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Malnutrition & the older patient James T. Birch, Jr., MD, MSPH Assistant Clinical Professor – Dept.
Malnutrition & the
older patient
James T. Birch, Jr., MD, MSPH
Assistant Clinical Professor – Dept. of Family Medicine
Division of Geriatric Medicine
Landon Center on Aging
KU Medical Center
February 19, 2007
Malnutrition & the older patient James T. Birch, Jr., MD, MSPH Assistant Clinical Professor – Dept.
Malnutrition & the older patient James T. Birch, Jr., MD, MSPH Assistant Clinical Professor – Dept.
Objectives  Outline the ACOVE indicators for malnutrition for community-dwelling and hospitalized older persons  Understand
Objectives
Outline the ACOVE indicators for malnutrition for
community-dwelling and hospitalized older
persons
Understand the physiologic changes that
contribute to the problem
Identify the risks of malnutrition in the elderly
patient
Discuss nutritional screening
and assessment tools
Objectives  Outline the ACOVE indicators for malnutrition for community-dwelling and hospitalized older persons  Understand
Objectives  Outline the ACOVE indicators for malnutrition for community-dwelling and hospitalized older persons  Understand
Objectives  Review basic nutritional requirements for the older patient  Discuss options for nutritional intervention
Objectives
Review basic nutritional requirements for
the older patient
Discuss options for nutritional intervention
Review the ethical considerations for
replacement of nutrition and hydration of
the older patient
Identify nutritional syndromes
Objectives  Review basic nutritional requirements for the older patient  Discuss options for nutritional intervention
Objectives  Review basic nutritional requirements for the older patient  Discuss options for nutritional intervention
Definition  Malnutrition is the condition that develops when the body does not get the right
Definition
Malnutrition is the condition that develops when
the body does not get the right amount of
vitamins, minerals, and other nutrients it needs to
maintain healthy tissues and organ function. The
condition may result from an inadequate or
unbalanced diet, digestive difficulties, absorption
problems, or other medical conditions. However,
there is no universally accepted clinical definition.
Definition  Malnutrition is the condition that develops when the body does not get the right
Definition  Malnutrition is the condition that develops when the body does not get the right
“Malnutrition is not something observed only in third-world countries.” 1 “Older persons suffer a burden of
“Malnutrition is not something
observed only in third-world countries.” 1
“Older persons suffer a burden of malnutrition that spans
the spectrum from under- to overnutrition.” 2
“Malnutrition in the elderly is one of the greatest threats to
health, well-being, and autonomy….”
1.
Kiseljak-Vassiliades, K., et al. Basic Nutrition for Successful Aging: Part 1. Clinical Geriatrics, Vol. 14(4);
April 2006
2.
Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine, Sixth Edition (GRS6); American
Geriatrics Society 2006
3.
Francesco, VD, et al. The Anorexia of Aging. Digestive Diseases 25(2); 2007
“Malnutrition is not something observed only in third-world countries.” 1 “Older persons suffer a burden of
“Malnutrition is not something observed only in third-world countries.” 1 “Older persons suffer a burden of
ACOVE - 3 Quality indicators for Malnutrition  ACOVE-3 indicators are comprised of IF-THEN- BECAUSE statements
ACOVE - 3
Quality indicators for Malnutrition
ACOVE-3 indicators are comprised of IF-THEN-
BECAUSE statements
Apply to community-dwelling AND hospitalized older
persons
8 quality indicators covering 4 domains
Indicators are not supported by RCTs (except one)
because most all studies have been small and involved
persons who met “narrow” entry criteria or which lacked
the highest quality of methodological rigor.
Indicators are a product of literature review and expert
panel consideration.
ACOVE - 3 Quality indicators for Malnutrition  ACOVE-3 indicators are comprised of IF-THEN- BECAUSE statements
ACOVE - 3 Quality indicators for Malnutrition  ACOVE-3 indicators are comprised of IF-THEN- BECAUSE statements
ACOVE-3 quality indicators  Indicator #1: ALL community-dwelling pts. Should be weighed at each physician office
ACOVE-3 quality indicators
Indicator #1: ALL community-dwelling pts.
Should be weighed at each physician office
visit and these weights should be
documented in the medical record
BECAUSE this is an inexpensive method to
screen for energy undernutrition and
obesity that has prognostic importance.
ACOVE-3 quality indicators  Indicator #1: ALL community-dwelling pts. Should be weighed at each physician office
ACOVE-3 quality indicators  Indicator #1: ALL community-dwelling pts. Should be weighed at each physician office
ACOVE-3 quality indicators  Indicator #2: IF a vulnerable elder has involuntary wt. loss of >
ACOVE-3 quality indicators
Indicator #2: IF a vulnerable elder has
involuntary wt. loss of > 10% of body wt.
over one year or less, THEN wt. loss (or a
related disorder) should be documented in
the medical record as an indication that the
physician recognized malnutrition as a
potential problem BECAUSE some patients
with wt. loss have potentially reversible
disorders.
ACOVE-3 quality indicators  Indicator #2: IF a vulnerable elder has involuntary wt. loss of >
ACOVE-3 quality indicators  Indicator #2: IF a vulnerable elder has involuntary wt. loss of >
ACOVE-3 quality indicators  Indicator #3: IF a community-dwelling vulnerable elder has documented involuntary wt. loss
ACOVE-3 quality indicators
Indicator #3: IF a community-dwelling
vulnerable elder has documented
involuntary wt. loss or hypoalbuminemia (<
3.5g/dL), THEN she or he should receive
an evaluation for potentially reversible
causes of poor nutritional intake BECAUSE
there are many treatable contributors to
malnutrition.
ACOVE-3 quality indicators  Indicator #3: IF a community-dwelling vulnerable elder has documented involuntary wt. loss
ACOVE-3 quality indicators  Indicator #3: IF a community-dwelling vulnerable elder has documented involuntary wt. loss
ACOVE-3 quality indicators  Indicator #4: IF a community-dwelling vulnerable elder has documented involuntary wt. loss
ACOVE-3 quality indicators
Indicator #4: IF a community-dwelling
vulnerable elder has documented involuntary
wt. loss or hypoalbuminemia (< 3.5g/dL), THEN
he or she should receive an evaluation for
potentially relevant comorbid conditions
including: Medications that might be associated
with decreased appetite (digoxin, fluoxetine,
anticholinergics), depressive symptoms, and
cognitive impairment BECAUSE each of these
represents a treatable contributor to
malnutrition.
ACOVE-3 quality indicators  Indicator #4: IF a community-dwelling vulnerable elder has documented involuntary wt. loss
ACOVE-3 quality indicators  Indicator #4: IF a community-dwelling vulnerable elder has documented involuntary wt. loss
ACOVE-3 quality indicators  Indicator #5: IF a vulnerable elder is hospitalized, THEN his or her
ACOVE-3 quality indicators
Indicator #5: IF a vulnerable elder is hospitalized,
THEN his or her nutritional status should be
documented during the hospitalization by
evaluation of oral intake or serum biochemical
testing (e.g., albumin, prealbumin, or cholesterol)
BECAUSE each of these measures has
prognostic significance and can identify older
persons at risk of malnutrition or adverse
outcomes (complications, prolonged length of
stay, in-hospital and up to one-year mortality).
ACOVE-3 quality indicators  Indicator #5: IF a vulnerable elder is hospitalized, THEN his or her
ACOVE-3 quality indicators  Indicator #5: IF a vulnerable elder is hospitalized, THEN his or her
ACOVE-3 quality indicators  Indicator #6: IF a hospitalized vulnerable elder is unable to take foods
ACOVE-3 quality indicators
Indicator #6: IF a hospitalized vulnerable
elder is unable to take foods orally for more
than 72 hours, THEN alternative
alimentation (either enteral or parenteral)
should be offered BECAUSE such patients
are at high risk of malnutrition that can
improve with caloric supplementation
ACOVE-3 quality indicators  Indicator #6: IF a hospitalized vulnerable elder is unable to take foods
ACOVE-3 quality indicators  Indicator #6: IF a hospitalized vulnerable elder is unable to take foods
ACOVE-3 quality indicators  Indicator #7: IF a vulnerable elder who was hospitalized for a hip
ACOVE-3 quality indicators
Indicator #7: IF a vulnerable elder who was
hospitalized for a hip fracture has evidence
of nutritional deficiency (thin body habitus
or low serum albumin or prealbumin),
THEN oral or enteral nutritional protein-
energy supplementation should be initiated
post-operatively BECAUSE RCTs have
indicated better outcomes in these pts.
ACOVE-3 quality indicators  Indicator #7: IF a vulnerable elder who was hospitalized for a hip
ACOVE-3 quality indicators  Indicator #7: IF a vulnerable elder who was hospitalized for a hip
ACOVE-3 quality indicators  Indicator #8: IF a vulnerable elder with a stroke has persistent dysphagia
ACOVE-3 quality indicators
Indicator #8: IF a vulnerable elder with a
stroke has persistent dysphagia at 14 days,
THEN a gastrostomy or jejunostomy tube
should be considered for enteral feeding
BECAUSE this method of feeding has
improved outcomes compared to oral
feeding.
ACOVE-3 quality indicators  Indicator #8: IF a vulnerable elder with a stroke has persistent dysphagia
ACOVE-3 quality indicators  Indicator #8: IF a vulnerable elder with a stroke has persistent dysphagia
Contributors to risk of malnutrition  The elderly are at higher risk of developing protein-calorie malnutrition
Contributors to risk of malnutrition
The elderly are at higher risk of developing
protein-calorie malnutrition and other vitamin
and mineral deficiencies.
The frequency of these events increases
with advancing age due to problems such
as poor dentition, loss of taste, difficulty
swallowing, malabsorption, and drug-
nutrient interaction
Contributors to risk of malnutrition  The elderly are at higher risk of developing protein-calorie malnutrition
Contributors to risk of malnutrition  The elderly are at higher risk of developing protein-calorie malnutrition
Contributors to risk of malnutrition  Other physical limitations such as inability to obtain necessary food
Contributors to risk of malnutrition
Other physical limitations such as inability
to obtain necessary food due to lack of
transportation and dependence on others
for shopping, lack of financial resources,
and functional limitations can contribute to
nutritional deficiencies
Contributors to risk of malnutrition  Non-perishable foods frequently contain high amounts of sodium and nitrates,
Contributors to risk of malnutrition
Non-perishable foods frequently contain high
amounts of sodium and nitrates, and processing
can remove vitamins.
Many drugs cause anorexia, gustatory changes,
and anosmia as major side effects.
Medications can also interfere with
nutrient availability
Contributors to risk of malnutrition  Non-perishable foods frequently contain high amounts of sodium and nitrates,
Contributors to risk of malnutrition  Non-perishable foods frequently contain high amounts of sodium and nitrates,
Risk Factors for Poor Nutrition Status Alcohol or substance abuse Cognitive dysfunction Decreased exercise Limited mobility,
Risk Factors for Poor Nutrition Status
Alcohol or substance abuse
Cognitive dysfunction
Decreased exercise
Limited mobility, transportation
Medical problems, chronic diseases
Medications
Depression, poor mental health
Functional limitations
Poor dentition
Restricted diet, poor eating habits
Inadequate funds
Limited education
Social isolation
(see MEALS ON WHEELS on pocket card)
Risk Factors for Poor Nutrition Status Alcohol or substance abuse Cognitive dysfunction Decreased exercise Limited mobility,
Risk Factors for Poor Nutrition Status Alcohol or substance abuse Cognitive dysfunction Decreased exercise Limited mobility,
Physiology-the “anorexia of aging”
Physiology-the “anorexia of aging”
Physiology-the “anorexia of aging”
Physiology-the “anorexia of aging”
Physiology-the “anorexia of aging”
Physiology-the “anorexia of aging”
Physiology-the “anorexia of aging”
Physiology-the “anorexia of aging”
Physiology  Changes in physiology, metabolism, body composition, and physical function in the older patient may
Physiology
Changes in physiology, metabolism, body
composition, and physical function in the
older patient may alter nutritional
requirements, so that standards applicable
to younger patient or middle-aged adults
cannot be applied to the elderly
Physiology  Changes in physiology, metabolism, body composition, and physical function in the older patient may
Physiology  Changes in physiology, metabolism, body composition, and physical function in the older patient may
Physiology  Changes in body composition  Decreased bone mass  Decreased lean mass  Decreased
Physiology
Changes in body composition
Decreased bone mass
Decreased lean mass
Decreased water content
Increased total body fat (greater
intra-abdominal fat stores)
Decline in organ function is highly variable
among individuals and may affect assessment
and intervention options
Physiology  Changes in body composition  Decreased bone mass  Decreased lean mass  Decreased
Physiology  Changes in body composition  Decreased bone mass  Decreased lean mass  Decreased
Physiology  Serum albumin is a recognized risk indicator for morbidity and mortality but is not
Physiology
Serum albumin is a recognized risk indicator for
morbidity and mortality but is not an indicator of
malnutrition because it lacks sensitivity and
specificity.
A modest decline does occur with aging
Half-life is ~ 20 days
Sensitive to hydration state and presence of
inflammation, surgery, and other severe disease
Physiology  Serum albumin is a recognized risk indicator for morbidity and mortality but is not
Physiology  Serum albumin is a recognized risk indicator for morbidity and mortality but is not
Physiology  Hypoalbuminemia in the A. Community Setting Functional limitation Sarcopenia Increased health care use Mortality
Physiology
Hypoalbuminemia in the
A. Community Setting
Functional limitation
Sarcopenia
Increased health care use
Mortality
Physiology  Hypoalbuminemia in the A. Community Setting Functional limitation Sarcopenia Increased health care use Mortality
Physiology  Hypoalbuminemia in the A. Community Setting Functional limitation Sarcopenia Increased health care use Mortality
Physiology  Hypoalbuminemia in the B. Hospital setting Increased length of stay Complications Readmissions Mortality
Physiology
Hypoalbuminemia in the
B. Hospital setting
Increased length of stay
Complications
Readmissions
Mortality
Physiology  Hypoalbuminemia in the B. Hospital setting Increased length of stay Complications Readmissions Mortality
Physiology  Hypoalbuminemia in the B. Hospital setting Increased length of stay Complications Readmissions Mortality
Physiology  There are some reports which express the use of caution with using albumin as
Physiology
There are some reports which express the
use of caution with using albumin as a
measurement of nutritional status in
“hospitalized” patients. It is inversely
correlated with markers of inflammatory
activity (ESR, CRP) and can behave as an
acute-phase reactant, with markedly
reduced levels in the setting of acute
illness.
Physiology  There are some reports which express the use of caution with using albumin as
Physiology  There are some reports which express the use of caution with using albumin as
Physiology  Prealbumin half-life ~ 48 hours  Responds rather quickly to increased protein intake 
Physiology
Prealbumin half-life ~ 48 hours
Responds rather quickly to increased protein
intake
Controversial with regards to its use as a marker
of malnutrition
Best used in conjunction with other parameters
(i.e. exam, BMI, CRP, hx of wt. loss, and various
nutritional assessments)
Also affected by changes in transcapillary escape
due to infection, inflammation, etc.
Physiology  Prealbumin half-life ~ 48 hours  Responds rather quickly to increased protein intake 
Physiology  Prealbumin half-life ~ 48 hours  Responds rather quickly to increased protein intake 
Physiology  Cholesterol Serum cholesterol has been linked to nutritional status. Levels <160mg/dl have been detected
Physiology
Cholesterol
Serum cholesterol has been linked to nutritional
status. Levels <160mg/dl have been detected in
patients with malignancy or other severe disease
states. Community-dwelling elderly with both
hypoalbuminemia and hypocholesterolemia
exhibit higher rates of functional decline and
mortality than those with either one alone.
Physiology  Cholesterol Serum cholesterol has been linked to nutritional status. Levels <160mg/dl have been detected
Physiology  Cholesterol Serum cholesterol has been linked to nutritional status. Levels <160mg/dl have been detected
Drugs that can cause ANOREXIA  digoxin  narcotic analgesics  phenytoin  K + supplements
Drugs that can cause ANOREXIA
digoxin
narcotic analgesics
phenytoin
K + supplements
SSRI’s / lithium
furosemide
Ca ++ channel blockers
ipratropium bromide
H 2 receptor
antagonists / PPIs
theophylline
spironolactone
Any chemotherapy
levodopa
metronidazole
fluoxetine
Drugs that can cause ANOREXIA  digoxin  narcotic analgesics  phenytoin  K + supplements
Drugs that can cause ANOREXIA  digoxin  narcotic analgesics  phenytoin  K + supplements
Drugs can interfere with senses of taste and smell  More than 250 medications reportedly disturb
Drugs can interfere with senses of
taste and smell
More than 250 medications reportedly disturb
gustatory sensation
More than 40 drugs reportedly disturb the sense of
olfaction
A few of these agents have been objectively
determined to affect these functions
via experiments,
clinical trials, or intensity
scaling
Drugs can interfere with senses of taste and smell  More than 250 medications reportedly disturb
Drugs can interfere with senses of taste and smell  More than 250 medications reportedly disturb
Drugs That Interfere With Gustation (taste) and Olfaction (smell) Gustation Olfaction  Allopurinol  Amitriptyline 
Drugs That Interfere With Gustation (taste)
and Olfaction (smell)
Gustation
Olfaction
Allopurinol
Amitriptyline
Amitriptyline
Codeine
Ampicillin
Dexamethasone
Baclofen
Enalapril
Dexamethasone
Flunisolide
Diltiazem
Flurbiprofen
Enalapril
Hydromorphone
Hydrochlorothiazide
Levamisole
Imipramine
Morphine
Labetalol
Pentamidine
Mexiletine
Propafenone
Ofloxacin
Nifedipine
Phenytoin
Promethazine
Propranolol
Sulfamethoxazole
Tetracyclines
Drugs That Interfere With Gustation (taste) and Olfaction (smell) Gustation Olfaction  Allopurinol  Amitriptyline 
Drugs That Interfere With Gustation (taste) and Olfaction (smell) Gustation Olfaction  Allopurinol  Amitriptyline 
Drug-nutrient interactions  Many of the aforementioned drugs and others interfere with the absorption of various
Drug-nutrient interactions
Many of the aforementioned drugs and
others interfere with the absorption of
various vitamins and minerals
Examples:
Antacids- Vitamin B 12 , folate, iron, total kcal
Diuretics- Zn, Mg, Vitamin B 6 , K + , Cu
Laxatives- Ca, Vitamins A, B 2 , B 12 , D, E, K
Drug-nutrient interactions  Many of the aforementioned drugs and others interfere with the absorption of various
Drug-nutrient interactions  Many of the aforementioned drugs and others interfere with the absorption of various
Drug-Nutrient Interaction Drug Reduced Nutrient Availability Alcohol Antacids Antibiotics, broad-spectrum Digoxin Zinc, vitamins A, B1, B2,
Drug-Nutrient Interaction
Drug
Reduced Nutrient Availability
Alcohol
Antacids
Antibiotics, broad-spectrum
Digoxin
Zinc, vitamins A, B1, B2, B6, folate, vitamin B12
Vitamin B12, folate, iron, total kcal
Vitamin K
Zinc, total kcal (via anorexia)
Diuretics
Laxatives
Lipid-binding resins
Metformin
Phenytoin/Salicylates
SSRIs
Trimethoprim
Zinc, magnesium, vitamin B6, potassium, copper
Calcium, vitamins A, B2, B12, D, E, K
Vitamins A, D, E, K
Vitamin B12, total kcal
Vitamin D, folate/Vitamin C, folate
Total kcal (via anorexia)
Folate
Basic Nutritional Requirements for the Older Patient  Estimated total daily energy need (based on body
Basic Nutritional Requirements for
the Older Patient
Estimated total daily energy need (based on body weight):
25-30 kcal/kg/day
Estimated total daily energy need (based on basal energy
expenditure; BEE):
Harris-Benedict Equation
Male BEE = 66 + (13.7
x kg) + (5 x cm) – (6.8 x age)
Female BEE = 655.1 + (9.563 x kg) + (1.850 x cm) -
(4.676 x age)
Results should be multiplied by 1.5 to estimate energy expenditure
of ill elderly patients
Basic Nutritional Requirements for the Older Patient  Estimated total daily energy need (based on body
Basic Nutritional Requirements for the Older Patient  Estimated total daily energy need (based on body
Basic Nutritional Requirements for the Older Patient  Carbohydrates should comprise 45-65% of total calories 
Basic Nutritional Requirements for
the Older Patient
Carbohydrates should comprise
45-65% of total calories
Fat should comprise 20-35% of
total calories
Protein should comprise
10-35% of total calories
Fluid : 30ml/kg/day or 1ml per kcal
intake
Basic Nutritional Requirements for the Older Patient  Carbohydrates should comprise 45-65% of total calories 
Basic Nutritional Requirements for the Older Patient  Carbohydrates should comprise 45-65% of total calories 
Basic Nutritional Requirements for the Older Patient  Estimation of protein: (0.8 to 1.5)gm/kg/day Restriction of
Basic Nutritional Requirements for
the Older Patient
Estimation of protein:
(0.8 to 1.5)gm/kg/day
Restriction of these amounts may be indicated
in renal or hepatic insufficiency
Estimation of fiber: (complex carbohydrates are
the preferred fiber source)
Men:
Women:
30 gm/day
21 gm/day
(see the 1-30-30 rule on the pocket card)
Basic Nutritional Requirements for the Older Patient  Estimation of protein: (0.8 to 1.5)gm/kg/day Restriction of
Basic Nutritional Requirements for the Older Patient  Estimation of protein: (0.8 to 1.5)gm/kg/day Restriction of
Nutritional Screening and Assessment  Nutrition Screening Initiative (NSI): collaborative effort of AAFP, ADA, and the
Nutritional Screening and
Assessment
Nutrition Screening Initiative (NSI):
collaborative effort of AAFP, ADA, and the
National Council on Aging
NSI completed a study in 1996, revealing
evidence that older patients admitted to the
hospital in poor nutritional states had longer stays
and increased rates of complications than well-
nourished patients.*
* Bagley, B; Nutrition and Health (Editorial); AFP, 57(5): March 1, 1998
Nutritional Screening and Assessment  Nutrition Screening Initiative (NSI): collaborative effort of AAFP, ADA, and the
Nutritional Screening and Assessment  Nutrition Screening Initiative (NSI): collaborative effort of AAFP, ADA, and the
Nutritional Screening and Assessment  The NSI developed a screening tool that can be completed by
Nutritional Screening and
Assessment
The NSI developed a screening tool that
can be completed by patients, family
members, or a health care professional
The tool consists of 10 questions which are
scored and placed in 3 categories:
No nutritional risk
Moderate nutritional risk
High nutritional risk
0-2 points
3-5 points
>6 points
Nutritional Screening and Assessment  The NSI developed a screening tool that can be completed by
Nutritional Screening and Assessment  The NSI developed a screening tool that can be completed by
Nutritional Screening and Assessment  NSI (points apply to “YES” answers)  I have an illness
Nutritional Screening and
Assessment
NSI (points apply to “YES” answers)
I have an illness or condition that made me change the kind
and/or amount of food I eat (2)
I eat fewer than two meals per day (3)
I eat few fruits or vegetables, or mild products (2)
I have 3 or more drinks of beer, liquor, or wine almost every day
(2)
I have tooth or mouth problems that make it hard for me to eat-2
I don’t always have enough money to buy the food I need (4)
I eat alone most of the time (1)
I take 3 or more different prescribed or OTC drugs per day (1)
Without wanting to, I have lost or gained 10 or more pounds in
the last six months (2)
I am not always physically able to shop, cook and/or feed myself
(2)
Nutritional Screening and Assessment  Mini Nutritional Assessment (MNA) is a validated screening and assessment tool
Nutritional Screening and
Assessment
Mini Nutritional Assessment (MNA) is a
validated screening and assessment tool
for identifying elderly patients with or at risk
for malnutrition
Developed by the Nestlé Research Center,
in collaboration with hospital clinicians
Nutritional Screening and Assessment  Mini Nutritional Assessment (MNA) is a validated screening and assessment tool
Nutritional Screening and Assessment  Mini Nutritional Assessment (MNA) is a validated screening and assessment tool
Nutritional Screening and Assessment  The MNA obviates the need for blood tests to screen and
Nutritional Screening and
Assessment
The MNA obviates the need for blood tests
to screen and monitor a patient’s nutritional
status
Composed of two sections: Screening and
Assessment
Nutritional Screening and Assessment  The MNA obviates the need for blood tests to screen and
Nutritional Screening and Assessment  The MNA obviates the need for blood tests to screen and
Nutritional Screening and Assessment  MNA Screening: In the screening section, five questions are asked, and
Nutritional Screening and
Assessment
MNA Screening:
In the screening section, five questions are asked,
and the patient's BMI (Body Mass Index) is
calculated, using the patient's height and weight.
From these six items, a score is calculated, which
will indicate whether there is possible malnutrition
Screening score: (max. 14 pts)
> 12 pts Normal; not at risk
< 11 pts Poss. malnutrition; go to assessment
Nutritional Screening and Assessment  MNA Screening: In the screening section, five questions are asked, and
Nutritional Screening and Assessment  MNA Screening: In the screening section, five questions are asked, and
Nutritional Screening and Assessment  MNA Assessment: Clarifies whether there is a future risk of malnutrition,
Nutritional Screening and
Assessment
MNA Assessment:
Clarifies whether there is a future risk of
malnutrition, or if malnourishment is currently
present. The assessment section is comprised of
10 questions, and two anthropometric measures –
mid-arm circumference and calf circumference.
Scoring (max. 16 pts); when added to screening
score, total max is 30 pts. If total is 17-23.5 pts,
pt is at risk of malnutrition and if <17 pts, the pt is
malnourished.
Nutritional Screening and Assessment  MNA Assessment: Clarifies whether there is a future risk of malnutrition,
Nutritional Screening and Assessment  MNA Assessment: Clarifies whether there is a future risk of malnutrition,
Nutritional Screening and Assessment  The MNA has demonstrated acceptable internal consistency, inter-observer reliability, and validity
Nutritional Screening and
Assessment
The MNA has demonstrated acceptable
internal consistency, inter-observer
reliability, and validity in studies of
community-dwelling, hospitalized, and
nursing home elderly individuals around the
world and in the U.S.
Beck, A., et al. European Journal of Clinical Nutrition. Nov 2001, Vol 55(11); 1028-33
Nutritional Screening and Assessment  The MNA has demonstrated acceptable internal consistency, inter-observer reliability, and validity
Nutritional Screening and Assessment  The MNA has demonstrated acceptable internal consistency, inter-observer reliability, and validity
Nutritional Screening and Assessment  Limitations of use of MNA: Lack of familiarity with the requirement
Nutritional Screening and Assessment
Limitations of use of MNA:
Lack of familiarity with the requirement of
measuring both mid-arm and calf
circumference
Nutritional Screening and Assessment  Limitations of use of MNA: Lack of familiarity with the requirement
Nutritional Screening and Assessment  Limitations of use of MNA: Lack of familiarity with the requirement
Nutritional Screening and Assessment  Geriatric Nutritional Risk Index (GNRI): requires measurements of height, albumin, and
Nutritional Screening and Assessment
Geriatric Nutritional Risk Index (GNRI): requires
measurements of height, albumin, and weight at
admission (also ideal weight as calculated from
the Lorentz equation). Nutritional risk is graded
based on results of calculations. It is a more
reliable prognostic indicator of morbidity and
mortality in hospitalized elderly. Low albumin and
elevated CRP correlate statistically with increased
nutritional risk (stronger than with prealbumin)
Nutritional Screening and Assessment  Geriatric Nutritional Risk Index (GNRI): requires measurements of height, albumin, and
Nutritional Screening and Assessment  Geriatric Nutritional Risk Index (GNRI): requires measurements of height, albumin, and
Body Size Classification Body Size Body Mass Index (kg/m²) Underweight < 18.5 Normal weight 18.5-24.9 Overweight
Body Size Classification
Body Size
Body Mass Index (kg/m²)
Underweight
< 18.5
Normal weight
18.5-24.9
Overweight
25-29.9
Obesity
≥ 30
Extreme Obesity
≥ 40
Nutritional Syndromes  Undernutrition-3 rd leading condition in hospital and home care sites and 4 th
Nutritional Syndromes
Undernutrition-3 rd leading condition in
hospital and home care sites and 4 th
leading condition in office practice and
nursing homes for which QI efforts would
improve the functional health of older
persons.
Nutritional Syndromes  Undernutrition-3 rd leading condition in hospital and home care sites and 4 th
Nutritional Syndromes  Undernutrition-3 rd leading condition in hospital and home care sites and 4 th
Nutritional Syndromes  Undernutrition: it is often clinically difficult to physically distinguish “cachexia” from “wasting” Cachexia
Nutritional Syndromes
Undernutrition: it is often clinically difficult
to physically distinguish “cachexia” from
“wasting”
Cachexia – (REE is increased)
Wasting –
(REE is decreased)
*REE – Resting energy expenditure
Nutritional Syndromes  Undernutrition: it is often clinically difficult to physically distinguish “cachexia” from “wasting” Cachexia
Nutritional Syndromes  Undernutrition: it is often clinically difficult to physically distinguish “cachexia” from “wasting” Cachexia
Nutritional Syndromes  Obesity – prevalence extends to the 60-70 age group  Adverse outcomes associated
Nutritional Syndromes
Obesity – prevalence extends to the 60-70 age
group
Adverse outcomes associated with obesity
include impaired functional status (esp. BMI>35),
increased health care resource use and increased
mortality
Poor diet quality and micronutrient deficiencies
are common in obese elderly pts., especially
women who live alone
Nutritional Syndromes  Obesity – prevalence extends to the 60-70 age group  Adverse outcomes associated
Nutritional Syndromes  Obesity – prevalence extends to the 60-70 age group  Adverse outcomes associated
Nutritional Syndromes  In the older obese patient, the focus should be on attaining a healthy
Nutritional Syndromes
In the older obese patient, the focus should be on
attaining a healthy weight to promote improved
function, overall health, and quality of life
A combination of dietary change, behavior
modification and increasing activity or exercise are
appropriate for most elderly obese patients.
Nutritional Syndromes  In the older obese patient, the focus should be on attaining a healthy
Nutritional Syndromes  In the older obese patient, the focus should be on attaining a healthy
Nutritional Syndromes However, homebound elderly are growing in number among the elderly obese. For those with
Nutritional Syndromes
However, homebound elderly are growing
in number among the elderly obese. For
those with frailty and obesity, the emphasis
may be better placed on preservation of
strength and flexibility rather than on weight
reduction.
Nutritional Syndromes However, homebound elderly are growing in number among the elderly obese. For those with
Nutritional Syndromes However, homebound elderly are growing in number among the elderly obese. For those with
Nutritional interventions  PREVENTION is easier than treatment  Intake improved by catering to food preferences;
Nutritional interventions
PREVENTION is easier than treatment
Intake improved by catering to food preferences;
avoid therapeutic diets with no known clinical
value
Prepare patients for meals with hand/mouth care;
proper positioning
Assist those who need assistance
Use herbs and spices to compensate for the
losses of senses of taste and smell
Nutritional interventions  PREVENTION is easier than treatment  Intake improved by catering to food preferences;
Nutritional interventions  PREVENTION is easier than treatment  Intake improved by catering to food preferences;
Nutritional interventions  Avoid rushing through a meal  Meals-On-Wheels wherever possible (Title III of Older
Nutritional interventions
Avoid rushing through a meal
Meals-On-Wheels wherever possible (Title
III of Older Americans Act)
Provide dietary supplements
Micronutrient supplements
Calcium and vitamin D
(1200mg/800 I.U.)
Nutritional interventions  Avoid rushing through a meal  Meals-On-Wheels wherever possible (Title III of Older
Nutritional interventions  Avoid rushing through a meal  Meals-On-Wheels wherever possible (Title III of Older
Nutritional interventions  Vitamin E has not been shown to reduce the progression of Alzheimer’s disease
Nutritional interventions
Vitamin E has not been shown to reduce
the progression of Alzheimer’s disease or
prevent coronary artery disease, but has
been associated with a higher risk of
hemorrhagic stroke; naturally occurring
vitamins may do a better job of preventing
cardiovascular disease and mortality.
Nutritional interventions  Vitamin E has not been shown to reduce the progression of Alzheimer’s disease
Nutritional interventions  Vitamin E has not been shown to reduce the progression of Alzheimer’s disease
Nutritional interventions  It has been suggested that multivitamins and antioxidants may help to prevent age-
Nutritional interventions
It has been suggested that multivitamins
and antioxidants may help to prevent age-
related cataracts and macular degeneration
Ask about and document all medications
and supplements being taken. Review the
necessity, safety, potential risks, and
adverse effects with the patient.
Nutritional interventions  It has been suggested that multivitamins and antioxidants may help to prevent age-
Nutritional interventions  It has been suggested that multivitamins and antioxidants may help to prevent age-
Nutritional interventions  DRUG TREATMENT: Appetite stimulants Cytokine-modulating agents Trophic agents
Nutritional interventions
DRUG TREATMENT:
Appetite stimulants
Cytokine-modulating agents
Trophic agents
Nutritional interventions  DRUG TREATMENT: Appetite stimulants Cytokine-modulating agents Trophic agents
Nutritional interventions  DRUG TREATMENT: Appetite stimulants Cytokine-modulating agents Trophic agents
Nutritional interventions  Appetite stimulants  mirtazapine (Remeron): 3.75-30mg PO at bedtime; enhances serotonin via antagonism
Nutritional interventions
Appetite stimulants
mirtazapine (Remeron): 3.75-30mg PO at
bedtime; enhances serotonin via antagonism of
the 5-HT 3 receptor
cyproheptadine (Periactin): 2-4mg PO orally
with meals; serotonin and histamine
antagonist with some anticholinergic
properties and potential for confusion in the
elderly
Nutritional interventions  Appetite stimulants  mirtazapine (Remeron): 3.75-30mg PO at bedtime; enhances serotonin via antagonism
Nutritional interventions  Appetite stimulants  mirtazapine (Remeron): 3.75-30mg PO at bedtime; enhances serotonin via antagonism
Nutritional interventions  Appetite stimulants  Megestrol (Megace) 320 – 800 mg PO in four divided
Nutritional interventions
Appetite stimulants
Megestrol (Megace) 320 – 800 mg PO in four
divided doses. Wt. gain is primarily fat;
associated with increased risk of DVT in
nursing home patients
Dronabinol (Marinol) 5-15mg/M 2 /day; a
cannabinoid associated with somnolence and
dysphoria in older persons
Nutritional interventions  Appetite stimulants  Megestrol (Megace) 320 – 800 mg PO in four divided
Nutritional interventions  Appetite stimulants  Megestrol (Megace) 320 – 800 mg PO in four divided
Ethical issues  For the nursing home patient, standards of care stipulate that a resident maintain
Ethical issues
For the nursing home patient, standards of
care stipulate that a resident maintain
acceptable parameters of nutritional status
(weight, protein levels) unless the clinical
condition is one wherein this is not
possible, and a resident should receive a
therapeutic diet when there is a problem.
Ethical issues  For the nursing home patient, standards of care stipulate that a resident maintain
Ethical issues  For the nursing home patient, standards of care stipulate that a resident maintain
Ethical issues  Adequate nutrition and hydration should always be provided to the elderly patient unless
Ethical issues
Adequate nutrition and hydration should always
be provided to the elderly patient unless invasive
nutritional support is refused by a fully-competent
patient (document in written form that pt. has
been informed of potential consequences of this
choice with witnesses) or the terminally ill patient
has executed a living will or advance directive that
excludes artificial feeding in the event of
unexpected death or terminal illness.
Ethical issues  Adequate nutrition and hydration should always be provided to the elderly patient unless
Ethical issues  Adequate nutrition and hydration should always be provided to the elderly patient unless
Ethical issues  Use caution with initiation of artificial nutrition and hydration in demented patients. This
Ethical issues
Use caution with initiation of artificial nutrition and
hydration in demented patients. This has not
been demonstrated to improve life expectancy or
quality of life.
Appropriate counseling of patient, family, and/or
surrogate of the consequences of withholding
nutrition and feeding is obligatory!
Consider palliative care in the setting of severe or
end-stage dementia, and in those cases where
living wills specify the withholding of artificial
nutrition and hydration.
Ethical issues  Use caution with initiation of artificial nutrition and hydration in demented patients. This
Ethical issues  Use caution with initiation of artificial nutrition and hydration in demented patients. This
SUMMARY  Malnutrition is remarkably common in the older adult  The risk of malnutrition in
SUMMARY
Malnutrition is remarkably common in the older adult
The risk of malnutrition in the elderly is high even in the
absence of clinical or social risk factors due to the
primitive so-called “anorexia of aging.”
Limitations in functional capacity, dentition, and support
systems contribute to the problem
Medications can and do adversely impact nutritional
status
Use of one of the screening tools can identify
undernourished individuals whose problems are
amenable to intervention
SUMMARY  Malnutrition is remarkably common in the older adult  The risk of malnutrition in
SUMMARY  Malnutrition is remarkably common in the older adult  The risk of malnutrition in
SUMMARY  Prevention is best, but implementation of interventions as early as possible (< 3 days
SUMMARY
Prevention is best, but implementation of
interventions as early as possible (< 3 days
since diagnosis) enhance more favorable
outcomes
Prealbumin alone is probably not a good
parameter for identifying malnutrition but when
combined with other measures such as serum
albumin, cholesterol, BMI, or CRP it can be
more useful.
Low albumin and elevated CRP can be
significant risk indicators while not being
“diagnostic” of the presence of malnutrition.
SUMMARY  Prevention is best, but implementation of interventions as early as possible (< 3 days
SUMMARY  Prevention is best, but implementation of interventions as early as possible (< 3 days
SUMMARY  Clarify patients’ advance directives whenever possible before initiating tube feedings or other artificial nutrition
SUMMARY
Clarify patients’ advance directives whenever
possible before initiating tube feedings or other
artificial nutrition and hydration.
Only a few of the quality indicators for
malnutrition have evidence to support them, but
the 8 ACOVE indicators we’ve discussed can
serve as measures that may differentiate
between quality and substandard care.
SUMMARY  Clarify patients’ advance directives whenever possible before initiating tube feedings or other artificial nutrition
SUMMARY  Clarify patients’ advance directives whenever possible before initiating tube feedings or other artificial nutrition
References  Nestle Nutrition; MNA (Mini Nutritional Assessment) http://www.nestle-nutrition.com/tools/mna.aspx  Malnutrition, Chap. 24; Geriatrics Review Syllabus,
References
Nestle Nutrition; MNA (Mini Nutritional Assessment)
http://www.nestle-nutrition.com/tools/mna.aspx
Malnutrition, Chap. 24; Geriatrics Review Syllabus, Sixth Edition; American Geriatrics
Society, 2006: PP 174-80
Reuben, D. Quality Indicators for Malnutrition for Vulnerable Community-Dwelling and
Hospitalized Older Persons; RAND Health;
http://www.rand.org/health/projects/acove/quality_indicators.html
Bagley, B. Nutrition and Health-Editorial; American Family Physician; March 1, 1998;
57(5)+-
Beck, A.M., et al. A six month’s prospective follow-up of 65+ y-old patients from general
practice classified according to nutritional risk by the Mini Nutritional Assessment; Euro
J of Clin Nutrition, 2001, Vol. 55: 1028-33
Lantz, M.S. Failure to Thrive; Clinical Geriatrics, March 2005, 13(3): pp 20-23
Kiseljak-Vassiliades, K., et al. Basic Nutrition for Successful Aging: Part 1; Clinical
Geriatrics, April 2006, 14(4):pp 16-24
Shenkin, A. Serum Prealbumin: Is It a Marker of Nutritional Status or of Risk of
Malnutrition?-Editorial; Clinical Chemistry: 52(12), 2006
Devoto, G., et al. Prealbumin Serum Concentrations as a Useful Tool in the Assessment
of malnutrition in Hospitalized Patients. Clinical Chemistry: 52(12):2281-85, 2006
Francesco, V.D., et al. The Anorexia of Aging; Digestive Diseases 25(2):129-137; 2007
References  Nestle Nutrition; MNA (Mini Nutritional Assessment) http://www.nestle-nutrition.com/tools/mna.aspx  Malnutrition, Chap. 24; Geriatrics Review Syllabus,
References  Nestle Nutrition; MNA (Mini Nutritional Assessment) http://www.nestle-nutrition.com/tools/mna.aspx  Malnutrition, Chap. 24; Geriatrics Review Syllabus,