Tackling malnutrition among older patients

Malnutrition is an important consideration in care of the elderly. It has a high prevalence in care homes and hospitals, but is also a risk for many elderly living at home. It impacts on quality of life, increases morbidity and incurs substantial financial costs associated with increased disease burden, nutrition support and increased length of hospital stay. This article reviews the causes and consequences of malnutrition in the elderly, how to identify those at risk, and intervention strategies to reduce prevalence.

In the UK it is estimated that 12% of over 65s living in the community are at high or medium risk of malnutrition. The prevalence is reckoned at 20% among those in residential accommodation and up to 40% in those admitted to hospital.¹

In a study of meals-on-wheels recipients in Ireland, over one-third of recipients (38.5%) were malnourished or at risk of malnutrition and over half (52.3%) were overweight or obese.²

Causes 

The risk of malnutrition increases with age and number of comorbidities.³ The multiple causes of malnutrition in the elderly include:

• Physiological decrease in appetite and food intake that accompanies normal ageing 

• Reduced taste and smell

• GI side effects of prescribed medications

• Acute and chronic disease 

• Poor dentition 

• Age-related achlorhydria

• Social factors such as poverty and isolation 

• Psychological factors such as depression and cognitive decline 

• Physical factors such as poor vision and reduced mobility.

In an Irish study of community-dwelling 60 to 92-year-olds, the strongest predictors of abnormal nutritional status were poor mobility and lack of social support. Other significant predictors of nutritional risk were age and deprivation.⁴

Data from the ELDERMET study in Ireland indicate that the diet of community-dwelling elderly individuals is sub-optimal, particularly among elderly males. A high rate of overweight/obesity was observed and consumption of energy-dense, low-nutrient foods was excessive among this population group. Older subjects (≥ 75 yrs) consumed significantly more desserts/sweets than younger elderly (64 to 74 years old). Intakes of dietary fat and saturated fat were high while dairy food consumption was inadequate in both males and females. Elderly females typically had a more nutrient-dense diet than males. A considerable proportion of subjects, particularly males, had inadequate intakes of calcium, magnesium, vitamin D, folate, zinc and vitamin C.⁵

Consequences of malnutrition

Malnutrition leads to a depletion of body stores of nutrients and loss of muscle mass (secondary sarcopenia). This in turn has many consequences including:

• Increased infections, delayed wound healing, increased surgical complications

• Increased hospital length of stay

• Increased hospital mortality

• Delayed rehabilitation and convalescence

• Reduced functional capacity and quality of life

• Increased GP visits and increased re-admissions to hospital – high social cost

• Higher healthcare costs.

Up to 70% of elderly patients are discharged from hospital weighing less than when they were admitted. This results in a ‘malnutrition carousel’ of more GP visits and subsequent increased risk of re-admission.⁶

Malnutrition and dementia

There is a strong association of malnutrition with dementia. Often the first sign of cognitive decline to become apparent to an older person’s relatives is self-neglect with resulting inadequate diet and weight loss. A recent study in Cork revealed that patients admitted to acute hospitals with dementia, were older and frailer, with higher comorbidity, malnutrition and lower functional status.⁷

Conversely, there is increasing evidence that malnutrition may be a contributory cause of dementia. Low intake of folic acid, vitamin B12 and long chain n-3 fatty acids of marine origin has been shown in observational studies to be associated with higher risk for Alzheimer’s disease.  

A review of long-term intervention studies has shown that adherence to a Mediterranean diet reduces the risk of developing dementia.⁶ Recently a number of studies have found a link between dementia and vitamin D deficiency.⁸

Identifying older adults at risk 

A range of simple and validated screening tools can be used to identify malnutrition in older adults, eg. MST, MNA-SF and MUST (see example in Table 1).³ The Royal College of Physicians UK has identified nutritional screening as an integral part of clinical practice.¹ Older adults should be screened for nutritional issues at diagnosis, on admission to hospitals or care homes and during follow-up at outpatient or GP clinics, at regular intervals.

A key barrier is that many GPs and nursing homes may either have no weighing scales or may not routinely weigh patients on admission or thereafter. This results in a failure to notice or act on any weight loss in older patients. 

Malnutrition and sarcopenia

The ‘cycle of frailty’ (see Figure 1) has been described,⁶ and related to this is the new concept of a malnutrition-sarcopenia syndrome, in which malnutrition aggravates and accelerates the intrinsic sarcopenic process. 

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It has been proposed that clinicians integrate nutrition assessment with sarcopenia screening for better targeted intervention.⁹

Interventions in acute settings

Policies to reduce malnutrition are well-established in many Irish hospitals but must be continuously audited to ensure they are adhered to. They include:

• An active nutrition committee which formulates policies on nutrition, hydration, and nutrition support

• Nutrition screening on admission and weekly thereafter with planned nutrition intervention carried out for medium and high-risk patients

• Protected mealtimes

• Communal dining where feasible

• Assistance with eating

• High calorie, high protein menu with additional snacks offered at regular intervals

• Texture modified menus 

• Food fortification

• Oral nutritional supplements (ONS).

As a way of reinforcing nutrition policy and gauging its effectiveness, Irish hospitals have taken part in the BAPEN malnutrition screening week survey since 2010. Furthermore, in 2015 HIQA launched the hospital self-assessment questionnaire on nutrition and hydration provision, and unannounced inspections have begun this year to assess adherence to best practice nutritional care.

Discharge planning for follow-on nutritional care 

There exists in many cases a gap around discharge planning which needs to be closed with respect to nutrition care. It may be necessary to formulate policies ensuring patients and carers are given written advice and instructions to enable continued adherence to nutrition support measures post-discharge, as well as information on how to recognise if further help with nutrition is needed and where to seek that help. 

Use of ONS in various settings

While promoting ‘food first’, ONS can often play an adjunct role. In the clinical setting, ONS have been shown to improve health outcomes in a number of controlled trials and also to have cost savings when used in hospitals post-operatively. In an analysis of 34 hospital-based studies, ONS reduced mortality from 25% to 19%, reduced complications from 41% to 18%, and reduced the length of hospital stay.¹⁰

In its guidance on cost saving, NICE identified nutritional support in adults (based on ONS and specialised forms of nutritional support) as the fourth intervention most likely to save money for the NHS. Cost-effectiveness of ONS can be extended to the community setting where they have been shown to increase energy and nutrient intakes among those at risk of malnutrition. In nursing homes, appropriate nutritional care that includes ONS can produce significant benefits.

Reducing malnutrition prevalence

Awareness of malnutrition must be heightened among older people, their families and the public at large, so that the importance of monitoring weight and acting on unplanned weight loss in older people is recognised.¹¹ Regular public education campaigns, information leaflets and newspaper articles could be a means to achieve this.

The INDI has useful factsheets accessible to the public on the website under the ‘healthy ageing’ section, including ‘Good nutrition for the older Person’, ‘A simple guide to the use of oral nutritional supplements’ and ‘Feeding strategies in dementia’. 

The Older Person and Dementia Special Interest Group of the INDI has excellent resources for members to download, including modified texture diet sheets and a high calorie, high protein diet sheet with tips on eating with a small appetite and food fortification. 

BAPEN has recently launched a website, www.malnutritionselfscreening.org, for the public to self-screen for malnutrition. It classifies risk as low, medium or high, based on BMI and any reported weight loss in the last three to six months. Those found at risk are directed to information which includes advice to eat three meals and include snacks and nourishing drinks, have full-fat products, repeat the screen monthly and speak to doctor or other health professional if concerned. An advice sheet ‘Your guide to making the most of your food’ is also available to download. The site also recommends that if food choice and quantity is limited, a one-a-day complete multivitamin-mineral supplement be commenced. 

Another excellent resource is ‘Managing adult nutrition in the community’ (www.malnutritionpathway.co.uk), a document by a multiprofessional consensus panel in the UK aimed at GPs and other community healthcare professionals. It includes a pathway for the appropriate use of ONS, and emphasises that when managing malnutrition, various members of the health profession team may need to be involved eg. dietitians, OTs, SALTs, public health nurses and community pharmacists.

A comprehensive report on meals-on-wheels in Ireland¹² outlined many practical solutions which could be employed to make food more accessible to vulnerable elderly. These include meals-on-wheels or a private meal delivery service, assistance with transport and shopping, a shopping companion, delivery of groceries to the home or help with food preparation.  Community centres and day care centres often provide cooked lunches, and a novel approach tried successfully in the UK is to host such lunches in pubs. 

New Irish research

Data is to be collected for Ireland on the extent of malnutrition in free-living older people as part of NUTRIMAL (novel NUTRItion solutions to combat chronic MALnutrition in the elderly), a new collaborative research project led by Prof Helen Roche at UCD. 

Another project, due to commence in March this year, is MaNuEL (Malnutrition in the Elderly knowledge hub). This is a European project with input from several groups in Ireland including INDI, IrSPEN and the major academic institutions. 

Among its goals are: development of a definition of treatable malnutrition in older persons; collection of information on published malnutrition screening tools for older adults and selection of  the preferred tool(s) for clinical practice; gathering of data on prevalence of malnutrition in older adults in different healthcare settings throughout Europe and development, implementation and monitoring of malnutrition prevention strategies. 

Conclusion

Estimates of the cost of malnutrition to the health service in Ireland are substantial, in the order of €1.4b per year or 10% of the healthcare budget.⁶ Therefore even small percentage reductions in malnutrition from earlier identification and treatment interventions could deliver large savings. 

While the well elderly are rightly encouraged to have healthy diets to help prevent cancer, diabetes and cardiovascular disease, we need to recognise those for whom adequate nutrition may be a challenge. Early identification and treatment of nutrition problems will lead to improved outcomes and better quality of life.

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References

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9. Vandewoude MFJ, Alish CJ, Sauer AC and Hegazi RA. Malnutrition-Sarcopenia Syndrome: Is this the future of nutrition screening and assessment for older adults? J Aging Res 2012; 2012:651570. Epub 2012 Sep 13
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11. “Malnutrition among Older People in the Community: Policy Recommendations for Change” 2006. http://www.european-nutrition.org/publications.cfm
12. O’Dwyer C and Timonen V. The Role and Future Development of the Meals-on-Wheels Service for Older People in Ireland. 2008 National Council on Ageing and Older People Report No. 104