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Editors

MerjaSuominen
TainaHellsten

Assessment of Nutritional Status in the Elderly

Essentials

  • Assessment of nutritional status is an important part of comprehensive health assessment. Changes associated with ageing increase the risk of malnutrition.
  • Sufficient intake of energy, proteins and other nutrients through the diet should be guaranteed.
  • An overweight person less than 75 years of age may slim with caution if he/she has comorbidities. Patients aged over 75 years rarely benefit from slimming.

Prevalence and pathophysiology

  • The prevalence of malnutrition among the elderly population is 5-10%. Check also local data concerning the prevalence.
    • 10-20% among patients aged over 80 years
    • 27-65% among elderly hospitalised patients
    • 30-80% among patients in institutional care
  • Physiological changes related to ageing http://www.dynamed.com/condition/frailty-in-older-adults increase the risk of malnutrition.
    • Muscle tissue is lost and the proportion of adipose tissue increases.
    • Slowing basal metabolic rate, reduced muscle mass and decreasing physical activity lead to a decreasing experience of hunger.
    • Delayed gastric emptying and longer presence of energy-rich metabolism products (glucose, free fatty acids) in the circulation prolong the feeling of satiety.
    • Glucose tolerance is reduced.
    • Susceptibility to fluid imbalance increases.
  • Malnutrition has numerous harmful consequences.
    • Increased morbidity and mortality
    • Delayed recovery from illnesses
    • Prolonged hospitalisation, increased demand for health services
    • Impaired resistance to infection, slower wound healing, increased risk of sepsis
    • Accelerated muscular wasting, diminished muscle function and strength, increased risk of falls and fractures

Causes

  • Problems in obtaining food
    • Financial (small pension, unwillingness to spend money on food)
    • Mobility issues, reduced functional capacity, lack of personal assistance
    • Clinging to old habits, alcoholism
  • Difficulty with chewing and swallowing
    • Stroke, dementia, Parkinson's disease, missing teeth, painful mouth
  • Increased nutritional requirements, especially for proteins
    • Infections, pressure sores
    • Trauma, surgery, particularly patients with hip fractures
    • Sarcopenia
  • Wasting diseases
    • Cancer, chronic infections (tuberculosis etc.)
    • Alzheimer's disease, other memory disorders
  • Impaired utilization of nutrients
    • Malabsorption (intestinal disorders, coeliac disease)
  • Other
    • Psychological causes (depression, delusion, mania)
    • Adverse drug effects (decreased appetite, dry mouth
    • Changes in taste or smell (age-related; adverse drug effects)

Diagnosis

  • Impaired nutritional status is in most cases suggested by unintentional weight loss, low body weight or low BMI.
  • Poor wound healing, poorly controlled chronic diseases and impaired physical performance may also be signs of impaired nutritional status.
  • The Mini Nutritional Assessment (MNA) test http://www.mna-elderly.com/ is a useful tool if suspecting impaired nutritional status.
  • The following laboratory tests are recommended: basic blood count (reduced Hb), plasma albumin, Na, K and creatinine.

Treatment

  • The aim of dietary treatment is to ensure an adequate intake of energy and proteins and other nutrients, in particular, as well as to maintain a good nutritional status http://www.dynamed.com/condition/unintentional-weight-loss-in-older-adults#DIET.
    • Nutritional supplementation, as required, appears to reduce mortality and complications.
  • The minimum daily dietary energy requirement is 1 600 kcal (6.5 MJ). This can be achieved by eating 2-3 meals and 2 snacks every day.
  • Further energy and protein should be included to enhance the diet, as necessary.
  • In people over 64, the daily intake of protein should be 1.2-1.4 g per kg of body weight (15-20% of energy intake).
    • During convalescence, the protein requirement is about 1.5 g per kg of body weight.
  • For elderly persons living at home, it is important to check eating and to use food delivery services and oral nutritional supplements, particularly after discharge from hospital.
  • Family style mealtimes in care institutions improve the quality of life and increase the intake of energy and nutrients.

Vitamins and minerals

  • Routine use of vitamins or minerals has not been proven beneficial.
  • Iron deficiency may lead to anaemia Iron Deficiency Anaemia.
  • Vitamin D
    • 10 µg (400 IU) daily is recommended for persons aged over 60 years, primarily from the diet.
    • For persons aged over 75 years, 20 µg (800 IU) daily is recommended as vitamin supplementation.
    • Vitamin D deficiency is common in those who mainly reside indoors, and routine vitamin D supplementation is justified.
  • 800-1 500 mg/day of calcium should be taken primarily through the diet.
  • Vitamin B deficiency may cause neuropathies or changes in blood count.
  • Folate deficiency is common.
  • Check also local recommendations that may vary due to different populations, diets and geographical areas.

Obesity

  • A BMI exceeding 30 is termed obesity.
    • Being slightly overweight (BMI 24-29) is rarely an indication for treatment.
  • An obese person may also have malnutrition (fat frail).
  • Weight loss and fluctuating weight can easily lead to muscle wasting and a relative increase in fat tissue.
  • In a patient aged less than 75 years, cautious weight reduction with the aid of increased physical exercise together with ensuring of sufficient protein intake is feasible in the treatment of diabetes, cardiac insufficiency, hypertension and osteoarthritis.
  • People aged over 75 years rarely benefit from slimming.

    References

    • Blomhoff R, Andersen R, Arnesen EK et al. Nordic Nutrition Recommendations 2023. Copenhagen: Nordic Council of Ministers, 2023 http://pub.norden.org/nord2023-003/nord2023-003.pdf.
    • Volkert D, Beck AM, Cederholm T, et al. ESPEN practical guideline: Clinical nutrition and hydration in geriatrics. Clin Nutr 2022;41(4):958-989 [PubMed]
    • Baldwin C, Kimber KL, Gibbs M ym. Supportive interventions for enhancing dietary intake in malnourished or nutritionally at-risk adults. Cochrane Database Syst Rev 2016;12():CD009840. [PubMed]
    • Tieland M, Dirks ML, van der Zwaluw N et al. Protein supplementation increases muscle mass gain during prolonged resistance-type exercise training in frail elderly people: a randomized, double-blind, placebo-controlled trial. J Am Med Dir Assoc 2012;13(8):713-9. [PubMed]