty in feeding oneself due to weakness, arthritis or other conditions such as Parkinson’s Disease, dysphagia, vomiting, painful mouth conditions, poor oral hygiene or dentition; restrictions imposed by surgery or investigations

    • Lack of food availability: poverty; poor quality diet at home, in hospital or in care homes; problems with shopping and cooking

    • Impaired absorption: This can be due to medical and surgical problems effecting digestion & stomach, intestine, pancreas and liver /or absorption

    • Altered metabolism: Increased or changed metabolic demands requirements related to illness e.g. cancer; surgery, organ dysfunction, or treatment

    • Excess losses: Vomiting; diarrhoea; nutrient fistulae; stomas; losses from nasogastric losses tube and other drains or skin exudates from burns
    People at risk of Malnutrition
    Those most vulnerable to malnutrition include:
    • People just discharged from hospital
    • Elderly people (16% in residential care)
    • People with cancer and other long-term conditions
    • People recovering from surgery
    Consequences of Malnutrition
    Malnutrition can often go undetected and when left untreated, it can have serious consequences on health, which include:
    • Increased risk to infections
    • Delayed wound healing
    • Impaired respiratory function
    • Muscle weakness and depression
    Costs of Malnutrition
    Malnutrition has been estimated to cost the NHS an incredible $12 billion each year, which is more than double the projected $5.7 billion cost that will be spent tackling obesity.
    This cost is based on patients who suffer from malnutrition:
    • Needing a greater number of GP consultations
    • Needing more frequent and more prolonged hospital admissions
    • Having a higher rates of complications and mortality compared with nourished patients
    Detection of Malnutrition
    With patients who you suspect are malnourished (or likely to become so), it is vital you identify the problem early so you can provide support and achieve the most effective use of resources.  Although biochemical measurements can contribute to nutritional assessment, none can reliably measure nutritional risk e.g. a low serum albumin is almost always a marker of an acute phase response or fluid overload rather than a marker of malnutrition.
    There is therefore really no alternative to measurements of weight and height, along with other anthropometric measures in specialist circumstances. These measurements can then be used with the following questions:
    • Has your patient been eating a normal and varied diet in the last few weeks?

    • Has your patient experienced intentional or unintentional weight loss recently? Obesity or fluid balance changes and oedema may mask loss of lean tissue. Rapid weight loss is a concern in all patients whether obese or not

    • Can your patient eat, swallow, digest and absorb enough food safely to meet their likely needs?

    • Does your patient have an unusually high need for all or some nutrients? Surgical stress, trauma, infection, metabolic disease, wounds, bedsores or history of poor intake may all contribute to such a need

    • Does any treatment, disease, physical limitation or organ dysfunction limit your patient’s ability to handle the nutrients for current or future needs?

    • Does your patient have excessive nutrient losses through vomiting, diarrhoea, surgical drains etc?

    • Does a global assessment of your patient suggest under nourishment? Low body weight, loose fitting clothes, fragile skin, poor wound healing, apathy, wasted muscles, poor appetite, altered taste sensation, altered bowel habit. Discussion with relatives may be important

    • In the light of all of the above, can your patient meet all of their requirements by voluntary choice from the food available?
    Understanding that asking these questions take a significant amount of time and expertise, a number of screening tools have been developed to help you identify whether your patient is at risk of malnutrition. Given the high prevalence of malnutrition and lack of proper management of patients in various settings, performing a routine nutritional ‘screening’ should result in early identification of patients who might have otherwise been missed.
    A screening tool should therefore help establish reliable pathways of care for patients with malnutrition. Screening for malnutrition (and the risk of malnutrition) should be carried out by healthcare professionals with appropriate skills and training.
    January 2, 2018
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