Malnutrition in Older Adults

Learning Objectives
Upon completion of this module, students should be able to:
Attitudes

Recognise that poor nutritional status is an often overlooked reversible

problem in the care of older adults.
Recognise that undernutrition is frequently a multifactorial problem of
complex bio-psycho-social-cultural aetiology.

Knowledge

Discuss age-related physiological changes and psychosocial risks that

can predispose to poor nutritional health.
Relate potential complications associated with anorexia, involuntary
weight loss (IWL), and protein energy malnutrition for older adults who
are: community dwelling, hospitalised, or residents in aged care
facilities.
Briefly explain these conditions: starvation, marasmus, cachexia,
kwashiorkor.
Describe the diagnosis and management of protein energy malnutrition
(PEM).

Skills

List medications in which poor nutritional status is commonly an issue.

Complete a nutritional status assessment of an older adult in the clinic,
at home, and aged care facility.
Recommend appropriate interventions for undernutrition in the clinic,
home, and aged care facility settings.

Module Content: Nutrition, Undernutrition, Malnutrition

I.
II.
III.
IV.
V.
VI.
VII.

Prevalence
Types of Malnutrition
Morbidity and Mortality Impact
Normal Ageing Changes
Normal Requirements
Contributing Factors
Screening and Assessment

I. PREVALANCE
Geriatric malnutrition is complex and multifactoral. Additionally,
three population subsets need to be considered when one
speaks of older adults: community dwelling, hospitalised, and
institutionalised in residential aged care settings.
Malnutrition as reduction in nutrient reserve

Ambulatory/Community Dwelling 1% to 15%

Hospitalized 35% to 65%
Institutionalized 24% to 60

Protein-Energy Malnutrition (PEM): presence of both clinical

and biochemical changes consistent with undernutrition.

Ambulatory/Community Dwelling 15%

Hospitalized 20% to 65%
Institutionalized 5% to 85%

II. TYPES OF MALNUTRITION

A. Kwashiorkor-like: acute or subacute type of PEM that develops
acutely or over weeks secondary to physiological stress or low protein
intake. As depletion of visceral proteins (albumin, transferrin,
prealbumin and retinol-binding protein) occurs, albumin levels drop,
oedema develops and there may not be any weight loss. The mortality
rate is high. Older adults who already have low serum total cholesterol
and serum albumin biochemical markers are at risk for more severe
acute illness (even with seemingly minor pathology) due to
accentuation of the normal age-related impaired immune response,
haematological function, and organ function. Kwashiorkor may also
develop concurrently with the pre-existing marasmus PEM subtype.
[mnemonic: Kwashiorkor Kwick]
B. Marasmus: more insidious development over months to years due to
poor food intake. Muscle wasting (beyond age-related sarcopenia that
can be found even in healthy, active older adults) develops in response
to the metabolism of skeletal muscle. Because muscle is metabolised
rather than serum or visceral proteins, the serum levels are normal or
close to normal. Mortality is much lower than for kwashiorkor.
However, marasmus can quickly develop into a kwashiorkor-like
malnutrition during periods of acute illness. [mnemonic: Marasmus
Muscles; Months]
C. Cachexia: hypermetabolic state of catabolism and proinflammatory
responses (mediated by cytokines such as TNF, IL-1 and IL-6) that
occur in both acute, life-threatening illnesses as well as chronic
conditions that can elicit an acute-type response. Examples include
cancer, COPD and chronic heart failure. Anorexia with reduced
nutritional intake, fatigue, severe weight loss, increased insulin

resistance, increased CRP, hypercortisolaemia and reduced albumin

synthesis can all occur. Cachexia does not usually respond to
hypercaloric intake. Interventions are aimed at the underlying
condition.
D. Starvation: hypometabolic state that occurs due to lack of adequate
food intake. Skeletal muscle mass is preserved until late in the
starvation course. Starvation does respond to hypercaloric intake.
E. Undernutrition: reduction in nutrient reserve

III. MORBIDITY AND MORTALITY IMPACT

Inadequate dietary intake can contribute to, or exacerbate disease,
advance age-related degenerative conditions, increase hospital stays
and costs, delay illness recovery in outpatients, and increase mortality
in older adults compared with older adults who are not nutritionally
compromised.
o Specific adverse effects of involuntary weight loss (IWL) in older
adults:
Anaemia, Immune dysfunction, Infections, Hip fracture,
Pressure Ulcers, Fatigue, Decreased cognitive function,
oedema, Muscle loss, Osteoporosis, Falls
NHANES III (National Nutrition Examination Surveys)
o Older women (mean age 66) with 5% or more body weight loss
over 10 years had two-fold increased risk of disability compared
with women of stable weight

The Geriatric Anorexia Nutrition (GAIN) Registry

o Adults living in permanent residential aged care and losing
weight have a higher mortality compared with those who
stopped losing weight [those who lost >5% weight in any one
month had a 10-fold increase in risk for death compared with
those who gained weight]
o Those who gained weight had a lower mortality than those
whose weight loss stabilised.

IV. NORMAL AGEING CHANGES

Reduced bone mass, lean body mass and water content

Increased total body fat and intra-abdominal fat stores (nearly doubled
adipose content after age 65)
Physiological Anorexia of Ageing
o Weight tends to stabilise until about the 6th or 7th decade, then
slowly declines
o Increased circulating cholecystokinin (the satiating hormone)
o Reduced relaxation of the fundus allows for quicker passage of
food into the antrum and this antral stretch also contributes to
early satiety in older adults
o Reduced BMR (basal metabolic rate) due to muscle mass
losses
o BMR is the primary determinant of total energy expenditure

Reductions in olfactory and gustatory (taste and texture discrimination)

senses
o Olfactory changes are thought to have a more negative impact
on appetite than changes in taste buds
o Mild decrease in saliva production
Decreased thirst perception, response to serum osmolality, and ability
to concentrate urine following fluid deprivation

Tendancy to constipation

V. NORMAL REQUIREMENTS

Generally fluid requirements in older adults are roughly estimated to be

at least 1500mls/day. Other formulas are 30-35mls/kg; or, 1500mls the
first 20kg + 20ml per additional kg.

A quick estimation of energy based on body weight: 25-30 kcal/kg/day

The Harris-Benedict (HB) equation is perhaps the most well-known and
utilised formula for calculating energy needs in hospitalised adults. It
calculates Basal Energy Expenditure (BEE) and then incorporates
gender and metabolic stress factors to estimate total energy demands.
[Resting Energy Expenditure (REE) is slightly higher than BEE.]
Although the equation does not always correctly estimate energy
needs, it may be the best available equation at this time. A study
published August 2007 in Clinical Nutrition, (26)4, 498-505 showed that
of the 5 best known energy equations, the HB had the lowest mean
difference between estimated needs and measured needs (using
indirect calorimetry, a metabolic cart, to measure substrate utilisation).
The HB equation and stress factors can be found at several websites.
Here is one of them:
http://healthlinks.washington.edu/nutrition/section13.html
o Macronutrient Needs
Pro 0.8g/kg/day (1.5 g/kg/day if stress)**
Fat 20% -35% total energy intake per day
CHO 45% - 65% total energy intake per day
Specific conditions may dictate changes; for
example: COPD patients may have less CO2
retention by reducing CHO substrate metabolism
and increasing fat calories. The work of breathing
(WOB) in COPD patients can lead to a pulmonary
cachexia.
Fibre 30 g/day (men); 21 g/day (women
** Sarcopenia is the age-related development and
progression of skeletal mass. The mechanisms of the universal
phenomenon are poorly understood. However, research has
suggested that moderate increases of dietary protein greater
than 0.8g/kg/day may enhance anabolism and slow skeletal

muscle mass losses with age. This would not be appropriate in

persons with renal disease. Resistance training also slows
sarcopenia and functional decline. Research abstract and full
text from the American Journal of Clinical Nutrition, May 2008,
can be accessed online at:
http://www.ajcn.org/cgi/content/full/87/5/1562S

Calcium recommended daily calcium intake is 1500 mg.

o
o
o
o
o

Ca+ critical to function of cells

99% of calcium stored in bones /teeth
Serum calcium does NOT reflect bone calcium
Ca+ is leeched from bones if needed
500 mg = Maximum absorbed at one time

Vitamin D is needed for calcium absorption. Vitamin D synthesis in

the skin requires the suns UV rays. Sufficient Vitamin D synthesis
solely through the sun requires 5-30 minutes of unprotected sun
exposure twice weekly. Complete could cover reduces UVB by 50%,
shade by 60%, and there is no UVB penetration through glass.
o Community dwelling older adults may be Vitamin D deficient due
to sun reduction or avoidance due to skin cancer concerns and
subsequent sun avoidance.
o Institutionalised frail older adults are usually sun-deprived and
usually require Vitamin D supplementation.

VI. CONTRIBUTING FACTORS TO UNDERNUTRITION

There are numerous risk factors for nutritional compromise, but
it has been reported that the most important are: low income,
social isolation, high stress level, poor appetite, visual
impairment, and medical illness.
1. Poverty and Near-poverty
Older women, and older adults living alone or living with
non relatives experience poverty rates higher than
average. Poverty rates are higher in rural than in urban
older populations. Since there is a close connection
between insufficient income and hunger this suggests
many older people are at risk for food insecurity and
hunger.
o Food Insecurity: occurs whenever the availability
of nutritionally adequate and safe food, or the
ability to acquire foods in socially acceptable ways,
is limited or uncertain.

Hunger: uneasy or painful sensation caused by

recurrent or involuntary lack of food and is a
potential, although not necessary, consequence of
food insecurity. Over time, hunger may result in
malnutrition."
o Food Insufficiency: an inadequate amount of food
intake due to lack of resources.
Functional Deficits: visual impairments, immobility,
tremors, dexterity problems, transportation lack to secure
food.
Cognitive, Psychiatric & Social: isolation, lack of
transportation, depression, dementia, paranoia. In
nursing homes, depression and other psychiatric
conditions account for nearly 60% of involuntary weight
loss.
Restrictive Diets: low sodium, low fat, diabetic, renal
Oral Problems: edentulous, poor fitting dentures, dental
pain, oral sores, xerostomia (due to medications,
Sjogrens disease), dysgeusia
Medical Conditions: COPD, cardiac disease,
dysphagias, Parkinsonism and other neurological
disorders, cancer, arthritis, infections, thyroid disorder,
malabsorption syndromes, GORD, alcoholism, and
others.
Polypharmacy as well as specific Offending Drugs:
Many medications have side-effects that can negatively
impact nutrition directly or indirectly, and eventually lead
to weight loss. The following potential effects and
associated medications are only a few examples:
o

2.
3.

4.
5.
6.

7.

Anorexia digoxin, spironolactone, furosemide,

phenytoin, K+ supplements
Nausea digoxin, NSAIDs, opioids, some antibiotics
Altered taste metronidazole, clarithromycin, ACEIs,
CCBs, metformin
Dysphagia bisphosphonates, NSAIDs, K+ supplements
Early satiety anticholinergics
Hypermetabolism thyroxine
Constipation -- opioids, iron, diuretics
Diarrhea antibiotics
Also consider the potential risk for free circulating
drug in undernourished persons taking
medications that are highly protein bound such as
digoxin.

VII. SCREENING AND ASSESSMENT

A. Screening

Nutritional screening tools are general survey, questionnaire, checklist

or scaled instruments to identify individuals in a group of older adults
with undernutrition or at potential risk. They can be self-administered,
volunteer or professionally administered. Screenings may lead to
individual nutritional assessments to diagnose and treat persons with
undernutrition. Seven criteria have been established for screening tool
selection: 1) simple easy to use and interpret; 2) acceptable to the
older adult; 3) accurate 4) cost benefits equal to or exceed cost; 5)
reliable; 6) sensitive; and 7) specific.
The Nutrition Screening Initiative (NSI) was developed to address the
prevalence of malnutrition among older adults; it was a collaborative
effort among the AAFP (American Academy of Family Physicians), the
ADA (American Dietetic Association), and others. Two of the tools
cited below (DETERMINE and NMA) were among the many outcomes
of the NSI.
1. DETERMINE: a checklist of warning signs of poor nutrition.
Disease
Eating Poorly
Tooth Loss/Mouth Pain
Economic Hardship
Reduced Social Contact
Multiple Medications
Involuntary Weight Loss / Gain
Needs self-care assistance
Eighty years old or over
The questions in the screening tool flow out of the
DETERMINE warning sign mnemonic above. The
questionnaire and scoring criteria can be found at:
http://geridoc.net/nutrition.html or
nutritionandaging.fiu.edu/downloads/NSI_checklist
.pdf
2. MNA: Mini-Nutritional Assessment is both a screening
and assessment tool. The MNA-SF (short form) is only a
screen and is Part I of the two-part MNA tool. The MNA
has been called the best screening tool for use in older
adults. More detailed Information and the tool itself can
be viewed at:
http://www.merck.com/media/mmpe/pdf/Figure_002-1.pdf
http://www.mna-elderly.com/forms/mna_guide_english.pdf
(color detailed MNA directions)
3. SCALES: this tool has been cross-screened with the
MNA and is useful in outpatient settings. Available online
at: http://www.merck.com/mrkshared/mmg/tables/61t3.jsp

B. Assessment
1. Detailed History and Exam
o Diet and weight history, Medical, Medications,
Psychiatric, Social (financial resources,
bereavement, isolation, alcohol), Functional
o Potentially Reversible Causes?
Meals on Wheels mnemonic in residential
aged care
Medications
Emotional (depression)
Alcoholism/ Anorexia tardive (late life
nervosa)
Late onset paranoia
Swallowing disorders
Oral problems
Nosocomial infections (H. pylori, C. Diff)
Wandering (& other dementia related
behavior [DRB] )
Hyperthyroidism / Hypoadrenalism /
Hypercalcemia
Enteric problems (malabsorption)
Eating Problems
Low salt diet
Stones (cholelithiasis)
2. Clinical Signs of Undernutrition
o Muscle wasting, loss of fat stores
o Percentage of IWL (involuntary weight loss)
5% in 30 days
10% in 6 months or less
o BMI < 21 [severe if <19]
o Weight < 80% IBW (ideal body weight)
o Anthropometrics
Mid-arm circumference and Triceps skin
fold measurements
< 10th percentile on normative values table
May yield more useful information over time
using the patient as his/her own control
Not commonly done unless part of Nutrition
Support Team or Registered Dietician
Consult
o Clinical signs of Dehydration
Reduced urine output
New or worsened orthostatic vital signs
Delirium

Xerostomia
Ropey saliva
Buccal mucosal dryness
Dry, furrowed tongue
Caution: patients with Sjogrens
disease often have xerostomia as
well as dryness of other mucous
membranes (depending on severity)
3. Biochemical Signs of Undernutrition
o Low Total Cholesterol (TC) [late sign]
o Serum Albumin < 35
half-life 2-3weeks
o The combination of BOTH low total cholesterol and
serum albumin confers even greater risk of
increased morbidity or mortality.
Low Albumin has prognostic significance
but is not sensitive nor specific for
malnutrition; it may actually be a marker of
inflammatory status due to cytokine activity
o Other testing that may be useful in searching for
potentially reversible underlying causes: FBC,
TFT, FOBs (faecal occult blood)

C. Treatment
1. Address the underlying cause when possible
o Example: treat the pain of arthritic hands (or any
significant pain), depressive pathology, GORD,
tremor, dental appliance fit, oral topical analgesics,
drug contributions, artificial saliva, etc
o Obtain dietician consult
o Estimate energy requirements
o Eliminate restrictive diets
Involve patient in food preferences
Use calorie dense foods
2. Liquid Supplements between meals
o Recall that supplements usually do not work in
cachexias (hypermetabolic states)
o Little benefit if given with meals
3. Smaller portions & more frequent eating rather than
traditional 3 meals
Consider disease specific recommendations in select
cases, such as switching substrate to low carbohydrate
(CHO) and higher balanced-fat calories in patients with
COPD. CHO substrate metabolism typically results in
increased CO2 production which can be burdensome on
the lungs to try to exhale it. The Respiratory Quotient
(RQ) is a ratio of C02 production to O2 consumption.

The RQ for CHO metabolism is higher than that for fat or

protein. Commercially available low CHO and balanced
high-fat nutritional supplements are available for patients
with COPD. These types of products may be helpful in
COPD patients who are hypercapnaeic. They also
provide denser calories which is usually beneficial in
persons with COPD since the work of breathing (WOB)
alone can be very costly in terms of caloric expenditures.
Low BMI in patients with COPD is associated with higher
mortality.
4. Consult a speech pathologist for evaluation and
management recommendations regarding dysphagia in
any one or more of the four phases of deglutition.
5. Carefully consider Orexigenic Drugs (so-called appetite
stimulants)
o Antidepressant
Mirtazapine: antidepressant with some
orexigenic properties. Sedating. Start with
low dose 15mg. Give at bedtime.
o Anabolic Steroid
Testosterone: Low levels correlate with
male sarcopenia. May be reasonable in
undernourished men with low testosterone
levels. Not commonly tried.
o Progestational Agent
Megestrol Acetate: (Megace ) 400 to 800
mg increases appetite (food intake) and
weight. Weight gain is fat. Risks: DVT,
markedly decreased testosterone levels,
adrenal suppression, edema, constipation,
hyperglycemia. Use in ambulatory persons
with cytokine excess. If used in men, may
consider use concurrently with testosterone.
o Prokinetic Agent
Domperidone: useful if gastroparesis and
nausea limit oral intake
o Glucocorticoids e.g. dexamethasone- but side
effects limit use

6. Nutrition Tubes
o commonly called feeding tubes although there is
nothing about these tubes that is feeding. The
term feeding carries heavy emotional and social
connotations. Rather, these are medical devices
used for a medical treatment that allows for an

o
o

alternative provision of nutrition (aka: artificial

nutrition).
May be appropriate in dysphagia given the
patients full medical context and QOL (quality of
life), especailly if some degree of recovery is
expected (e.g following stroke)
They are not recommended in end-stage
dementia (studies show no benefit)
They are not appropriate if the primary purpose is
to prevent aspiration pneumonia as there is no
research demonstrating PEG (percutaneous
endoscopic gastrostomy) tubes prevent
pneumonia