Malnutrition in the Elderly : A Multifactorial Failure to Thrive

clinical contributions
Malnutrition in the Elderly:
A Multifactorial Failure to Thrive
By Carol Evans, RNP, MS, MA
Poor nutritional status and malnutrition in the elderly
lem by unplugging the refrigerator each evening at 8
population are important areas of concern. Malnutri-
pm when she prepared for bed. When informed of this
tion and unintentional weight loss contribute to pro-
situation, the family replaced the refrigerator, and the
gressive decline in health, reduced physical and cogni-
abdominal symptoms and weight loss subsided.
tive functional status, increased utilization of health care
Although only 1% of older adults who are indepen-
services, premature institutionalization, and increased
dent and healthy are malnourished, the Health and
mortality. Nonetheless, many health care practitioners
Nutrition Examination Survey (HANES) data indicated
inadequately address the multifactorial issues that con-
that 16% of community-dwelling Americans older than
tribute to nutritional risk and to malnutrition. A com-
65 years consumed fewer than 1000 calories per day—
mon assumption is that nutritional deficiencies are an
a statistic that would place these persons at high risk
inevitable consequence of aging and disease and that
for undernutrition.1,2 The nutritional risk increases in
intervention for these deficiencies are only
the community-dwelling elderly who are sick, poor,
minimally effective. Nutritional assessment
homebound, and have limited access to medical care.
Nutritional
and treatment should be a routine part of
Malnutrition can become a major concern. The inci-
assessment and
care for all elderly persons, whether in the
dence of malnutrition ranges from 12% to 50% among
treatment should
outpatient setting, acute care hospital, or
the hospitalized elderly population and from 23% to
be a routine part
long-term institutional care setting.
60% among institutionalized older adults.1,3 When not
of care for all
A conventional, disease-specific perspec-
directly attributable to underlying disease, weight loss
elderly persons …
tive may not always lead clinicians to the
in the institutionalized elderly is most commonly due
underlying cause of malnutrition and weight
to depression, use of anorexigenic drugs, and depen-
loss. For example, an 85-year-old woman with a three-
dency on staff for feeding.
month history of intermittent abdominal pain, nausea,
Malnutrition is often due to one or more of the fol-
diarrhea, and gradual weight loss, had been living in-
lowing factors: inadequate food intake; food choices
dependently in a mobile home park. Her daughter,
that lead to dietary deficiencies; and illness that causes
who lived nearby, brought the woman home for some
increased nutrient requirements, increased nutrient loss,
meals and prepared leftovers and meals for her to warm
poor nutrient absorption, or a combination of these
in the conventional or microwave oven when she was
factors.4 Nutritional inadequacy in the elderly can be
alone. The initial medical examination showed no un-
the result of one or more factors—physiologic, patho-
derlying cause for the weight loss and abdominal symp-
logic, sociologic, and psychologic (Table 1). The diffi-
toms. The patient was given medication for the ab-
culty for the clinician is in identifying the underlying
dominal discomfort and was encouraged to add
factors contributing to the problem and how to inter-
over-the-counter nutritional supplements to her daily
vene effectively.
diet, yet the patient’s condition continued to decline. A
A physiologic decline in food intake has been seen
referral to the Kaiser Permanente (KP) case manage-
in people as they age regardless of chronic illness and
ment program for the frail elderly led to a home visit—
disease. Physiologic changes that decrease food in-
and to a revelation about the abdominal symptoms:
take—often referred to as the anorexia of aging—in-
The case manager discovered that the elderly woman’s
volve alterations in neurotransmitters and hormones
refrigerator was noisy and had been disturbing her
that affect the central feeding drive and the peripheral
sleep. The woman had attempted to address this prob-
satiation system.2,5,6 Loss of lean body mass and the
Carol Evans, RNP, MS, MA, has worked for ten years as the geriatric nurse practitioner
member of the skilled nursing facility team in the Diablo Service Area in the KP Northern
California Region. She also practices on a half-time basis in the Neurology Department
at KP Hayward as a Parkinson’s disease specialist. E-mail: carol.e.evans@kp.org.
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clinical contributions
Malnutrition in the Elderly: A Multifactorial Failure to Thrive
Table 1. Factors influencing nutritional inadequacy in the elderly population 5,10
Physiologic
Pathologic
Sociologic
Psychologic
Decreased taste
Dentition
Ability to shop for food
Depression
Decreased smell
Dysphagia, swallowing problems
Ability to prepare food
Anxiety
Dysregulation
Diseases (cancer, CHF, COPD,
Financial status
Loneliness
of satiation
diabetes, ESRD, thyroid)
low socioeconomic
Delayed gastric
Medications (diuretic,
Impaired activities of
Emotionally
emptying
antihypertensive, dopamine
daily living skills
stressful
agonist, antidepressant,
life events
antibiotic, antihistamine)
Decreased
Alcoholism
Lack of interactions with
Grief
gastric acid
others at mealtime
Decreased lean
Dementia
Dysphoria
body mass
CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; ESRD = end-stage renal disease.
decreased basal metabolic rate observed in persons of
keeping, taking medications, managing finances, us-
advanced age also may influence appetite and food
ing the telephone) leads to dependence on others.
Malnutrition may
intake. Sensory decline in both olfaction and taste de-
Nutritional problems are further compromised by in-
be a presenting
creases the enjoyment of food, leads to decreased di-
adequate social support networks and by resultant so-
symptom of
etary variety, and promotes increased dietary use of
cial isolation, which commonly leads to apathy about
depression in the
salt and sugar to compensate for these declines.5
food and therefore decreased intake.
elderly.
Underlying pathology and medical treatment can di-
Late life can be a time of multiple losses. The older
rectly cause anorexia and malnutrition. Disorders of
person has experienced change and loss through re-
the gastrointestinal system—ranging from problems
tirement, disability and death of friends and family
with dentition and swallowing to dyspepsia, esoph-
as well as change in financial, social, and physical
ageal reflux, constipation, and diarrhea—are related
health status. These changes may lead to depres-
to poor intake and malabsorption of nutrients. Many
sion, a well-known cause of anorexia and weight
diseases (eg, thyroid, cardiovascular, and pulmonary
loss. Even transient depressed mood (as with be-
disease) often lead to unintentional weight loss
reavement) can cause clinically significant weight
through increased metabolic demand and decreased
loss. Depression is often unrecognized in older per-
appetite and caloric intake.7 Chronic illnesses such as
sons, many of whom are seen for distinctly somatic
diabetes, hypertension, congestive heart failure, and
complaints. Malnutrition may be a presenting symp-
coronary artery disease are treated with dietary re-
tom of depression in the elderly.
strictions and with medication that affects food in-
Assessment of nutritional status and weight loss should
take. Because sugar, salt, and fat contribute to the
start with questioning the patient about any history of
taste of food, dietary restrictions may make food un-
weight loss during the past three months and past year
palatable. Drugs affect nutritional status through side
and about the the patient’s perceived nutritional prob-
effects (eg, anorexia, nausea, and altered taste per-
lems. Including a family member or caregiver is help-
ception) and through alteration of nutrient absorp-
ful for obtaining an accurate history. A thorough gen-
tion, metabolism, and excretion.8
eral assessment should consider the following:
Socioeconomic status and functional ability are often
• Severity of nutritional compromise and rate of
major indicators of nutritional status. The cost of hous-
weight decline;
ing and medical expenses (most notably, medication)
• Patient’s living situation (living independently,
often competes with the money needed for food.
alone, in an assisted living facility, or in a skilled
When financial concerns are present, meals are often
nursing facility);
skipped and food that is purchased may not provide
• Functional status, specifically including mobility, abil-
a nutritionally adequate diet. Declines in functional
ity to shop and prepare meals, ability to feed self;
status both physical and cognitive, affect a person’s
• Mental and psychologic status, including depres-
ability to shop for food and to prepare meals. Loss of
sion and any decline in memory or cognition;
instrumental skills related to activities of daily living
• Dietary assessment: intake of food and fluids in
(eg, shopping, transportation, meal preparation, house-
the past day; availability of food and types of food
The Permanente Journal/ Summer 2005/ Volume 9 No. 3
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clinical contributions
Malnutrition in the Elderly: A Multifactorial Failure to Thrive
consumed; methods used for meal preparation;
• Encourage use of flavor enhancers and frequent
and identity of person or persons preparing the
small meals;
patient’s meals;
• Offer liquid nutritional supplements for use be-
• Medical and surgical history, including gastrointes-
tween (not with) meals;
tinal, cardiac, respiratory, and renal disease, re-
• Improve protein intake by adding meat, peanut
current infection, and psychiatric illness;
butter, or protein powder;
• Current use of medication.6,9
• Treat depression with antidepressants that do not
The physical examination should be narrowly focused
aggravate nutritional problems;
on information obtained in the medical history and
• Remove or replace medications that have anor-
must assess the patient’s current weight and body mass
exia-producing side effects;
index (BMI); oral cavity, especially the dentition and
• Evaluate swallowing as well as functional ability
ability to swallow; and gastrointestinal as well as respi-
to manage eating;
ratory systems.
• Obtain a social services assessment of living situ-
Diagnosis of a specific problem focuses intervention
ation of community-dwelling adults.6
on treatment of the underlying cause. Often, however,
The hospital and skilled nursing facility settings
a team approach is needed to address problems of
present additional factors that influence nutrition. The
nutrition and weight loss. Nurses, dieticians, a speech
nursing staff of these facilities can assess the ability of
therapist, an occupational therapist, and social services
a hospitalized patient or nursing facility resident to chew
staff can contribute important components to the treat-
and swallow foods of various consistencies, to feed
ment of malnutrition. Terri Franklin, a registered dieti-
himself or herself, and to perform the necessary tasks
cian for outpatient services at the KP Walnut
of eating.6 Interventions in the institutional setting in-
Creek Medical Center, states that she can help
clude the following actions:
Nurses, dieticians,
improve nutrition and stabilize weight loss for
• Ensure that patients are equipped with all neces-
a speech therapist,
failure-to-thrive patients who are referred to her.
sary sensory aids (glasses, dentures, hearing aids).
an occupational
Terri believes that dieticians are somewhat
• Ensure that the patient is seated upright at 90o,
therapist, and
underutilized in the outpatient setting, but she
preferably out of bed and in a chair.
social services staff
does receive a substantial number of referrals
• Ensure that patients residing in a long-term care
can contribute
for frail elderly patients. She states that certain
facility eat in the dining room.
important
clinicians regularly send e-consults to the dieti-
• Ensure that food and utensils are removed from
components to the
cians but that other physicians never issue such
wrapped or closed containers and are positioned
treatment of
referrals.
within the patient’s reach.
malnutrition.
Susan Feledy, RN, case manager for the Com-
• Remove or minimize unpleasant sights, sounds,
plex Chronic Conditions Case Management Pro-
and smells.
gram at the KP Redwood City Medical Center,
• Allow for a slower pace of eating; do not remove
encourages referrals when the patient clearly has
the patient’s tray too soon.
medical, psychologic, and social issues that need to
• Consider ethnic food preferences and permit fami-
be addressed. The ability of case managers to meet
lies to bring specific foods.
with the patient and family and to make a home visit
• If the patient must be fed, allow adequate time
if indicated can often make a big difference in im-
for chewing, swallowing, and clearing throat be-
proving the health of a frail elderly person. Determi-
fore offering another bite. Rapport between pa-
nation of appropriate referrals is often based on the
tient and feeder is critical.
patient’s cognitive status and whether the patient can
• Demented patients may need to be reminded to
understand and implement recommendations of each
chew and swallow and may benefit from avail-
specialist. Social services should be included if the pa-
ability of “finger foods.”
tient has financial concerns or questions regarding in-
• Encourage the family to be present at mealtime
dependent living.
and to assist in the feeding.10
Interventions appropriate for addressing nutritional de-
Several medications have been used to stimulate ap-
ficiencies may include one or more of the following
petite, but they should not be considered firstline treat-
actions:
ment. Megestrol acetate, dronabinol, and oxandrolone
• Remove or substantially modify dietary restrictions
have been used to treat cachexia and anorexia in pa-
(ie, liberalize the patient’s diet);
tients with AIDS and cancer. Limited studies have pro-
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clinical contributions
Malnutrition in the Elderly: A Multifactorial Failure to Thrive
duced mixed evidence regarding the long-term effec-
loss and malnutrition that do not respond to inter-
tiveness of these agents in the geriatric population.11
vention are often important clinical indicators of
As a nurse practitioner working in long-term care fa-
worsening health status. ?
cilities, I often address the issue of weight loss that
continues after nutritional support measures have failed;
References
in this situation, three primary options are evaluated
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medication, or 3) enteral feeding. (A group of KP nurse
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Opportunities
Problems are only opportunities in work clothes.
— Henry Kaiser, 1882-1967, American industrialist
This “Moment in History” quote collected by Steve Gilford, KP Historian
The Permanente Journal/ Summer 2005/ Volume 9 No. 3
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