Answer:
Nutrition is an important determinant of health in persons over the age of 65. Malnutrition in the elderly is often underdiagnosed. Careful nutritional assessment is necessary for both the successful diagnosis and development of comprehensive treatment plans for malnutrition in this population. The purpose of this article is to provide clinicians with an educational overview of this essential but often underecognized aspect of geriatric assessment. This article will review some common issues in nutrition for the elderly in both hospital and community settings. The complexity and impact of multiple comorbidities on the successful nutritional assessment of elderly patients is highlighted by using case scenarios to discuss nutritional issues common to elderly patients and nutritional assessment tools. Three case studies provide some context for an overview of these issues, which include the physiology of aging, weight loss, protein undernutrition, impaired cognition, malnutrition during hospitalization, screening procedures, and general dietary recommendations for patients 65 years of age and older.
Keywords: nutrition, elderly, weight loss, vitamin and mineral supplementation
Introduction
Nutrition is an important determinant of health in elderly patients. Over the past decade, the importance of nutritional status has been increasingly recognized in a variety of morbid conditions including cancer, heart disease, and dementia in persons over the age of 65 (Basran and Hogan 2002; Tessier 2002; Keller et al 2003; Takashashi et al 2003; Coombs et al 2004; Van Wymelbeke et al 2004). Although there is no uniformly accepted definition of malnutrition in the elderly, some common indicators include involuntary weight loss, abnormal body mass index (BMI)1, specific vitamin deficiencies, and decreased dietary intake (Reuben et al 2004). Malnutrition in older patients is regularly underdiagnosed (Gariballa 2000), and many physicians have expressed their need for more education regarding nutritional status in older patients (Mihalynuk et al 2004). For example, health practitioners may not readily recognize weight loss in the elderly as a morbid symptom of malnutrition because some weight loss may be associated with age-related reductions in muscle mass (Kane et al 1994). Similarly, elderly patients with concurrent obesity often have protein undernutrition that may be overlooked.
Many elderly patients have an increased risk for malnutrition compared with other adult populations. It is estimated that between 2%–16% of community-dwelling elderly are nutritionally deficient in protein and calories (Whitehead and Finucane 1997). If mineral and vitamin deficiencies are included in this estimate, malnutrition in persons over the age of 65 may be as high as 35% (Chandra 2002). The situation for hospitalized seniors is also disturbing. Studies of hospitalized older patients suggest that between 20%–65% of these patients suffer from nutritional deficiencies (Elmstahl et al 1997; Sullivan and Lipschultz 1997; Hall et al 2000), and the prevalence of malnutrition in long-term care facilities is estimated to be between 30%–60% (Rudman and Feller 1989). The elderly also often have multiple comorbidities that contribute to overall nutritional compromise. Given these complex contributing factors, a careful nutritional assessment is necessary for both the successful diagnosis of malnutrition in the elderly and the development of appropriate and comprehensive treatment plans.
This article reviews some issues in nutrition common to hospitalized and community-dwelling seniors. Three introductory case studies provide context for a discussion of the complexity of nutritional assessment of elderly patients, including the physiology of aging, weight loss, protein undernutrition, cognitive impairment and vascular risk factors, malnutrition during hospitalization, and general dietary recommendations for patients 65 years of age and older. Each of these sections conclude with key points emphasizing the significance of these issues to a comprehensive nutritional assessment in the elderly patient. Following this discussion, we will return to the case studies to suggest how specific clinical strategies can improve the functional status of these patients.
Case studies
The following three case studies highlight common complications in malnourished elderly patients. Consider these cases as we discuss major principles of nutritional assessment of elderly patients. Each scenario is comprehensively addressed at the end of the article.
