Journal of the Royal Society of Medicine

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Malnutrition screening in the elderly population
Dylan Harris and Nadim Haboubi
J R Soc Med 2005 98: 411

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11 Also sensitivity). since its relation to morbidity and mortality is stronger than that of IS THERE A SUITABLE SCREENING TEST? obesity.1 The complex characteristics associated with nutritional problems so that biological process of ageing is accompanied by many socio. 2013 411 . a single nutritional marker would be consistently addition a decrease in physical activity leads to reduction of abnormal in patients with protein-energy malnutrition (high lean body mass and accumulation of body fat. universally accepted criteria to define malnutrition. even if the specificity is lower. lengthy hospital stays and rehabilitation. excess or prevalence was reckoned at 20% among those in residential imbalance of energy. the individuals identified can undergo full nutrition economic factors that also impact on nutritional status. infections. as well as being quick and simple. postoperative complications. weight 25–29. and made normal by medical factors such as poor visual acuity and prescribed nutritional support. and there DOES MALNUTRITION HAVE A NEGATIVE must be benefit from nutritional intervention in those EFFECT ON OUTCOME? identified by screening. it must have a National Health Service has been estimated at £260 million negative effect on outcomes. in Ideally. obese 30–39. integral part of clinical practice. valid and a year.13 The College identified nutritional screening as an outcome. normal 18.9.14 acceptable screening test must be available to detect those who are malnourished or at risk of malnutrition. over- Departments of 1Geriatric Medicine and 2Medicine. four criteria must be satisfied: malnutrition must be a The economic cost of preventable malnutrition to the frequent cause of ill-health in this population. undernutrition rather than respiratory function and death. consistently normal in patients without protein- important are social factors such as poverty and isolation. reliable. Nevill Hall Hospital.sagepub.2–7 pressure ulcers. The above question is difficult to answer in the absence of institutionalization.9 assessment and possible intervention. BMI may be unreliable in the presence Correspondence to: Dr Dylan Harris of confounding factors such as oedema or ascites. looks for escalating frailty and physical dependence.12 Many of these are reversible or responsive to treatment.18 Malnourished older people are at increased IN THE ELDERLY POPULATION? risk of falls. a simple.22 taste.20 Anorexia and weight loss are common in the elderly and the The process. with 12% of those living in the Body mass index (weight[kg]/height[m2]) predicts disease community at high or medium risk of malnutrition.7. nutrition-specific psychological factors such as depression and dementia.10.10 Contributing factors are altered smell/ treatable malnutrition.10.5–24. and (unaffected by non-nutritional factors). poor dental health and age-related achlorhydria.10 In 2002 the Royal College of Body mass index (BMI) Physicians highlighted the over-65s as a nutritionally vulnerable group.9 and extreme obesity Abergavenny.5.9.6 The World Health Organization categorizes underweight as BMI 518. accompanies normal ageing can be augmented by acute and Furthermore.8 The prevalence of malnutrition increases with Nutritional screening. poor wound healing. South Wales NP7 7EG. However.com by guest on May 1.23 medication. energy malnutrition (high specificity). protein and other nutrients causes accommodation and up to 40% in those admitted to adverse effects on body form.13. it must have good sensitivity for detecting chronic disease. needs to physiological decrease in appetite and food intake that be acceptable to patients and healthcare workers.98:411–414 Malnutrition is a state in which a deficiency. function and clinical hospital. in its various forms.19 overnutrition is the main cause for concern.1.1.1 To justify screening for this state in the elderly. malnutrition on physical and psychosocial outcomes.4.21. The risk both in those termed underweight and in those who are obese. In this review we consider whether There is ample evidence of the adverse consequences of these conditions are satisfied by tests of various kinds.com may not identify significant unintentional weight loss if Downloaded from jrs. impaired muscle and In the older population.4. and E-mail: dylangharris@hotmail. JOURNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 98 September 2005 Malnutrition screening in the elderly population REVIEW ARTICLE Dylan Harris MB MRCP 1 Nadim Haboubi MD FRCP 2 J R Soc Med 2005. UK 440.15–17 and seemingly these are independent of underlying disease WHAT IS THE EXTENT OF MALNUTRITION and disability.

23 Mid. B12. supra-iliac. including decreased lymphocyte proliferation. perioperative body mass index. differences between popula- is also important (including thiamine.8.5. psychological stress or acute disease in the albumin has been most widely adopted because it predicts preceding three months. over because of vertebral compression. weight loss during the preceding three months.20 complications) in older people. pyridoxine. tions studied and diversity of outcome measures.35. Most trials have used primary nutritional outcome measures No biochemical marker on its own offers a satisfactory such as weight change and dietary intake rather than screening test. is The MNA has predictive validity for adverse health not the only factor affecting these proteins. neuropsychological problems. loss of muscle tone fifty combinations have been tried.11 Malnutrition contributes to age-related immune dysregula. Nutritional state.20.16 Transferrin component of the MNA offers strong evidence that is a more sensitive indicator of early protein-energy malnutrition is absent.27 For this reason.8 MUST but requires a skilled technique. retinol-binding months. intended users. others being outcome. Several different sites can was developed primarily for use in the community be used—subscapular. mortality and other outcomes (for example.10 A low IN THOSE IDENTIFIED BY SCREENING? total cholesterol has also been correlated with risk of The above key question is made difficult to answer by the malnutrition3 and assessment of vitamin and trace element status wide range of interventions. protein and thyroxine-binding prealbumin. the general practitioner as well as length of hospital especially in the acutely ill. and screening tools use alternatives such as measurement acceptability. females). (where it predicts admission rates and need for general calf.27 Furthermore.com by guest on May 1.25. it detects risk of malnutrition at a time when albumin levels and BMI are Biochemical markers still normal. This limits their usefulness. programmes. however. nursing homes and hospitals. likelihood of discharge to a nursing home and of albumin means that serum albumin does not respond to mortality.20. Their main value is in more detailed mortality. mortality in elderly wards. chronic infection and hepatic disease. some criteria.6.19.14 On assessment (particularly risk stratification of patients existing evidence. triceps.32 The score for screening is derived from six Serum proteins synthesized by the liver have been used as components—reduced food intake in the preceding three markers of nutrition—albumin.14. biceps. compared it with various other validated screening tools upper arm circumference is a helpful indicator of malnutrition and found it as good as and faster than most (3–5 applicable in ill patients (normal 23 cm males. the long half-life stay.28 The Mini Nutritional Assessment (MNA) was developed to Anthropometric indices are simple and inexpensive to evaluate the risk of malnutrition in the elderly in home-care obtain. morbidity and functional outcomes. 422 cm minutes).30 content and also reflects total body muscle mass. mortality and rate of visits to inflammation and infection.36 calcium.21. iron deficiency.16 In addition.31 moreover.6.16 A low total lymphocyte count signifies a poor prognosis and is independent of low serum albumin. medium or high Anthropometry on the basis of three components—BMI. discharge the mass of the muscle group is proportional to its protein destination in orthopaedic patients).8 validated.sagepub.29 but have to be interpreted in the light of age. folate and ferritin).18 appear beneficial in terms of weight gain.8 Below we discuss two that have been well of ulna length. arm muscle Downloaded from jrs.23 predictive validity in the hospital environment (length of Use of arm circumference depends on the assumption that hospital stay.34 pregnancy. 2013 . social functioning. JOURNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 98 September 2005 used as a single assessment. scoring systems. serum mobility. riboflavin. The distribution of skinfold thickness varies with practitioner visits) but has also been shown to have high ageing and between sexes and between ethnic groups. IS NUTRITIONAL INTERVENTION BENEFICIAL tion.21 A score of 11 or more on the screening short-term changes in protein and energy intake.17. history of Skinfold thickness can be measured with standardized callipers unexplained weight loss and acute illness effect.21 Stratton et al.17. hypoxaemia. In theory it gender and ethnicity. some are unreliable in should be better at identifying frail elderly patients at risk of conditions that cause limb oedema.6 Of these. reliable Malnutrition screening tools measurement of height can be difficult in the elderly In view of the limitations of individual methods.26 Furthermore. The Malnutrition Universal Screening Tool (MUST) derives a score classifying malnutrition risk as low. dietary supplementation does 412 identified by screening) and for monitoring. with different and postural changes.33 The MNA has also shown itself malnutrition but is unreliable in conditions including practical and reliable.21. undernutrition since it encompasses physical and mental aspects of health. however. vitamin D. thigh. transferrin.

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