Elsevier

Nutrition

Volume 16, Issue 1, January 2000, Pages 50-63
Nutrition

Review Articles
Assessment of protein energy malnutrition in older persons, part I: history, examination, body composition, and screening tools

https://doi.org/10.1016/S0899-9007(99)00224-5Get rights and content

Abstract

Protein-energy malnutrition is a prevalent problem in older persons. Its relation to increased morbidity and mortality has been well documented. Early recognition of malnutrition allows for a timely intervention. A large proportion of chronic diseases affecting older persons can be either prevented or significantly improved by improving nutrition, which underscores the importance of developing a screening system that can trigger a more comprehensive evaluation when indicated. Screening for malnutrition in older persons can be difficult because of the normal age-related changes in many of the commonly used parameters. A comprehensive nutritional evaluation includes a complete history and physical examination in addition to a more specific nutrition-oriented assessment. Specific nutritional assessment includes estimating food intake, anthropometric measurements, and evaluation of several biochemical parameters commonly affected by changes in nutritional status. In this article, we review the commonly used tools for nutritional assessment in older persons. The goal is to promote disease-free, active, and successful aging.

Introduction

Malnutrition is the state produced by the intake of too few macronutrients (protein-energy undernutrition, vitamin and mineral deficiency), too many macronutrients (obesity), or excessive amounts of inappropriate substances such as alcohol. When defined as a decrease in nutrient reserve, undernutrition is prevalent in 1% to 15% of ambulatory outpatients, 25% to 60% of institutionalized patients, and 35% to 65% of hospitalized patients.1, 2, 3, 4, 5

Malnutrition can adversely affect the well-being of older persons, causing a decline in functional status and worsening of existing medical problems. Among community-dwelling elderly, a relation between dietary quality and dependency in activities of daily living has been shown.6, 7 In hospitalized patients, a clear correlation has been shown between the parameters reflecting poor nutrition (such as cholesterol, albumin, and body mass index [BMI]) and rate of in-hospital complications, re-admissions, and mortality.8, 9, 10

Undernutrition increases the risk of respiratory and cardiac problems,4, 5 infections,11 deep venous thrombosis and pressure ulcers,12 peri-operative mortality,3, 13, 14 and multi-organ failure.15 Undernutrition has been associated with severe immune dysfunction, including a decrease in CD4 T-lymphocytes.16 Economically, the results of undernutrition are devastating because malnourished patients are more likely to stay longer in the hospital and have more complications as opposed to patients of normal weights.17, 18, 19, 20

The prevalence of overweight in persons 65 to 74 y old is 25% in men and 40% in women in the United States. Old black women living below the poverty level have the highest rates of being overweight.21 Being overweight has been strongly linked to hypertension, diabetes mellitus, hypercholesterolemia, respiratory impairment, and degenerative joint disease.22 However, recent evidence has shown a reverse relation between being overweight and hip fracture.23

This article reviews the different approaches to nutritional assessment and screening for malnutrition in older persons.

Section snippets

Routine history and physical examination

This section reviews the routine history and physical examination, with a special focus on the findings suggestive of increased nutritional risk. Identification of these risk factors is the first step toward the modification of the malnutrition process. Risk factors for malnutrition can be easily remembered by using the mnemonic MEALS ON WHEELS (Table I).

Obtaining a history from an elderly person should be performed with the understanding that a debilitated older person may not provide

Evaluation of dietary intake

There are four main methods to obtain information regarding eating habits and the amount of food consumed. A trained dietitian should collect this information.

The DETERMINE checklist

The DETERMINE Checklist was produced by the Nutrition Screening Initiative (NSI), a national consortium of health care professionals interested in nutrition and aging that includes more than 40 organizations.99 This interdisciplinary effort is aimed at incorporating nutritional screening and intervention in the American health care system.

The DETERMINE Your Nutritional Health Checklist is a list of 10 statements on a single page. These statements represent different common risk factors for

The instant nutritional assessment (INA)

Designed by Selzer et al.,110 the INA is one of the simplest screening tools, is easy to use, and is widely popular in many institutions. It depends on evaluating three parameters: lymphocyte count, albumin, and weight change per unit of time. To facilitate remembering these three parameters, this tool is often referred to as LAW (the first letter of each parameter).111

The subjective global assessment (SGA)

Developed by Detsky et al.,112 the SGA incorporates functional capacity as an indicator of malnutrition and also relies heavily

Practitioner-administered sophisticated screening tools

The aforementioned tools provide simple methods to identify patients at an increased risk for malnutrition who will benefit from an early intervention. Those patients should undergo an extensive nutritional evaluation that includes a nutritional history, physical examination including anthropometrics, and special laboratory tests.

Body composition and percentage of body fat

Understanding the normal changes in the body and its composition with increasing age and their health implications are important to the health care and nutritional support of elderly subjects. Changes in stature, weight, and body composition after age 60 y have been well documented. Large changes in these measurements have been reported to be associated with increased morbidity and mortality in elderly subjects.125, 126, 127, 128, 129, 130

A middle-age body composition changes such that the

References (291)

  • R.K. Johnson et al.

    Correlates of over- and underreporting of energy intake in healthy older men and women

    Am J Clin Nutr

    (1994)
  • W. Mertz

    Food intake measurementsis there a “gold standard”?

    J Am Diet Assoc

    (1992)
  • R.M. Angus et al.

    A simple method for assessing calcium intake in Caucasian women

    J Am Diet Assoc

    (1989)
  • K.O. Musgrave et al.

    Validation of a quantitative food frequency questionnaire for rapid assessment of dietary calcium intake

    J Am Diet Assoc

    (1989)
  • S.K. Kumanyika et al.

    Dietary assessment using a picture-sort approach

    Am J Clin Nutr

    (1997)
  • P. O’Hanlon et al.

    Dietary studies of older Americans

    Am J Clin Nutr

    (1978)
  • J.R. Mahalko et al.

    Comparison of dietary histories and seven-day food records in a nutritional assessment of older adults

    Am J Clin Nutr

    (1985)
  • H.K. Evans et al.

    Dietary record method comparison for hospitalized elderly subjects

    JAMA

    (1985)
  • W.A. van Staveren et al.

    Assessing diets of elderly peopleproblems and approaches

    Am J Clin Nutr

    (1994)
  • S.A. Bingham et al.

    Using biochemical markers to assess the validity of prospective dietary assessment methods and the effect of energy adjustment

    Am J Clin Nutr

    (1997)
  • F.A. Larkin et al.

    Comparison of estimated nutrient intakes by food frequency and dietary records in adults

    Am J Diet Assoc

    (1989)
  • J.V. White et al.

    Nutrition Screening Initiativedevelopment and implementation of the public awareness checklist and screening tools

    J Am Diet Assoc

    (1992)
  • L.E. Johnson

    Malnutrition

  • Lennard-Jones JE. A positive approach to nutrition and treatment. London: King’s Fund,...
  • H.O. Studley

    Percentage of weight loss. A basic indicator of surgical risk in patients with chronic peptic ulcer

    JAMA

    (1936)
  • J.A. Windsor et al.

    Risk factors for post-operative pneumoniathe importance of protein depletion

    Ann Surg

    (1988)
  • S.W. Sem et al.

    An attempt to identify and describe a group of non-institutionalized elderly with the lowest nutritional score

    Compr Gerontol

    (1988)
  • A. Bianchetti et al.

    Nutritional intake, socioeconomic conditions, and health status in a large elderly population

    J Am Geriatr Soc

    (1990)
  • R. Bienia et al.

    Malnutrition in the hospitalized geriatric patient

    J Am Geriatr Soc

    (1982)
  • J.F. Potter et al.

    In-hospital mortality as a function of body mass indexan age-dependent variable

    J Gerontol Med Sci

    (1988)
  • Patterson BM, Cornell CN, Carbone B, et al. Protein depletion and metabolic stress in elderly patients who have a...
  • B.R. Bistrian et al.

    Cellular immunity in adult marasmus

    Arch Intern Med

    (1977)
  • R. Holmes et al.

    Nutritional know-how. Combating pressure sores nutritionally

    Am J Nurs

    (1987)
  • A.S. Detsky et al.

    Predicting nutrition-associated complications for patients undergoing gastrointestinal surgery

    JPEN

    (1987)
  • J.A. Windsor et al.

    Weight loss with physiologic impairmenta basic indicator of surgical risk

    Ann Surg

    (1988)
  • E.A. Deitch et al.

    The gut as a portal of entry for bacteremiarole of protein malnutrition

    Ann Surg

    (1987)
  • F.E. Kaiser et al.

    Idiopathic CD4+ T lymphopenia in older persons

    J Am Geriatr Soc

    (1994)
  • I. Warnold et al.

    Clinical significance of preoperative nutritional status in 215 non-cancer patients

    Ann Surg

    (1984)
  • J.A. Windsor et al.

    Weight loss with physiologic impairmenta basic indicator of surgical risk

    Ann Surg

    (1988)
  • D.B. Reuben et al.

    Nutrition screening in older persons

    J Am Geriatr Soc

    (1995)
  • F.X. Pi-Sunyer

    Medical hazards of obesity

    Ann Intern Med

    (1993)
  • S.L. Greenspan et al.

    Fall severity and bone mineral density as risk factors for hip fracture in ambulatory elderly

    JAMA

    (1994)
  • M.P. Thompson et al.

    Unexplained weight loss in the ambulatory elderly

    J Am Geriatr Soc

    (1991)
  • C.Y. Lew-Ting

    Egg phobia in retirement homeshealth risk perceptions among elderly Chinese

    Cult Med Psychiatry

    (1997)
  • W.M. Thompson et al.

    Dentures, prosthetic treatment needs, and mucosal health in an institutionalized elderly population

    N Z Dent J

    (1992)
  • J.M. Weiffenbach

    Test and smell perception in aging

    Gerontology

    (1984)
  • B.J. Baum

    Research on aging and oral healthan assessment of current status and future needs

    Spec Care Dent

    (1981)
  • R.B. Hickler et al.

    Nutrition and the elderly

    Am Fam Phys

    (1984)
  • L.M. Bartoshuk

    Taste. Robust across the age span?

    Ann NY Acad Sci

    (1989)
  • J.V. White

    Risk factors for poor nutritional status in older Americans

    Am Fam Phys

    (1991)
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      In our review, no feeding assistance interventions demonstrated improvements in weight or MAMC. While MAMC may be a more sensitive indicator of protein reserves in the body as compared to weight [51], the two studies reporting MAMC had interventions of short duration (16 days and 3 months, respectively) and small sample sizes, which may have influenced the ability to demonstrate benefits [28,39]. In addition factors such as a suppressed appetite due to illness or drug side effects may also contribute to the difficulties in achieving improvements in acutely ill older patients, such as [28], emphasizing the need to evaluate the varied underlying causes of malnutrition which may not be addressed through feeding assistance alone.

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