Across most of the globe, the percentage of elderly persons has increased radically. The elderly frequently have outlived a spouse, particularly women, and find themselves living alone on a pensioner’s income. This population is particularly at risk for malnutrition. This paper will discuss some of the sources of nutritional risk, how they can be assessed, interventions available to a gerontological nurse practitioner, and some community resources.
1. Causes of malnutrition among the elderly
As individuals age, physiological changes in several systems take place that can impact nutrition, specifically perceptual, renal, gastrointestinal systems (Guigoz, Vellas, & Garry, 1996). Also, chronic disease, social isolation and medication can have adverse effects on nutrition. The result is a reduction in the quality of life and an increase in the susceptibility to infections (Guigoz, Vellas & Garry, 1996). Guigoz, Vellas and Garry (1996) state that the elderly most at risk are those in nursing homes, homebound or hospitalized. Pereira, Bulik, Weaver, Holland & Platts-Mills (2015) found that nutritional status among the elderly does not differ by gender, urban or rural location of level of education. However, there was a greater rate of malnutrition was greater among those with depression, residing in an assisted living complex, or having trouble buying groceries (Pereira, Bulik, Weaver, Holland & Platts-Mills (2015). In their literature review on nutrition among nursing home residents, Tamura, Bell, Masaki and Amella (2013) found that low body mass index was associated with lack of mobility, diminished oral intake, chewing and swallowing problems, and being female and older. Factors associated with malnutrition included dementia, diminished oral intake, chewing and swallowing problems and being older (Tamura, Bell, Masaki & Amella, 2013).
2. Assessing malnutrition among the elderly
Instruments for the assessment of nutrition among the elderly have been around for some time. Young, Kidson, Banks, Mudge and Isinring (2013) compared seven different nutrition assessment scales to determine which are the most accurate at assessing malnutrition among the elderly. The authors determined that different scales measured different aspects of nutrition. Although most of the screening tools performed well, the Mini Nutritional Assessment short form (Rubenstein, Harker, Salva, Guigoz & Vellas, 2001) was best at identifying patients at risk for malnutrition, whereas the Subjective Global Assessment (Detsky, et al., 1987) was better at identifying existing malnutrition. None of the instruments adequately assessed energy intake among the hospitalized patients.
Given the above information, a gerontological nurse practitioner could identify individuals who are at risk of malnutrition by first applying several scales to assess cognition, mobility/ability to live independently, and nutrition, specifically Mini-Mental Status Examination (Folstein, Folstein, McHugh, 1975), Instrumental Activities of Daily Living (Gallo & Paveza, 2006), and Mini Nutritional Assessment short form (Rubenstein, Harker, Salva, Guigoz & Vellas, 2001). The other critical factors to be taken into consideration are social isolation, changes in body mass index, and chewing and swallowing difficulties.
3. Interventions for malnutrition
The first intervention for elderly individuals who had been identified as malnourished would be rehydration followed by treating the symptoms. Rypkema et al. (2003) recommend a change to a high energy diet and/or protein-energy supplements until a satisfactory body mass index is reached. Care must be taken to avoid re-feeding syndrome, which can occur if nutritional support is introduced too soon after a period of malnutrition. After five or more days of severely reduced nutrition, nutritional support should be introduced in increments of 50% (Strategies to improve nutrition, 2011). This intervention would be followed up with swallowing therapy, if indicated.
The second intervention would be medical, which would include a physical examination based on information acquired in the medical history, the current body mass index, oral cavity examination with particular attention to the teeth, and an examination of the respiratory and gastrointestinal systems (Evans, 2005). A review of the current medications is also required.
Malnutrition among the elderly is a complex condition with many causes. Feeding into the condition is loss and bereavement associated with old age, cognitive decline, and mobility issues. The third intervention requires a social services team that can assess the socioeconomic situation of the individual and make the necessary recommendations. A social services investigation would entail an examination of social interactions at the individual’s place of residence, the physical conditions of the home, for example, is the refrigerator operating properly, and most importantly, alerting family and friends of the situation.
4. Community resources for malnutrition
The American Society for Parenteral and Enteral Nutrition (website http://www.nutritioncare.org/malnutrition/) focusses on malnutrition among hospitalized patients and has resources that are appropriate for nurses, nurse practitioners, clinicians, clinical dietitians, administrators, and patients and their caregivers. The website contains information on publications, nutrition guidelines, research and practice toolkits, events, and an up-to-date list of nutrition supplement shortages. Elder Helpline is an organization that provides contact information numerous private, public and volunteer agencies that provide nutritious meals for the elderly, assistance for grocery shopping, and aids for preparing meals in the home. Home Health Care Services provide a range of services for homebound seniors, including nursing, speech-therapy, dietitians, physical and occupational therapy, and medical social workers.
References
Detsky, A.S., McLaughlin, J.R., Baker, J.P., Johnston, N., Whittaker, S., Mendelson, R.A., and Jeejeebhoy, K.N. (1987). What is subjective global assessment of nutritional status? Journal of Parenteral and Enteral Nutrition, 11, 8-13.
Evans, C. (2005). Malnutrition in the elderly: A multifactorial failure to thrive. Permanente Journal, 9(3), 38–41.
Folstein, M., Folstein, S. E., McHugh, P. R. (1975). “Mini-Mental State” a Practical Method for Grading the Cognitive State of Patients for the Clinician. Journal of Psychiatric Research, 12(3), 189-198.
Gallo, J. J. & Paveza, G. J. (2006). Activities of daily living and instrumental activities of daily living assessment. In J.J. Gallo, H.R. Bogner, T. Fulmer, & G.J. Paveza (Eds.), Handbook of Geriatric Assessment (4th ed., pp. 193-240). Burlington, MA: Jones and Bartlett Publishers.
Guigoz, Y., Vellas, B. & Garry, P. J. (1996). Assessing the Nutritional Status of the Elderly: the Mini Nutritional Assessment as Part of the Geriatric Evaluation. Nutrition Reviews, 54(1), S59-S65. DOI: http://dx.doi.org/10.1111/j.1753-4887.1996.tb03793.x
Pereira, G. R., Bulik, C. M., Weaver, M. A., Holland, W. C. & Platts-Mills, T. F. (2015). Malnutrition Among Cognitively Intact, Noncritically Ill Older Adults in the Emergency Department. Annals of Emergency Medicine, 65(1), 85-91.
Rubenstein, L. Z., Harker, J. O., Salva, A., Guigoz, Y. and Vellas, B. (2001) Screening for undernutrition in geriatric practice: developing the short-form mini-nutritional assessment (MNA-SF). The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 56, M366–M372.
Rypkema, G., Adang, E., Dick, H, Nabera, T. De Swarts, B. Disselhorst, L., Goluke-Willemse, G. & Olde Rikkert, M. (2003). Cost-effectiveness of an interdisciplinary intervention in geriatric inpatients to prevent malnutirtion. The Journal of Nutrition, Health & Aging, 8(2), 122-127.
Strategies to improve nutrition in elderly people. (2011). Better Practice Journal. Website available at http://www.bpac.org.nz/BPJ/2011/may/elderly.aspx
Tamura, B., Bell, C. L., Masaki, K. H. & Amella, E. J.(2013). Factors associated with weight loss, low BMI, and malnutirtion among nursing home residents: A systematic review of the literature. Journal of the American Medical Directors Association, 14(9), 649-655.
Young, A. M., Kidson, S., Banks, M. D., Mudge, A. M., & Isinring, E. A. (2013). Malnutrition screen tools: Comparison against two validated nutrition assessment methods in older medical inpatients. Nutrition, 29(1), 101-106.
