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Journal of Nursing

Malnutrition in the Elderly: An Unrecognized Health Issue 

by Danielle Maher, Student Nurse and Carol Eliadi EdD, JD, APRN, Massachusetts College of Pharmacy and Health Sciences Worcester MA [email protected]


Malnutrition is defined as an imbalance of nutrients caused by either an excess intake of nutrients or a nutritional deficit. Malnutrition is becoming increasingly more common among the elderly population. This is a cause for concern considering malnutrition negatively affects the health of the older adult. An estimated 5-10% of elderly people living in the community setting are malnourished (Furman, 2006). About 60% of hospitalized older adults (age 65 or older) and 35-85% in long-term care facilities are experiencing malnutrition (Furman, 2006). From these statistics, malnutrition seems to be even more prevalent in hospitals and long-term care facilities, as compared to community-dwelling older adults. In the United States, the elderly population is expected to double and reach approximately 72 million people by 2030 (NIH, 2006). Addressing the more complex needs of the older adult, including nutritional needs, represents an important public health issue given the changing demographics. 

Several risk factors for malnutrition have been identified, including physical, social, and medical factors. Physical factors that affect malnutrition include oral health, physical impairments, early satiety, and taste and smell changes (Hall & Brown, 2005). Poor dentition can cause difficulty with chewing food and swallowing, leading to a decrease in nutrient intake. Physical impairments such as physical immobility or the inability to feed oneself, can cause difficulty in acquiring, preparing, and eating foods. Elders also experience early satiety and physiological appetite loss (Visvanathan & Chapman, 2009). Older adults experience less of a feeling of hunger and experience a feeling of fullness more quickly as compared to younger adults (younger than 65 years old). A decrease in both taste and smell are normal parts of aging. This alteration can cause a decreased interest in food as well and a subsequent decrease in the intake of nutrients. 

Social factors that affect malnutrition include, living alone, financial concerns, and restrictive diets. Living alone, especially for men, results in the decreased intake of food. Elders experiencing financial concerns, such as poverty or low-income, may not be able to buy a sufficient amount of food. Many times choices need to be made between buying food and paying for other necessities such as medications, heat, rent, etc. Cultures, religions, allergies, and preferences can also cause some elders to have more restrictive diets. These restrictive diets increase the risk for malnutrition, especially for protein malnutrition. Medical factors such as dementia, polypharmacy, chronic illness, and depression can cause malnutrition in the elderly population as well. Dementia and cognitive disabilities can cause self-neglect and decreased food intake. Many older adults take multiple medications daily. These medications interact with food and impact absorption, metabolism, and excretion of nutrients (Visvanathan & Chapman, 2009). 

Malnutrition in the elderly is a major concern because it can cause adverse outcomes. Malnutrition impacts morbidity, mortality, hospital length of stay, functional disabilities, and physical complications. Malnutrition can cause increased infection, electrolyte imbalances, altered skin integrity, anemia, weakness, and fatigue (Furman, 2006). Loss of appetite and unintentional weight loss are two of the most obvious signs of malnutrition. Other signs include, dull and dry hair, conjunctival dryness, receding gums, mental confusion, sensory loss and motor weakness. 

As the research statistics indicate, not only is malnutrition prevalent in the elderly, it is also frequently misdiagnosed or unrecognized. Many nurses and other health care professionals are not properly screening or assessing malnutrition in the elderly (Furman, 2006). 

In “Recognition by medical and nursing professionals of malnutrition and risk of malnutrition in elderly hospitalised patients”, Adams, Bowie, Simmance, Murray and Crowe developed a study that examined the level of recognition of nutrition risk factors and malnutrition in the elderly (over the age of 70) by health care professionals. The article also studied the views held by health care professionals involving those risk factors that they believed impacted malnutrition and treatment options (Adams et al., 2008). This study found that 97% of these patients were either malnourished or at risk for malnutrition, however only 19% were recognized by healthcare professionals as malnourished or at risk and only 7% of those identified were referred to the dietician. Fifty-three patients experienced a loss of appetite, yet only 9% were referred to a dietician. The study also noted that only 3 of the 100 patients had their body weight documented in their medical record. From the questionnaire, the researchers found that the doctors and nurses demonstrated deficient knowledge of malnutrition risk factors such as loss of appetite or unintentional weight loss (Adams et al., 2008).


Similar results were found in the study “Nutritional screening and perceived health in a group of geriatric rehabilitation patients” (Soderhamn, Backrach-Lindstrom, & Ek, 2007). Nutritional screening was performed on geriatric patients and compared the results to the notes written by nurses concerning the nutritional status of their patients. The study examined 147 elderly (age 65 or older) patients in a rehabilitation setting. The author initially screened the participants using the nutritional screening tool, Nutritional Form For the Elderly (NUFFE). NUFFE has 15 items that assess dietary history, dietary assessment, and general assessment such as the ability to self-feed. Each item is worth three points. A higher score indicates a greater risk for under-nutrition. In addition, the participants were questioned about their perceived level of health and overall health history. Eighty-one percent of the participants were found to be at risk for under-nutrition. Thirteen percent of participants were identified as being at a high-risk for under-nutrition. A relationship was reported between the participants’ perceived level of health and their risk for malnutrition. When comparing these results to the nursing notes, the authors found that 48 patients out of the 101 found to be at risk, were not identified as at risk for under-nutrition by the nursing staff. As a result, these patients were not provided a nutritional plan of care (Soderhamn et al., 2007). 

Both of these studies reflect the prevalence of malnourishment and risk for malnutrition in the elderly population. It also demonstrates that malnutrition in the elderly is poorly recognized and documented by healthcare providers, particularly nurses who are often in the best situation to assess and monitor the nutritional well being of patients. Of equal concern is the fact that the study results reported that even when patients were identified as malnourished, they were rarely referred to a dietician. 

Various nutritional screening tools are available to nurses that can readily assist them in assessing the nutritional status of their patients. However in many clinical settings, such tools are not being used. In “Nurses’ views and practices regarding use of validated nutrition screening tools”, nurses’ views and practices regarding use of nutrition screening tools were examined (Raja et al., 2008). The study was conducted on medical and surgical wards at three hospitals in Australia. The nurses that participated utilized the Malnutrition Screening Tool (MST) and the Malnutrition Universal Screening Tool (MUST). The results demonstrated that even though the respective facilities required nutrition screening, compliance with the use of the screening tools by nurses was low. The nurses identified several reasons for the noncompliance including, higher priority physician orders, lack of awareness of evidence-based practice of nutrition screening, and the perception of the nurses that their professional judgment/assessment was as equally sufficient as the screening tools. Nurses also voiced some concerns related to utilizing the various nutrition assessment screening tools. They mentioned that the MUST tool was difficult to complete. In addition, the nurses expressed concern that the completion of the screening tools often served to substitute for actual verbal communication with the patients (Raja et al, 2008). The study’s results demonstrated that even with the availability of nutrition screening tools, nurses remain non-compliant with routinely assessing the nutrition status of their patients. 

Nutrition assessment should be an essential part of the nursing assessment that is routinely completed on all older adults. Nurses need to understand the importance of conducting a nutritional assessment as a strategy to prevent adverse outcomes. In “To screen or not to screen for adult malnutrition?” a systematic review was conducted to determine if malnutrition is unrecognized and under-treated (Elia, Zellipour, & Stratton, 2005). The researchers also assessed whether nutritional interventions provided to malnourished patients produced clinical benefits. The study supported other findings that malnutrition is common in nursing homes and hospitals. The researchers found that malnutrition goes unrecognized in various hospital settings not only in the United States, but globally. Unrecognized malnutrition was detected in 60-85% of patients in British hospitals, 64% in a Norwegian hospital, and 73% in a Singaporean hospital. The researchers examined the efficacy of conducting nutritional screening interventions and applying appropriate interventions. Nutrition screening was found to increase the detection of malnutrition, increase the awareness among nurses as to the incidence of malnutrition, increase the number of referrals to dieticians and occupational therapists, and increase patient satisfaction. Due to the increase in the detection of malnutrition and subsequent intervention, the study reported a decrease in infections and in length of stay (Elia et al., 2005). From this systematic review, one can conclude that unrecognized and under-treated malnutrition is an international problem affecting the older adult population. Implementing nutritional screening can help improve the detection of malnutrition and provide appropriate interventions that can lead to a decrease in subsequent morbidity and mortality related to malnutrition. 

In conclusion, various studies support the notion that malnutrition, especially under-nutrition, is prevalent among the elderly population. Normal physiological processes as well as psychosocial factors result in the elderly being at a higher risk for malnutrition than the younger population. Malnutrition leads to a decline in health and possibly death. The literature supports the fact that malnutrition is often unrecognized and under-treated by nurses and healthcare professionals. According to literature, nutritional screening tools have been found to increase the detection of malnutrition in the elderly, however, even when nutritional screening tools are available, barriers remain that prevent healthcare workers from effectively utilizing these resources to assess nutritional well being and provide necessary interventions. Several studies have suggested lack of awareness and knowledge regarding the availability and usefulness of nutritional screening tools and insufficient time in the nurses’ schedule as barriers to conducting a thorough nutritional assessment on older adult patients. Nutrition screening should become an essential part of routine nursing practice when caring for older adults and nurses should take advantage of the evidence based tools that are readily available to assist them in quantifying and qualifying the incidence of malnutrition and/or risk for malnutrition in their older adult patients. 


References

Adams, N.E., Bowie, A.J., Simmance, N., Murrary, M., & Crowe, T. (2008). Recognition by 

Medical and nursing professionals of malnutrition and risk of malnutrition in elderly 

Hospitalised patients. Nutrition and Dietetics (65): 144-150. 


Elia, M., Zellipoud, L., & Stratton, R.J. (2005). To screen or not to screen for adult 

Malnutrition? Clinical Nutrition (24): 867-884. 


Furman, E.F. (2006). Undernutrition in Older Adults Across the Continuum of Care. 

Journal of Gerontological Nursing (32)1: 22-27. 


Hall, B., & Brown, L. (2005). Food Security Among Older Adults in the United States. 

Topics in Clinical Nutrition (20)4:329-336.


National Institutes of Health. (2006). Dramatic Changes in U.S. Aging Highlighted in New 

Census, NIH Report. Retreived on January 19, 2010 from NIH website via

http://www.nih.gov/news/pr/mar2006/nia-09.htm.


Raja, R., Gibson, S., Turner, A., Winderlich, J., Porter, J., Cant, R., & Aroni, R. (2008).

Nurses’ views and practices regarding use of validated nutrition screening tools. 

Australian Journal of Advanced Nursing (26) 1: 26-33. 


Soderhamn, U., Backrach-Lindstrom, M., Ek, A.C. (2007). Nutritional screening and perceived

Health in a group of geriatric rehabilitation groups. Journal of Clinical Nursing (16):

1997-2006. 


Visvanathan, R., & Chapman, I.M. (2009). Undernutrition and Anorexia in the Older Person. 

Gastroenterology Clinics of North America (38): 393-409.

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