Revised by: Sharee A. Wiggins, NP, Post-MS(N), BC-GNP, BC-ANP (2018, 2015, 2014, 2010)
Developed by: Sharee A. Wiggins, NP, Post-MS(N), BC-GNP, BC-ANP (2007)
Original document by Daniel Swagerty, MD, MPH (2002)
Geriatric undernutrition is often a multifactorial problem of complex bio-psycho-social-cultural etiology
Common contributions to undernutrition include: medications, poverty or near-poverty, depression, social isolation, oral problems (pain, poorly fitting appliance), therapeutic diets, unrecognized swallow impairment, functional deficits, chronic pain, any number of chronic illnesses, cognitive impairment, and anorexia of aging (complex phenomenon with increased leptin and cholecystokinin; reduced ghrelin and other changes)
The federal CMS regulations manual suggests these metrics for identifying significant unintended weight loss in the nursing home: 5% in 1 month, 7.5% in 3 months, and 10% in 6 months. More than this for each time period is considered severe weight loss
In addition to serial weight loss measurements, clinical lab tests that can help identify malnutrition include: Albumin, Prealbumin and Total Cholesterol in persons not taking statin drugs. The proteins are neither sensitive nor specific for malnutrition but do reflect proinflammatory conditions of which malnutrition is one. Sometimes a CRP is useful unless the person has another diagnosed proinflammatory condition.
Protein Energy Malnutrition (PEM) subtypes include: marasmus (insidious over months), cachexia (cytokine mediated hypermetabolic catabolic condition), and kwashiorkor-like (acute development)
Hospitalized older adults who are admitted to the acute setting in an under-nourished state are at greater risk for nosocomial infections, reduced function, increased length of stay, increased cost of hospitalization, and increased mortality
Nutrition tubes are medical devices for a medical intervention: the delivery of water and commercial liquid nutrition.
COPD patients will generally have a lower RQ (respiratory quotient) and reduced CO2 production by switching from CHO substrate to balanced FAT substrate.
Several agents have been used or theoretically considered over the years to be orexigenic, or appetite stimulating. Good studies are lacking for many and side effects can be problematic.
Megesterol acetate has been used in the past but is considered inappropriate in older adults for weight gain purposes due to lack of real efficacy and the risk of DVT in patients who are dehydrated and non-ambulatory.
Mirtazapine continues to the “go to” drug when an orexigenic is desired. Several side effects are associated with this agent, with common side effects being increased appetite and weight gain.
Module Content: Nutrition, Undernutrition, Malnutrition
Geriatric malnutrition is complex and multifactoral. Three population subsets need to be considered when one speaks of “older adults”: community dwelling, hospitalized, and institutionalized in long-term care settings.Protein-energy malnutrition (PEM) is known to be a major contributor to poor prognosis in older adults.
- PEM in community-dwelling older adults – up to 4%
PEM in older adults in hospital or rehab units – 50%
PEM in those living in LTC – 30-40% (Scheinfeld, 2014)
There are numerous risk factors for nutritional compromise, but it has been reported that the most important are: low income, social isolation, high stress level, poor appetite, visual impairment, and medical illness.
- Poverty and Near-poverty
Older women, and older adults living alone or living with non-relatives experience poverty rates higher than average. Rural elderly have higher poverty rates than urban elderly; this gap is greatest in those aged 85 or older. Since there is a close connection between insufficient income and hunger this suggests many older Americans are at risk for food insecurity and hunger.
- Hunger: “uneasy or painful sensation caused by recurrent or involuntary lack of food and is a potential, although not necessary, consequence of food insecurity. Over time, hunger may result in malnutrition."
- Food Insecurity: “occurs whenever the availability of nutritionally adequate and safe food, or the ability to acquire foods in socially acceptable ways, is limited or uncertain.”
- Food Insufficiency: “an inadequate amount of food intake due to lack of resources.”
- SNAP -- The Supplemental Nutrition Assistance Program (formerly called food stamps) is administrated by the Kansas Department of Social and Rehabilitation Services. Special provisions apply for households with an elderly or disabled person or farm income. Benefits are downloaded onto a unique debit card called an Electronic Benefits Transfer (EBT) card that can be swiped at the grocery checkout like any debit or credit card. The old paper coupon system was known as "food stamps." This can be confusing since there are no food stamps in use anymore, but the SNAP program in Kansas is known as either the Kansas Food Stamp Program or the Kansas Food Assistance Program.
- Elderly Nutrition Program (ENP) -- Authorized by the Older Americans Act, The Administration on Aging’s Elderly Nutrition Program (ENP) provides funds for two older adult nutrition programs administered by the Department of Health and Human Services Administration on Aging. The meals must provide a minimum of one-third of the recommended daily allowances (RDA).
- The Older Americans Act (OAA) requires that nutritional programs provide nutritional screening. The ENP program is available to anyone over age 60 plus, but it is not an entitlement program so there may be a waiting list or no service in some communities due to limited funding. Most Kansas communities have an Elderly Nutrition Program.
- Congregate Meals: hot meals offered to groups of older adults at a variety of locations such as senior centers, churches, schools and others. Secondary benefits include reduction of isolation through the social setting.
- Home Delivered Meals (aka: Meals on Wheels): meets the same criteria as congregate meals, but is provided for older adults unable to attend a congregate site.
- Functional Deficits: visual impairments, immobility, tremors, dexterity problems, transportation lack to secure food.
- Cognitive, Psychiatric & Social: isolation, lack of transportation, depression, dementia, paranoia. In LTC, depression and other psychiatric conditions account for nearly 60% of involuntary weight loss.
- Therapeutic/Restrictive Diets: low sodium, low fat, diabetic, renal
- Oral Problems: edentulous, poor fitting dentures, dental pain, oral sores, xerostomia (due to medications, Sjogren’s disease), dysgeusia (idiopathic or specific medication side-effect)
- Medical Conditions: COPD, cardiac disease, dysphagias, Parkinsonism and other neurologic disorders, cancer, arthritis, infections, thyroid disorder, malabsorption syndromes, Helicobacter pylori, dyspepsia, alcoholism, Failure to Thrive (FTT) and others.
Robertson, R. G., & Marcos, M. (2004, July 15). Geriatric Failure to Thrive. American Family Physician; 70(2):343-350. Accessed online October 15, 2010 and November 2014 at: http://www.aafp.org/afp/2004/0715/p343.html
- The Institute of Medicine defined failure to thrive late in life as a syndrome manifested by weight loss > 5 percent of baseline, decreased appetite, poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol levels. FTT also commonly includes exhaustion, weakness and slow gait speed defined as >6-7 seconds to walk 15 feet (UpToDate, February, 2018)
- Prevalence of failure to thrive increases with age and is associated with increased costs of medical care and high morbidity and mortality rates. In elderly patients, failure to thrive is associated with increased infection rates, diminished cell-mediated immunity, hip fractures, decubitus ulcers, and increased surgical mortality rates.
- Affects 5 to 35 percent of community-dwelling older adults, 25 to 40 percent of nursing home residents, and 50 to 60 percent of hospitalized veterans.One study found that the in-hospital mortality rate in patients with failure to thrive was 15.9 percent. Failure to thrive should not be considered a normal consequence of aging, a synonym for dementia, the inevitable result of a chronic disease, or a descriptor of the later stages of a terminal disease.
- The FRAIL mnemonic can help quickly identify frailty with 3 or more “YES” responses to the following: (UpToDate, February, 2018)
- Fatigue – Are you fatigued?
- Resistance – Can you climb one flight of stairs?
- Ambulation – Can you walk one block?
- Ilnesses – more than 5
- Loss of weight – greater than 5%
- Polypharmacy as well as specific Offending Drugs:
Many medications have side-effects that can negatively impact nutrition directly or indirectly, and eventually lead to weight loss. The following potential effects and associated medications are only a few examples:
- Anorexia – digoxin, spironolactone, furosemide, phenytoin, K+ supplements
- Nausea – digoxin, NSAIDs, opioids, some antibiotics
- Dysgeusia – (altered taste) - oral metronidazole (metallic taste), clarithromycin, ACEIs, CCBs, metformin
- Dysphagia – bisphosphonates, NSAIDs, K+ supplements
- Early satiety –anticholinergics
- Hypermetabolism – thyroxine
- Constipation -- opioids, iron, diuretics
- Diarrhea – antibiotics
Also consider the potential risk for increased free circulating drug in undernourished persons taking medications that are highly protein bound such as digoxin.
Nutritional screening tools are general survey, questionnaire, checklist or scaled instruments to identify individuals in a group of older adults with undernutrition or at potential risk. They can be self-administered, volunteer or professionally administered. Screenings may lead to individual nutritional assessments to diagnose and treat persons with undernutrition. Seven criteria have been established for screening tool selection: 1) simple– easy to use and interpret; 2) acceptable to the older adult; 3) accurate 4) cost – benefits equal to or exceed cost; 5) reliable; 6) sensitive; and 7) specific. The Nutrition Screening Initiative (NSI) was developed to address the prevalence of malnutrition among older adults.
DETERMINE: a checklist of warning signs of poor nutrition.
Tooth Loss/Mouth Pain
Reduced Social Contact
Involuntary Weight Loss / Gain
Needs self-care assistance
Elder above age 80
MNA: Mini-Nutritional Assessment is both a screening and assessment tool. The MNA-SF (short form) is
only a screen and is Part I of the two-part MNA tool. The MNA has been called the best screening
tool for use in older adults. More detailed Information and the tool itself can be viewed
- Detailed History and Exam
- Diet and weight history, Medical, Medications, Psychiatric, Social (financial resources, bereavement, isolation, alcohol), Functional
- Potentially Reversible Causes?
- Meals on Wheels mnemonic in LTC
Anorexia tardive (late life nervosa)/Alcoholism
Late life paranoia
Nosocomial infections (H. pylori, C. Diff)
Wandering (& other dementia related behavior [DRB] )
Hyperthyroidism / Hypoadrenalism / Hypercalcemia
Enteric problems (malabsorption)
Low salt diet
- Clinical Signs of Undernutrition
- Muscle wasting, loss of fat stores
- Involuntary Weight Loss (IWL)
- 5% in 30 days
- 10% in 6 months or less
- BMI < 21 [severe if <19]
- Biochemical Signs of Undernutrition
- Total Cholesterol (TC) < 160 [late sign]
- Acquired: not due to statin or lifelong lower values
- Serum Albumin < 3.5
- half-life 2-3 weeks
- Pre-albumin < 15
- half-life 2-3 days
- The combination of BOTH low total cholesterol and serum albumin/prealbumin confers even greater risk of increased morbidity or mortality.
- Low Albumin and Pre-albumin have prognostic significance but are neither sensitive nor specific for malnutrition; they may actually be markers of inflammatory status due to cytokine activity
- Serum Transferrin < 180
- Other testing that may be useful in searching for potentially reversible underlying causes: CBC, FOBT, (fecal occult blood testing), TSH
- Clinical signs of Dehydration
- Reduced urine output
- New or worsened orthostatic vital signs
- “Ropey” saliva
- Buccal mucosal dryness
- Dry, furrowed or scrotal tongue
- moist scrotal tongue is normal variant
- Caution: patients with Sicca or Sjogren’s disease often have xerostomia as well as dryness of other mucous membranes (depending on severity)
- Address the underlying cause when possible
- Example: treat the pain of arthritic hands (or any significant pain), depressive pathology, GERD, tremor, dental appliance fit, oral topical analgesics, drug contributions, artificial saliva, etc
- Obtain Registered Dietician consult, if needed - particularly in acute setting and with nutrition via tube
- Estimate energy requirements
- Eliminate therapeutic diets
- Involve patient in food preferences
- Smaller more frequent portions
- Use calorie dense foods
- Liquid Supplements between meals
- Ice cream shakes (aka: “house shakes” with or without extra scoops of protein powder) can have too large a volume and actually promote anorexia if given with a meal. Even the smaller volume commercial shakes such as Mighty Shakes® should be between meals and/or at bedtime
- OTC liquid nutrition tends to be less dense and larger volume (8 ounces). Examples include: Ensure®, Ensure Plus®, Equate® (Walmart brand of same product if it states “compare with Ensure” etc; and much less expensive), Boost®, Boost Breeze® (fruit-flavored non-opaque products), and many more. All are lactose free.
- Calorie and micronutrient dense low volume commercial liquid supplements are not likely to reduce gastric space, but are best absorbed between meals
- Commercial liquid supplements can have 1-2 calories per ml. Using a product such as 2Cal® only 30mls tid would result in 180 extra calories per day. These specialized and nutritionally dense products are expensive and LTC facilities do not like to use them for this reason.
- Consider disease specific recommendations in select cases, such as switching to low carbohydrate (CHO) and higher balanced-fat calories in patients with COPD. CHO substrate metabolism typically results in increased CO2 production which can be burdensome on the lungs to try to exhale it. The Respiratory Quotient (RQ) is a ratio of C02 production to O2 consumption. The RQ for CHO metabolism is higher than that for fat or protein. Commercially available low CHO and balanced high-fat nutritional supplements are available specifically for patients with COPD. (Examples: Nutren ®, Pulmocare ®.) These types of products may be helpful in COPD patients who are hypercapnic. They also provide denser calories which is usually beneficial in persons with COPD since the work of breathing (WOB) alone can be very costly in terms of caloric expenditures. Low BMI in patients with COPD is associated with higher mortality.
- Consult SLP (speech language pathologist) for evaluation and management recommendations regarding dysphagia in any one or more of the four phases of deglutition.
- Carefully consider Orexigenic Drugs (so-called appetite stimulants)
- Mirtazapine: (Remeron ®) antidepressant with some orexigenic properties. Sedating. Start with low dose. Give at bedtime. Common.
- Anabolic Steroids
- Testosterone: Low levels correlate with male sarcopenia. Testosterone is not used for weight loss and is increasingly controversial even with osteoporosis. However, patients on the supplement for specific indication may have concurrent appetite and weight improvement.
- Progestational Agent
- Megestrol Acetate: (Megace ®) Risks: DVT, markedly decreased testosterone levels, adrenal suppression, edema, constipation, hyperglycemia. Use in ambulatory persons with cytokine excess. Note: this drug is on the Beer’s list of Potentially Inappropriate Medications for the Elderly.
- Cannabis Agent
- Dronabinol: (Marinol ®) increased desire for food and hedonia eating. Antiemetic and analgesic benefits. Reduction of aggression in Alzheimer’s patients. Considered by some as ideal medication in palliative and end-of-life care. Avoid use in dysphoric patients. Side-effects may include delirium, somnolence, and ataxia.
- Prokinetic Agent
- Metoclopramide: (Reglan ®) useful in gastroparesis. May cause dystonia and precipitate Parkinsonism symptoms
- Other drugs associated with weight gain, not used for orexigenic purposes:
- Tricyclic antidepressants (not recommended in elderly)
- Glucocorticoids – side effect of use
- Antipsychotic agents – monitor diabetics closely especially with Haloperidol, Olanzapine, and Risperidone
- Nutrition Tubes
- commonly called “feeding tubes” although there is nothing about these tubes that is “feeding.” The term “feeding” carries heavy emotional and social connotations. Rather, these are medical devices used for medical treatment of specialized Nutrition Support that allows for an alternative provision of nutrition (aka: artificial nutrition and hydration -- ANH).
- May be appropriate in dysphagia given the patient’s full medical context and QOL (quality of life) otherwise
- They are not recommended in end-stage dementias by the American Medical Directors Association (AMDA) and other organizations.
- The American Geriatrics Society (AGS) published a position paper on the use of nutrition via tubes in May 2013.
- They are not without potential major complications: aspiration, peritonitis, hemorrhage, buried bumpers, local wound infection, fistula, pain, inadvertent removal.
- Minor complications include external PEG site leakage and maceration, as well as PEG lumen obstruction necessitation removal and replacement. Use of Zinc oxide ointment on the peri-PEG tissue can be useful for tissue protection in event of external leakage.
- For non-ambulatory patients, the risk of sacral pressure ulcer is increased since the use of PEG infusions requires elevation of the head of the bead (commonly about 30 degrees) and this increases shear forces, particularly if the patient also has urinary incontinence or diaphoresis
- PEG tubes are not appropriate if the primary goal is to prevent aspiration pneumonia
- No research demonstrating PEG (percutaneous endoscopic gastrostomy) tubes prevent pneumonia
- SBFT ** Small bore flexible nutrition tubes placed either nasoenterally or nasogastrically may be appropriate for short-term nutrition [2-4 weeks].
- ** Note: the term “Dobbhoff” should not be used since it is only one manufacturer’s brand name. Dobbhoff was an early mercury-weighted nasoenteral tube. No tubes are mercury weighted anymore.
Particularly in the acute setting, consult a registered, licensed dietician (RD/LD), often masters prepared, to help with recommendations for commercial nutrition product selection, infusion calculation and timing recommendations, and enteral nutrition follow-up monitoring. There are commercial nutrition infusion products for hepatic and renal conditions, diabetes, COPD and others. It is important to remember that while these products are nutritionally complete (micronutrients) most do not contain fiber. Only a few product examples are provided in the slide photo below.
Mary Hobbs is a 92 year-old white female widow who lives in an Independent Living (IL) apartment of a large continuing care retirement community (CCRC). She has support from a daughter and two daughters-in-law who look in on her regularly. She is followed for chronic atrial fibrillation. Her only medication is digoxin 0.25 mg every day. She is seen in the CCRC clinic about every three months for regular follow-up. When last seen she weighed 130 pounds and was noted to be in good health. She presents today, accompanied by her daughter, for her routine visit and states all is going well. However, shortly after her last visit her son died and she has been very sad and tearful. She denies a poor appetite, but a of weight loss of 7 pounds. since her last visit is noted. During the interview, she seems to fixate on her son's death and how difficult it is for her to accept, but says she will just have to adjust. Her daughter is quite concerned about her mother, noting increasing isolation and anorexia. She also relates that over the past 2 years her mother has been more forgetful and less motivated. These symptoms worsened following the death of her son. There is a congregate meal opportunity in either of two dining room options in the facility, but Mrs. Hobbs has never participated and refuses to do so presently. The family prepares meals and delivers them to Mrs. Hobbs, but frequently notice they are not being eaten. They also take her grocery shopping where she selects foods of her preference. Much of this goes uneaten. They have noticed when she comes to their homes for a meal or to stay overnight, her appetite is good and her spirits are much better. Mrs. Hobbs has been invited to live with her daughter, but refuses to leave her own apartment and is insistent about remaining independent.
- What risk factors are present for nutritional compromise and dehydration in Mrs. Hobbs?
Examination reveals that Mrs. Hobbs weighs 123 pounds and is 5 feet 5 inches tall. Her sitting VS are: blood pressure 130/80, pulse 80 irregular; standing BP changes to 118/72 and pulse of 90. HEENT exam reveals temporalis muscle atrophy. She is edentulous with apparently well-fitting dentures. No oral lesions are present. Tongue is midline with slight loss of papillae. Lungs are clear. Heart sounds are irregular with a grade Il/VI systolic murmur. The abdomen is soft and nontender. Bowel sounds are normal. Extremities are without edema. Fat stores seem adequate with no obvious muscle atrophy. Mental status examination reveals short-term memory loss, poor concentration, and poor insight. There are no focal neurologic deficits. Laboratory: electrolytes within normal limits; blood urea nitrogen 28; creatinine 0.8; glucose 120; calcium 9.1; serum albumin 3.2; hemoglobin 11.4; hematocrit 35.1 with normal MCV and MCHC. WBC count is 8.2 with normal differential. Serum iron within normal limits. Transferrin is 252, B12 300, folate 4.5, TSH 3.2, total T4 6.1.
- What additional information is needed to further assess her nutritional and hydration status?
- What interventions would be appropriate at this time?
Approximately 3 weeks after Mrs. Hobbs was seen, her daughter brings the patient to the emergency room. There she gives a history of near-syncope after some prolonged standing waiting for the CCRC activity bus to pick her up. In the emergency room she is found to weigh 118 pounds. Her blood pressure supine is 120/76, pulse 86 irregular, which drops to 100/60 and pulse increases to approximately 100 irregular upon standing. No history suggesting infection. No history of nausea or vomiting. No cardiac symptoms. Laboratory: BUN 30, creatinine 1.3, digoxin level 1.8, electrolytes are within normal limits, glucose 100. No significant change in hemoglobin/hematocrit. Urinalysis: specific gravity 1.024, no protein, no glucose. WBC count, 5 to 7. No RBC's. Electrocardiogram: atrial fibrillation approximately 80 to 90. No change from previous ECG. She is treated with intravenous fluids in the emergency room and feels better after 500 cc of intravenous (IV) D5 0.5% normal saline. Her orthostasis resolves and she is discharged from the emergency room with follow-up planned in 2 days. Her digoxin dose is reduced to 0.125 mg.
- What further management issues are now present?
- What would be the benefits of a home visit in this patient?
- What interventions would you consider for her hydration maintenance, improved nutritional intake, and concern about grief, depression, and/or early dementia?
Ann Jones is a 67 year old white woman. She is single and has never been married. She has had difficulty with weight management over her lifetime. Currently, she is being treated with glipizide for Type II diabetes mellitus. She is a non-smoker and does not drink alcohol. She tries to follow a diabetic diet, but admits she is somewhat non-adherent. Her mother died in her late 60s due to a myocardial infarction and also had diabetes mellitus. Mrs. Jones is 5 ft 5 in. tall and weighs 190 pounds (BMI = 31.6). Her body habitus resembles an apple. Vital signs: BP 150/90 mm Hg; pulse 80 beats/min and regular; and respirations 16 per minute. Physical exam reveals central obesity with normal musculature of the extremities. Cardiovascular examination is within normal limits. There is no evidence of end organ damage by the diabetes mellitus. Laboratory: postprandial glucose is 190; serum albumin is 3.2; serum cortisol is normal; and serum cholesterol is 158.
- Is Mrs. Jones obese?
- What are Mrs. Jones' risk factors for cardiovascular disease?
- Does Mrs. Jones' body shape contribute to her health problems?
- Is Mrs. Jones nutritionally compromised?
Nutrition Case Study #3: "Increase the dietary fat content – are you kidding? What would my husband’s cardiologist say? "
Mr. Munsing is an 80 year-old Caucasian male admitted to hospital with severed COPD. He has chronic anorexia and a 21 pound weight loss (12%) the past 8 weeks. His height is 68 inches and admit weight is 154 pounds. He is pursed-lip breathing and sitting in tripod position.
PMH: CHF, HTN, Diverticulitis, CAD, Myocardial Infarction 18 months ago
Current Meds: ASA, Albuterol, Azmacort, Ipratropium, Prednisone, Vasotec, Lasix, KCL, Lisinopril
Diet: Low Fat, low Na+ per cardiology (diligently adhered to by his wife when preparing his food); Ensure Plus with meals.
Labs: Albumin 1.9; Total Cholesterol 87, Hgb 8.5
By the 4th hospital day he became febrile, reported oral pain (oral candidiasis was noted on exam), and had developed pseudomenbranous colitis diarrhea occurring several times daily.
- What are major indicators of malnutrition in this patient?
- What are the likely consequences of this man’s nutritional status?
- What interventions might you consider?
- Do you have any nutritional recommendations specific to the COPD?
- Are there any non-nutritional interventions that should be addressed this point?
IX. Selected Other References
Evans, W. J. (2010). Skeletal muscle loss: cachexia, sarcopenia, and inactivity. American Journal of Clinical Nutrition,2010;91(suppl):1123-7S.
Parrish, C. R. (2006, October). Serum proteins as markers of nutrition: What are we treating? Practical Gastroenterology:46-64.
Rhodes, Ramona. (2014, September). When evidence clashes with emotion: feeding tubes in advanced dementia. Annals of Long-Term Care, 22(9). Accessed online April, 2018 at: http://www.annalsoflongtermcare.com/article/when-evidence-clashes-emotion-feeding-tubes-advanced-dementia
Scheinfeld, N. S. (2014, May). Protein-Energy Malnutrition. Medscape. Accessed online April, 2018 at: http://emedicine.medscape.com/article/1104623-overview