e-SPEN, the European e-Journal of Clinical Nutrition and Metabolism 4 (2009) e289–e299

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e-SPEN, the European e-Journal of

Clinical Nutrition and Metabolism
journal homepage: http://www.elsevier.com/locate/clnu

Educational Paper

Basics in clinical nutrition: Nutrition in the elderly

Zeno Stanga
University Hospital, Bern, Switzerland

a r t i c l e i n f o

Article history:
Received 4 June 2009
Accepted 4 June 2009

Keywords:
Energy balance
Appetite
Elderly
Bacterial overgrowth

Learning objectives
 To understand some of the relevant physiological changes of
aging
 To understand the mechanism of malnutrition in the elderly
 To know the prevalence, causes and consequences of
malnutrition in the elderly
 To be able to screen and assess elderly patients for malnu-
trition in the context of health and disease
 To be able to manage and treat malnutrition in the elderly
1. Introduction
The over 65 age group forms an ever increasing proportion of
the population, particularly of Western countries. In the USA, for
example, the fastest growing segment of the population is among
those living 85 years or longer. The impact that these demographic
changes have on the health care system is already being noticed in
acute, chronic and long-term care facilities. Although the recent
European Seneca survey showed a low incidence of malnutrition in
the community among the healthy elderly, protein energy malnu-
trition (PEM) accompanied by micronutrient deficiencies is a major
problem in the elderly suffering from poor health. Severe PEM has
been found in 10–38% of older out patients, 5–12% of the home-
bound, 26–65% of elderly hospital in-patients and 5–85% of insti-
tutionalised individuals. Morley also reported some degree of
malnutrition in 15% of community–dwelling older subjects. In 1977
Exton Smith and colleagues reported a 4% incidence of malnutrition
E-mail address: espenjournals@espen.org (Editorial Office).
in the elderly United Kingdom population in the community. Their
scheme shown in Figure 8.5 describes its main causes, which may
also be remembered using the mnemonic MEALS-ON-WHEELS
(Table 1). In a large general practice database in the South of
England, using BMI and anthropometric measurements, Edington
found a 10% prevalence rate of malnutrition among patients living
at home and suffering from cancer or chronic disease. McWhirter
and Pennington found that not only were 40% of elderly patients
malnourished on admission to hospital, but that this went largely
unrecognised, only 5% of the undernourished being referred for
dietary help. These gained weight whereas the majority lost weight
during their hospital stay.
2. Malnutrition in the elderly and outcome
There are particular features in the elderly. There is relationship
between Body Mass Index (BMI) and standardized mortality. Early
in life the greatest risk is overweight. Decade by decade the
emphasis shifts so that, among the elderly, it is those with a low
BMI that have the highest mortality. In our first fractured femur
study there was a clear relationship between mortality and nutri-
tional status assessed anthropometrically. Fifteen years later we
confirmed this, showing that MAC was the best predictor of
outcome. For each cm decrease in MAC the odds of dying increased
by a factor 0.89, p ¼ 0.0087. Age, dementia and TSF were also
significantly correlated with mortality after fractured femur. A
number of studies have also shown an inverse relationship between
nutritional status on the one hand and complication rate, prolonged
convalescence and longer stay on the other. Conversely, nutritional
intervention has been shown to result in more rapid rehabilitation,
higher discharge rate and lower mortality. Perioperative studies,
conducted mainly in the elderly, have also shown lower infection

1751-4991/$ - see front matter Ó 2009 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.eclnm.2009.06.019
e290 Z. Stanga / e-SPEN, the European e-Journal of Clinical Nutrition and Metabolism 4 (2009) e289–e299

Table 1 of the Mini Nutritional Assessment (MNAÒ), can be performed in

‘Meals-on-Wheels’ – mnemonic for the causes of weight loss (From Miller et al. the ambulatory, hospital, and institutional elderly populations. The
1991).
scale (score range 0–14) comprises 6 items covering global
Medications behaviour, subjective factors, and weight and height. For patients to
 Emotional problems (depression) be at high risk (11 points or below), further nutrition assessment
 Anorexia, anorexia tardive, or abuse of elders
 Late-life paranoia
can be performed to define the degree of malnutrition and the most
 Swallowing disorders (dysphagia) appropriate plan for nutritional care.
 Oral factors The best validated nutritional risk assessment tool is shown in
 No money (poverty) the second part of the Mini Nutritional Assessment, and was
 Wandering (dementia)
developed through collaboration between Toulouse University, The
 Hyperthyroidism, hyperparathyroidism, hypoadrenalism
 Enteric problems (malabsorption) Medical School in New Mexico and the Nestle Research Centre
 Eating problems (inability to self-feed) (Switzerland). The scale comprises 12 items covering anthropo-
 Low-salt, low cholesterol diet metric measurements, dietary behaviour, global and subjective
 Stones, social problems factors. It takes 10–15 minutes and the score range is 0–30. A score
of 24–30 indicates no nutritional risk, 17–23.5 nutritional risk and
less than 17 high nutritional risk or likely malnutrition. Validation
rates as a result of oral supplements or enteral feeding, particularly studies showed that 75% of patients can be classified without
among patients with prior malnutrition (Fig. 1). further evaluation.
Many observational and intervention studies have used BMI and
3. Detection of malnutrition in the elderly arm anthropometric values to classify nutritional groups. These
should be related to centile values from a reference population of
Early recognition of malnutrition allows for a timely interven- the same age and sex, although there is a paucity of data on the very
tion. Screening for malnutrition (Table 2), as shown in the first part old (>75) with which to compare such values. MAC and TSF > 15th

Fig. 1. Inter-relationship of the factors, which may influence the nutritional status of the elderly (Source: Department of Health and Social Security. London, 1979).
 Z. Stanga / e-SPEN, the European e-Journal of Clinical Nutrition and Metabolism 4 (2009) e289–e299
Table 2
Mini Nutritional Assessment MNAÒ Societe des Produits Nestle – Trademark owner. Ó Societe des Produits Nestle 1994. Reproduced with permission.
centile has been regarded as normal, 5–15th centile as moderate,
and <5th centile as severe malnutrition. These measurements are
particularly useful in the bed bound or mentally impaired elderly.
Campbell and colleagues using arm muscle area (AMA; derived
from MAC – TSF), TSF and BMI in 758 subjects over 79 years of age,
showed a correlation between low values and death rate. Height is
also lost with age, thereby inflating the normal range for BMI,
which may account for the higher cut-off value of 22 between
normal and undernourished compared with 20 in a younger age
group. Height measurement is also problematic in the presence of
kyphosis or inability to stand, although horizontal measuring
devices have been used as have surrogates for height such as demi
span (from the suprasternal notch to the web between the third
and fourth finger with the arm outstretched) or sitting knee to heel
length. Body mass indices have been derived from such data.
Serum creatinine and urinary creatinine excretion reflect
muscle mass and therefore decline with age (Table 3). The creati-
nine height index (CHI) also declines with age and has been used as
a parameter of nutritional assessment:
CHI ¼ ½actual urinary creatinine=predicted
urinary creatinine from height  100
Functional measurements such as hand muscle strength, FEV1
(Forced Expiratory Volume), or peak expiratory flow rates have
been advocated and used in younger adult populations but may be
difficult to assess in the very elderly.
e291
Assessment in frail geriatric patients differs from a standard
medical evaluation by including nonmedical domains and by
emphasizing functional ability and quality of life. This assessment
aids in the development of plans for treatment and follow-up.
Nutritional assessment in the elderly should be supplemented with
a short evaluation of the principal domains assessed in all forms of
geriatric assessment such as functional ability, physical health,
cognitive and mental health, and the socioenvironmental situation.
Standardized instruments make evaluation of these domains more
reliable and efficient. Functional ability is estimated with measures
of ADL (Activities of daily living) and IADL (Instrumental activities
of daily living). ADLs are self-care activities that a person must
perform every day (e.g., eating, dressing, bathing, transferring
between the bed and a chair, using the toilet, controlling bladder
and bowel). Patients unable to perform these activities cannot
obtain adequate nutrition and require caregiver support 12–24 h/
day. IADLs are activities that enable a person to live independently
in a house or apartment (e.g., preparing meals, performing
housework, taking drugs, going on errands, managing finances,
using a telephone). Reliable instruments for measuring patients’
abilities to perform ADLs and IADLs and for determining what kind
of assistance may be needed include the Katz ADL Scale and the
Lawton IADL Scale. Several screening tests for cognitive dysfunction
have been validated; the Mini-Mental State Examination is popular
because it efficiently tests most of the major aspects of cognitive
function. Of the several validated screening instruments for
depression, the Geriatric Depression Scale is easy to use and is
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Table 3 response to cold making such individuals susceptible to mild

Creatinine height index as a function of age (Modified from Driver and McAlevy degrees of hypothermia. Since a fall of 1–2  C in core temperature is
1980).
sufficient to impair cognitive function, coordination and muscle
Age group Number of Creatinine Creatinine strength it can render thin elderly individuals particularly suscep-
(years) patients excretion (mg day1) height, index tible to injury and falls.
25–34 73 w1862 10.6 Total body water (TBW) falls with age (17% decrease in women
45–54 152 w1689 9.6
from the third to eighth decade, 11% decrease in men in the same
65–74 68 w1409 8.0
75–84 29 w1259 7.2 period). This decrease primarily reflects a decline in intracellular
water (ICW), as extracellular water (ECW) remains constant. The
change in ICW results from the age-associated fall in lean body
mass (73% water content), as estimated from total body potassium
widely accepted (Table 4). Factors that affect the patient’s
(TBK). Although ICW declines over the life span, it does so in
socioenvironmental situation are complex and difficult to quantify.
proportion to TBK; because potassium is found almost exclusively
They include the social interaction network, available social
within cells, the constancy of the TBK/ICW ratio indicates that the
support resources, special needs, and environmental safety and
intracellular concentration of solute is probably unchanged with
convenience, which influence the treatment approach used. Such
normal ageing. The age-related fall in ICW or the increased ratio of
information can readily be obtained by an experienced nurse or
ECW/ICW do not of themselves cause the disorders of water
social worker.
metabolism that are encountered in the elderly. However, diseases
become more common as age progresses as does the use of drugs to
4. Changes in body composition and function treat them. Both may modify body composition and fluid and
electrolyte physiology.
Nutritionally man has four ages. The first is one of growth and
development in childhood and adolescence. The second is one of 5. Energy balance
consolidation in the 20s and early thirties, when muscle mass and
bone density continue to increase and physical activity remains at Daily energy expenditure consists of basal or resting energy
its peak. expenditure, diet induced thermogenesis and that associated with
From the mid 30s muscle mass tends to decline and fat mass to activity. Changes in all components may occur with age. Firstly, as
increase (particularly abdominally) depending on dietary and lean mass declines, BMR in relation to body weight declines
exercise habits. These changes are accompanied by a gradual although per kg fat free mass it remains unchanged or only slightly
decline in muscle strength and fitness performance. In the event of diminished. Reports indicate a reduction in the BMR of 10–20%
illness there may be pathological reductions in weight over short between 30 and 75 years of age (Fig. 2) although in those who
periods of time resulting in a rapid decline in function with maintain their lean mass through regular exercise BMR may remain
disability, failure to thrive and even death. unchanged; secondly with diminished food intake diet induced
Since metabolic rate is largely a function of lean mass, BMR per thermogenesis is less; thirdly activity lessens, particularly with
kg body weight declines although per kg lean mass it remains fairly
constant or falls slightly throughout life. With age there is also
a decline in the mass of other protein moieties including connective
tissue, collagen (e.g. in skin and bone), immune cells, and carrier
and other proteins. This overall decline in body cell mass results in
a diminished reserve to meet the demands of illness. The reduction
in total body potassium with age is disproportionally greater than
that of protein. Studies have shown that this relates to the fact that
skeletal muscle mass, which contains the highest concentration of
potassium, is reduced to a greater degree than other protein con-
taining tissue. Body fat, particularly that distributed centrally,
increases in middle life, but with the increasing anorexia of the over
75s, fat mass tends to decline. A gradual loss of bone density occurs
in both sexes from the early 30s onwards. In women, however this
is accelerated at the menopause. Osteoporosis, defined as a bone
density > 2 standard deviations below the mean of a young healthy
population of the same sex, gives increasing risk of fractures with
age. This condition is exacerbated by malnutrition, low weight,
poor intake of vitamin D and calcium, and lack of physical exercise
as well as low sex hormone levels. Thermoregulation may be
impaired with age and the problem is greatly enhanced by protein
energy malnutrition. Low body weight inhibits the thermogenic

Table 4
Geriatric depression scale – 4, Score: cut-off value ¼ 2 (from Yesavage JA et al 1983).

Question Yes No
Are you basically satisfied with your life? 0 1
Do you feel that your life is empty? 1 0
Are you afraid that something bad is going to happen to you? 1 0
Do you feel happy most of the time? 0 1
Fig. 2. Age-related changes in body composition, food intake and energy expenditure.
e294 Z. Stanga / e-SPEN, the European e-Journal of Clinical Nutrition and Metabolism 4 (2009) e289–e299
disability. These changes, despite the age related decline in energy
intake, result in a positive energy balance in middle life and the
changes in body composition described above. Finally with the
onset of anorexia in the very old, energy balance becomes negative
and BMI and fat mass decline. Similarly, anorexia and weight loss
associated with chronic disease may also be associated with a fall in
BMR.
6. Appetite in the elderly
There is a decline with age in the two components of taste i.e.
olfaction and the taste buds (Fig. 3). These changes act together to
decrease the perception of the hedonic qualities of food. The slight
increase in taste thresholds that occurs with ageing suggests a need
for richer tastes of food for older persons. Many of the complaints
concerning the quality of food by older nursing home residents can
be traced to the altered hedonic qualities of food with ageing.
Schiffmann et al. reported that flavour enhancement can reverse
the decreased enjoyment of food in some older persons. Geriatric
subjects often complain of anorexia and impaired taste sensation
and have decreased food consumption. A number of causes of
anorexia in the elderly have been proposed, including changes
in taste acuity, altered amino acid and catecholamine concentration
in the hypothalamus and whole brain, as well as changes in
membrane fluidity and receptor function. Zinc deficiency has also
been implicated, but zinc supplementation caused no improve-
ment. With ageing, the decline in gastric emptying rate of
large meals has been associated with earlier satiation. Morley’s
group have shown a decreased adaptive relaxation of the fundus of
the stomach to food in the elderly resulting in more rapid antral
filling and satiety. The observation that intraduodenal infusion of
nutrients causes diminished hunger in the young persons, but not
Fig. 3. Anorexia of ageing.
in older persons, suggests that the earlier satiation seen in response
to a meal in the elderly is due predominantly to signals from the
stomach rather than the intestine. Morleys group used this
phenomenon to show that a liquid preload (that empties from the
stomach within 60 min) increased total calories ingested when
given 60 min before the meal, but not when given just before the
meal. This suggests that the best strategy for oral supplement
administration is an aperitif 1 h before meals. Once food is ingested,
a variety of messages from the stomach and intestine, as well as
levels of circulating nutrients, and availability of stored nutrients
interact to signal the state of satiety or hunger to the brain. These
messengers have been characterized as the peripheral satiety/
satiation system. The symptom ‘‘appetite’’ is therefore a compli-
cated process composed of many intrinsic (perception of internal
signals like sense of olfaction, taste, vision, hearing, hormones, etc.)
and extrinsic factors (social and emotional problems, medications,
etc.). In elderly men as testosterone levels fall there is also a recip-
rocal rise in leptin, reversible by testosterone administration, which
may contribute to diminished appetite.
7. Small-bowel bacterial overgrowth in elderly people
Over the past 60 years the ‘‘stagnant loop syndrome’’ has
become established as a cause of malabsorption and multiple
deficiencies in patients with stricture, diverticulosis, or surgically
induced lesions in the small intestine. Abnormal bacterial coloni-
zation of the upper small bowel proved to be the underlying cause
of malabsorption in this condition. Bacterial overgrowth can also
occur without any anatomical defect in the small bowel in cases of
gastric achlorhydria and in various motility disorders, including
diabetic neuropathy and scleroderma. Since 1977, small numbers of
elderly patients have been described with bacterial contamination
of an anatomically normal small bowel. Haboubi and Montgomery
confirmed that the small-bowel bacterial overgrowth is a clinically
significant cause of malabsorption and malnutrition in elderly
people and have also shown that this can be equally severe whether
or not there is an anatomical defect in the small bowel and whether
or not there is gastric hypochlorhydria. The malabsorption is fully
correctable by antibiotic therapy. The mouth-to-caecum transit
time, which tends to increase in old age, was selectively prolonged
in this particular group of elderly patients, including those with an
anatomically normal bowel.
8. The ageing immune system
There is a decline in the relative mass of immune tissue over the
life-cycle, beginning with the involution of adenoids in childhood
and the thymus in young adults, and an associated decline in
immune function. The classical view of immune ageing is of an
immunodeficiency state that predisposes to progressive T-cell
dysfunction with advancing age. This has been implicated in the
aetiology of many of the chronic degenerative diseases of the
elderly, including arthritis, cancer, vascular injury, and autoim-
mune-immune complex disease, as well as increased susceptibility
to infectious disease. Immunosenescence is generally characterised
by decreased proliferation of T lymphocytes and impaired T-helper
activity, which lead to impaired cell-mediated and humoral
responses to T cell-dependent antigens (these immune alterations
are similar to those observed in patients with Acquired Immune
Deficiency Syndrome) (Table 5).
Paradoxically, there is an increased incidence of autoantibodies
and of benign monoclonal B lymphocyte proliferations with
monoclonal antibody production. The immune system is also
influenced by dietary lipids that are precursors of eicosanoids,
prostaglandins and leukotrienes; eicosanoid synthesis can be
 Z. Stanga / e-SPEN, the European e-Journal of Clinical Nutrition and Metabolism 4 (2009) e289–e299 e295

Table 5 because of non-uniform organ deterioration, underlying chronic

Effects of protein–energy malnutrition (PEM) on the immune system in older disease, dietary regimens, an already compromised nutritional
individuals: comparisons with healthy old individuals (From Morley 1998).
state, and other factors related to ageing.
Immune status Healthy old Old individuals with Although many age-related changes have been described in the
individuals PEM
gastrointestinal tract, they mostly have little effect on drug absorp-
Delayed cutaneous Decreased Markedly decreased tion. Age-related changes in body composition, such as reduced body
hypersensitivity
size, reduced lean body mass and reduced total body water together
Total lymphocyte count Normal Decreased
T-cell proliferation Decreased Markedly decreased with increased fat mass, mean that the volume of distribution for
CD3 Decreased Markedly decreased lipid-soluble drugs tends to increase in old age, while that of
CD4 Normal Decreased water-soluble ones diminishes. This means, for example, that highly
CD8 Normal Mild decrease water-soluble drugs like digoxin will achieve therapeutic concen-
CD4/CD8 Normal Decreased
Interleukin – 1 release Decreased Markedly decreased
trations with a lower dose. Further more, the kidneys excrete many of
Interleukin – 2 release Normal Decreased these water-soluble drugs and age-related declines in glomerular
Interleukin – 6 release Increased Decreased filtration will prolong their elimination. Many drugs bind to plasma
Antibody production Increased Decreased proteins, particularly albumin, although generally it is only unbound
Gut immune barrier function Mild decrease Markedly decreased
drug that is active. Healthy ageing is not associated with significant
changes in albumin concentration but sick old people often have
hypoalbuminaemia. Drugs that bind extensively to albumin
modified by dietary antioxidants such as vitamins E and C, sele-
(e.g. warfarin, tolbutamide) will have much higher concentrations of
nium and copper. Zinc deficiency is also associated with impaired
free drug in hypoalbuminaemic people and there will be consider-
T-cell function. A suboptimal zinc intake in experimental animals
able potential for toxicity. As well as the pharmacokinetic changes,
causes marked atrophy of the thymus, and a reduction in leuko-
pharmacodynamic changes are also common in old age. A variety of
cytes and in antibody-mediated and delayed-type hypersensitivity
commonly prescribed medications and non-prescription drugs
responses. The exaggerated susceptibility of humans to disease
warrant special consideration because of their influence on nutrition
with age, when periods of nutrition-related vulnerability coincide
status or the effect of diet on drug response.
with suboptimal immune function, underscores the negative
interaction between compromised nutrition status and immuno-
competence. Adequate nutrition may be of pivotal importance in 10. Changes in nutrient requirements
terms of disease prognosis, especially in the frail elderly in whom
immune function has already declined. 10.1. Total energy
Chandra proposed five main conclusions concerning nutrition
and immunity in the elderly: As described above, the decrease in the components of total
energy expenditure with age means that total energy requirements
1. Immunological decline is not an inevitable part of ageing; thus, diminish, as in most cases does energy expenditure/kg body
many elderly subjects maintain vigorous immune responses at weight, although BMR per kg of fat free mass remains either
a level that is comparable to that seen in younger subjects. unchanged or diminishes slightly. The average hospital in-patient
2. Nutritional deficiencies are quite common in this age-group; needs a total energy intake of approximately 1.3 times estimated
approximately 35% of the elderly show evidence of PEM or BMR to maintain weight and 1.5–1.7 times BMR if weight gain is
selected nutrient deficiencies. desired. An intake of 30–35 kcal kg1 day1 will therefore meet the
3. The correction of nutritional deficiencies does improve needs of most elderly hospital patients’ requirements.
immune responses even in old age.
4. Appropriate nutritional counselling and dietary therapy,
10.2. Protein
sometimes with medicinal supplements, results in reduced
respiratory illness.
In the absence of advanced liver or kidney disease, a dietary
5. Multivitamin, multimineral supplements in the elderly can
protein intake of 12–15% of total energy is well tolerated. The current
lead to improved lymphocyte function and fewer infections.
RDA of 0.8 g of protein kg1 day1 is adequate in health provided
that it is mostly first class protein and that energy needs are fully
9. Drug interactions in the elderly met. However as Munro has pointed out, some elderly people
continue to lose substantial amounts of body protein even when
In everyone, an inevitable decline in physiological function will receiving 0.8 g protein$kg1 day1. He suggested the need for a small
occur with age and will ultimately affect well being. At present, repletion allowance over and above the RDA and that the elderly
persons 65 years of age and over represent about 13% of the total should not consume less than 12–14% of their diminishing caloric
population, yet they use close to 30% of all prescribed and over-the- intake as protein. The Toulouse group have suggested that an ideal
counter medications, related to the frequency of chronic illness and protein intake for the elderly should be 1 g kg1 day1 since, in
disabilities. The average older person living at home with multiple a long term community follow up study, illnesses, and hospital
problems may be using from three to seven (or more) different admissions were fewer in those who ate this or more, compared
medications daily at any given time; in long-term care institutions with those who ate less. The requirements of the sick elderly are
the amount increases to ten or more different drugs per day. Drugs correspondingly higher, i.e. 1–1.5 g kg1 day1. Although concern is
often influence nutrient disposition through their effects on often expressed about providing high protein diets (greater than 15%
appetite, nutrient absorption, metabolism, and excretion. In addi- protein as calories) to elderly patients for fear of precipitating renal
tion to these effects, food itself or specific constituents in food or problems, there is no evidence to indicate that this occurs in patients
beverages, as well as vitamin, mineral, and other food supplements, who do not have pre-existing renal disease. Patients who are
can influence drug behaviour. Nutrient and drug interactions are immobile, bed-bound, or non-ambulatory may be in negative
likely to occur in elderly patients not only because of drug- or food- nitrogen balance due to the effects of inactivity. Providing excess
induced alterations in nutrient and drug metabolism but also protein may not reverse this process; instituting an appropriate
e296 Z. Stanga / e-SPEN, the European e-Journal of Clinical Nutrition and Metabolism 4 (2009) e289–e299
exercise program while administering adequate amounts of protein
may preserve muscle mass, or at least decrease the rate of loss.
10.3. Fat
Dietary fat intake can be limited to 30% or less of the total
calories consumed without having a negative impact on nutrient
balance. Indeed this characterizes the so called ‘‘healthy diet’’ to
prevent arterial disease. Interestingly, the RDA for essential fatty
acids (EFA) can be provided by as little as 2–3% of the total calorie
intake i.e. only 9–10 g of the EFA, linoleic and linolenic acid, from
animal and vegetable foods. However, over-restriction of fat to less
than 20% of daily energy intake may affect the quality of the diet. In
parenteral nutrition, however 40–60% of energy may be provided
from fat during acute illness, although for long-term treatment this
should be reduced to 30%. Serum total cholesterol and low-density
lipoprotein (LDL) cholesterol level increase linearly in the third
through fifth decades, plateau in the sixth and seventh, and decline
after 70 years of age, while the mean high-density lipoprotein
(HDL) cholesterol remain constant throughout the life span.
10.4. Carbohydrates
There is no RDA for either simple or complex carbohydrates,
because no individual sugar has been identified as an essential
nutrient. Most diets contain 45–50% of their daily calories as
carbohydrates. However, the current consensus favours an increase
in slowly absorbed carbohydrates such as starches to 55–60% of
total calories. Carbohydrates provide the bulk of calories in enteral
feedings and in parenteral formulas. Since carbohydrate tolerance
diminishes with advancing age, carbohydrates should be from
complex sources whenever possible and blood sugars monitored.
Many elderly develop a deficiency of the intestinal enzyme, lactase.
Without hydrolysis, the lactose is not absorbed, but metabolised by
colonic bacteria. The resultant metabolites, including gas forma-
tion, produce the symptoms of flatulence, cramping, and diarrhoea,
which lead to the avoidance of milk and other dairy products in the
diet. This avoidance is unfortunate because of the high nutrient
value of milk.
10.5. Fibre
Dietary fibre consists of polysaccharide plant materials resistant
to digestion by small bowel enzymes. The soluble fibres, such as
pectin, however, are broken down to short chain fatty acids e.g.
acetate and butyrate which are important nutrients for the colonic
mucosa and upon which that organs capacity to absorb salt and
water depends. These products may also be absorbed and can meet
up to 5% of energy needs. The non-soluble fibres remain undigested
and help to bulk the stool preventing constipation, a prevalent
condition in the elderly. Therefore attention should be paid to the
fibre content of normal food, oral supplements and enteral feeds
particularly in the elderly.
10.6. Fluids
Water as a nutrient is particularly important in elderly patients
because of their penchant for rapid shifts in fluid compartments.
Daily fluid requirements can generally be estimated at approxi-
mately 1 ml kcal1 ingested or 30 ml kg1. An assessment of fluid
balance is the key to diagnosing some of the non-specific
complaints and cognitive changes that may be encountered in sick,
elderly patients. Dehydration and electrolyte imbalances may
contribute to non-specific, difficult to diagnose complaints.
10.7. Vitamins
Vitamin requirements have not been established for persons
over the age of 65 years and nutrition surveys evaluating the intake
of nutrients by population groups have rarely included represen-
tative samples of the over 75s. Subclinical vitamin deficiencies are
common among elderly persons, although their clinical significance
is controversial. The physiologic stress of illness may be sufficient to
deplete rapidly any residual stores, and cause deficiencies. The
effects of acute or chronic disease states have not been clearly
identified in many of the reports. Requirements for some vitamins
have been noted to change with advanced age. Elderly subjects may
not be able to clear retinyl esters through the liver rapidly enough
to avoid toxicity; recommendations have, therefore, been made
that requirements for vitamin A be lowered, although specific
levels have not been identified. There is no established requirement
for b-carotene and no toxic level of intake has been cited. The
elderly may have difficulty clearing circulating levels of b-carotene,
but there do not appear to be any deleterious side effects other than
discoloured skin. Requirements for vitamins E and K do not change,
but vitamin K levels may be affected by the use of antibiotics,
sulpha drugs, or vitamin K antagonists. Requirements for vitamin D
intake may increase with advancing age, and the risk of deficiency
may increase considerably. Institutionalised elderly people for
example may not have adequate sun exposure, their kidneys may
not convert 25-hydroxy vitamin D to 1,25-hydroxy vitamin D
efficiently, and their diets may be deficient due to their perceived
intolerance to, or dislike of, dairy products. Water soluble vitamin
requirements remain fairly constant throughout adulthood,
although there is some evidence of increased needs for vitamin B12
and vitamin B6. Folate requirements may decrease, but there is no
evidence of altered need for other water soluble vitamins. Paren-
terally fed patients are at less risk of inadequate vitamin intake than
are enterally fed patients because of the routine addition of vitamin
preparations to parenteral solutions. Indeed it is not uncommon to
find that tube-fed elderly patients do not receive adequate volumes
of enteral formulas to meet 100% of the Recommended Dietary
Allowances. Since requirements for some vitamins and minerals are
increased during periods of illness or stress, these patients may
therefore become chronically undernourished unless additional
supplements are given.
10.8. Minerals
Minerals (calcium, phosphorus, magnesium, iron, zinc, iodine,
chromium, molybdenum, and selenium) requirements do not seem
to be altered by old age, but amounts adequate to maintain serum
levels must be provided by both enteral and parenteral solutions.
With the increasing use of long-term nutritional support in
chronically ill patients, mineral and trace metal deficiencies may
occur more frequently. Two major concerns relate to intake of iron
(anaemia) and calcium (osteoporosis). Zinc, magnesium, and some
others trace minerals may be present in less than optimal
concentrations, but much more work is needed before recom-
mendations can be made about their intake. Additionally, dietary
sodium and its role in hypertension have stimulated concern and
controversy.
11. Nutritional intervention
In relation to hospital patients, there is now strong evidence
that, with current catering arrangements, patients are eating
insufficient to meet their metabolic needs in hospital. A recent
study in Nottingham showed that, if patients chose the maximum
menu, they could receive 1800 kcal a day (Fig. 4). However,
 Z. Stanga / e-SPEN, the European e-Journal of Clinical Nutrition and Metabolism 4 (2009) e289–e299
Fig. 4. Food intake: breakfast þ lunch þ supper þ snacks (assumes breakfast ad
snacks ¼ 600 kcal from Stephen et al. 1997).
measurements of portions showed that these often contained less
than 80% of the assumed amount and that, on the geriatric wards,
the wastage rate of food was 40–60%, giving energy and protein
intakes less than 75% of recommended values. This explains why
the majority of patients lose weight in hospital. When portion sizes
were reduced and energy and protein density of the food was
increased, waste fell by 30% and energy intakes rose to 96% of
recommended levels, although protein intakes were still low
indicating the necessity for even greater fortification of the menu
with protein. Strategies to target and improve the use of hospital
food in elderly patients need to be considered. These include more
appropriate menus, more appropriate meal patterns to meet the
frequent small meal habits of the elderly, the use of snacks between
meals, the use of trained hostesses to help patients with eating, and
use of special high energy density food. Ödlund-Olin in Stockholm,
Gall in London, and Kondrup in Copenhagen have also shown that
increasing the energy density of hospital food given to elderly
patients caused them to gain weight and improve function.
Making a nutritional care plan for an elderly patient requires
consideration of more factors than in the younger patient. Oral
treatment is preferred and represents a particular challenge to
relatives, nurses and physicians; Peake et al. showed that the
compliance with oral supplements by elderly patients was only
about 52% (prescribed volume 353 ml, consumed only 183 ml).
Factors affecting compliance were; failure of delivery to patients,
lack of staff supervision, excessive volume prescribed, nausea,
palatability and taste. Potter described close to 100% compliance
when supplements were administered under nursing supervision
on drug rounds.
For elderly, chronically ill patients receiving oral or enteral diets,
increasing the amount of fibre in their diets will contribute to
enhanced bowel motility; adequate fluid must also be provided to
contribute to normal bowel function. Controlled trials of oral
supplements, nasogastric tube feeding and intravenous feeding
have all shown that the elderly may have an improved outcome
with such nutritional intervention.
11.1. Pressure sores
The elderly are at particular risk of pressure sores. Ek described
the principle risk factors as immobility, physical condition and
nutritional status. With the onset of pressure sores the inflamma-
tory response, nutritional status deteriorates further, creating
a vicious circle. Nutritional support plays an important role there-
fore in the management of this condition.
e297
11.2. Osteopenia with ageing
The evidence linking negative calcium balance with bone loss
later in life is strongly suggestive. Although errors inherent in a diet
history, particularly when it is extrapolated over long periods of time
makes studies in this area difficult. Several studies however have
shown a positive relationship between the bone density of healthy
young women and lifetime calcium intake and physical activity. An
inverse relationship between hip fractures and calcium intake has
also been demonstrated by several studies in women and one in men.
Many factors associated with ageing can contribute to a negative
calcium balance and subsequent bone loss including immobilization,
illness, lack of exercise, malnutrition, medications (corticosteroids,
thyroid hormones, heparin, diuretics, antacids, antibiotics,
anticonvulsants), and endocrine disorders (hyperadrenocorticalism,
hyperparathyroidism, hyperthyroidism). Undernutrition, particu-
larly PEM, contributes to the occurrence of osteoporotic fracture, by
lowering bone mass and altering muscle strength as well as
impairing recovery (see above).
Fractures associated with bone loss and ageing are primarily
related to low bone mass/density that occurs later in life as dis-
cussed in the section on body composition. This low bone mass/
density may result from low peak bone mass at maturity or rapid
bone loss with ageing. The role of a life-long high calcium diet
appears to be in the development of a higher peak bone mass as
well as retardation of ageing loss. Calcium supplementation in later
life seems to benefit bone mass by slowing the rate of loss.
11.3. The aged diabetic
Glucose tolerance decreases with age so that non-insulin-
dependent diabetes mellitus (NIDDM) becomes common,
occurring in up to 18% of individuals over 65 years of age. In
approximately half these individuals, however, the diagnosis is not
made. The prevalence of diagnosed diabetes in elderly people is
expected to increase by 44% in the next 20 years. Elderly diabetic
patients utilize the health care system more then non-diabetics and
about 30% of diabetics aged 65–74 years are hospitalised each year.
All elderly patients should therefore be screened for this condition.
A strong association between obesity and NIDDM is suggested
by the fact that 80% of middle-aged persons with adult-onset
diabetes mellitus are obese. Obesity is thought to affect carbohy-
drate metabolism by inducing tissue insulin resistance and causing
a compensatory increase in circulating insulin levels. This may be
ameliorated by increased physical activity, and is made worse by
increased body weight and abdominal adiposity. Caloric restriction
to induce weight loss can return glucose metabolism to normal in
some patients. A healthy eating programme with adequate intakes
of vegetables, low in fat and with regular fish (w-3 fatty acids)
should be instituted.
11.4. Cardiovascular system and ageing
Coronary artery arteriosclerosis which is largely a diet related
condition exacerbated by other risk factors such as smoking,
hypertension and inactivity begins in young adulthood and
increases progressively with age. Furthermore the prevalence of
vessel narrowing and stenosis increases with age with more than
50% prevalence of occlusion of at least one of the three major
coronary arteries by the age of 55–64 years. Asymptomatic coro-
nary artery disease is present in an occult form in many people
during life, which becomes important when one attempts to assess
the impact of age on cardiovascular function. Improved dietary
habits with less fat and more fish and vegetables could have a major
effect on public health and reduce cardiovascular disease.
e298 Z. Stanga / e-SPEN, the European e-Journal of Clinical Nutrition and Metabolism 4 (2009) e289–e299
Blood pressure also increases with age in Western societies. The
exact mechanisms underlying this increase are not clear, but
dietary factors such as salt and fat intake may be important.
11.5. Malnutrition and mental function in the elderly
Prolonged suboptimal intake of micronutrients may lead, via
series of mechanisms to impairment of cognitive performance;
conversely malnutrition is commonly the result of pre-existing
mental impairment due to chronic diseases. Severe deficiency
leading to major cognitive injury is nevertheless rare, although
vitamin B deficiency in alcoholism or a low vitamin B12 level are
important conditions to exclude.
11.6. Cancer in the elderly
Approximately half of all the new cancers in the Western
population occur in individuals over the age of 65 years and many
of them have a nutritional origin. Gastrointestinal, prostate, and
breast cancer are responsible for over half the cancers in patients
over 60 years of age. Although the cancer incidence rises with age,
it begins to decrease in those 85–90 years of age. Obesity is asso-
ciated with a marked increased risk of postmenopausal breast
cancer, and bowel cancer in men. Overweight and immunose-
nescence can possibly predispose neoplasms in the elderly people.
The concept that diet can modulate the prevalence of cancer is
old. In 1933, Stocks and Karn found that high intake of whole-meal
bread, vegetables, and fresh milk was associated with a decrease in
cancer incidence at several sites. The role of diet in cancer aetiology
is an area of intense research worldwide. Nutritional support has an
important part to play in the care of cancer patients but only in the
presence of significant malnutrition.
11.7. Ethical considerations
Medical ethics are based on the principles of autonomy (the
patients right to self determination), beneficence (doing only those
things that are of benefit to the patients), non-maleficence
(avoiding harm) and justice (equal care for all). These consider-
ations play an important role when planning nutritional care of the
elderly. A recent review for example came to the conclusion that
there was no benefit to the elderly demented patient from artificial
nutrition support and that the risks outweigh the benefits. Simi-
larly with dysphagia in major stroke it is important to ascertain
whether the patient expresses or has expressed in the past any
wishes concerning tube feeding and to respect these. We need
much more concrete evidence concerning the benefits of PEG
feeding in this group before recommending its general use,
although individual patients have clearly benefited. It is important
to recognise when the patient is close to the end of life, and when
artificial nutrition is futile or indeed harmful or uncomfortable.
12. Summary
The elderly as a group are particularly susceptible to malnutri-
tion especially when suffering from chronic mental or physical
disease. Elderly patients should all be screened for risk of malnu-
trition and have an appropriate care plan. Where significant
malnutrition exists there is clear evidence of benefit from nutrition
support. There is suggestive evidence that good nutrition and even
the use of vitamin and mineral supplements may have an impor-
tant preventive role in maintaining health and quality of life in the
elderly. In making any care plan, ethical considerations are
important, respecting the patient’s autonomy, ensuring benefit and
avoiding harm.
Conflict of interest
There is no conflict of interest.
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