What is Malnutrition?
Malnutrition is a state of nutrition (under or over nutrition) 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. We will focus on under nutrition as a nutritional concern. The main cause for concern among older people in the UK is that they are not eating enough to maintain good nutrition. Among the population of older people in residential care there are many more underweight people than there are overweight or obese people, and in old age being underweight poses a far greater risk to health than being overweight. The most recent information on the nutritional status of older people in Britain was reported in the National Diet and Nutrition Survey (NDNS) of people aged 65 years and over in 1998. In this survey, 3% of men and 6% of women living at home were underweight, while comparable figures for those in residential care were 16% and 15% respectively.
It is suggested, however, that risk of undernutrition is still not adequately identified in older people and that undernutrition is often associated with hospitalisation and poor health status.1 The level of undernutrition among older people with dementia in residential care is likely to be even higher, with estimates that as many as 50% of older people with dementia have inadequate energy intakes. Undernutrition is related to increased mortality, increased risk of fracture, increased risk of infections and increased risk of specific nutrient deficiencies leading to a variety of health-related conditions that can greatly affect the quality of life. Disease can also exert a potent influence on malnutrition as medical conditions can reduce food intake and impair digestion and absorption of nutrients as well as affect how the body metabolises and utilises them.
The causes of undernutrition in older people in residential care are often multi-factorial: low income, living alone, limited mobility, and lack of facilities and social network can lead to undernutrition before admission, and this is often exacerbated by depression, bereavement and confusion. Factors that have been associated with undernutrition in care situations include: lack of palatability of food and inflexible timing of meals, lack of assistance with eating or loss of independence in eating, lack of acceptability of food provided to ethnic minorities and lack of awareness of the need for assessment and documentation of older people at risk of undernutrition.
Malnutrition can be significant if a person has:
• a BMI of less than 18.5 kg/m2 • had unintentional weight loss greater than 10% within the last 3-6 months • a BMI less than 20kg/m2 and has had unintentional weight loss greater than 5% 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. 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. 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. Prevalence of malnutrition amongst the 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, dysphasia, 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
As we have seen, the groups 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
Risk factors more specific to the elderly:
Dementia and other neurological disorders:
– Alzheimer’s disease
– Other forms of dementia
– Confusional syndrome
– Consciousness disorders
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
Detection of Malnutrition
There is 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 our resident been eating a normal and varied diet in the last few weeks? • Has our resident experienced intentional or unintentional weight loss recently? Rapid weight loss is a concern in all patients/residents whether obese or not • Can our residents eat, swallow, digest and absorb enough food safely to meet their likely needs? • Does our resident 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 out resident’s ability to handle the nutrients for current or future needs? • Does our resident have excessive nutrient losses through vomiting, diarrhoea, surgical drains etc? • Does a global assessment of our resident 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 our resident 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 our residents are at risk of malnutrition.
Given the high prevalence of malnutrition and lack of proper management of patients/residents in various settings, performing a routine nutritional ‘screening’ should result in early identification of patients/residents who might have otherwise been missed. A screening tool should 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.