Journal of the Royal Society of Medicine

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

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2013 411 .com by guest on May 1. nutrition-specific psychological factors such as depression and dementia. protein and other nutrients causes accommodation and up to 40% in those admitted to adverse effects on body form.21.1. it must have a National Health Service has been estimated at £260 million negative effect on outcomes.19 overnutrition is the main cause for concern.6 The World Health Organization categorizes underweight as BMI 518. 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.13.10 Contributing factors are altered smell/ treatable malnutrition.8 The prevalence of malnutrition increases with Nutritional screening.sagepub. with 12% of those living in the Body mass index (weight[kg]/height[m2]) predicts disease community at high or medium risk of malnutrition.10. malnutrition on physical and psychosocial outcomes. over- Departments of 1Geriatric Medicine and 2Medicine. valid and a year.7. BMI may be unreliable in the presence Correspondence to: Dr Dylan Harris of confounding factors such as oedema or ascites.15–17 and seemingly these are independent of underlying disease WHAT IS THE EXTENT OF MALNUTRITION and disability. needs to physiological decrease in appetite and food intake that be acceptable to patients and healthcare workers.22 taste. normal 18. UK 440. South Wales NP7 7EG. a simple. poor wound healing. Nevill Hall Hospital.9 assessment and possible intervention. excess or prevalence was reckoned at 20% among those in residential imbalance of energy. 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. and E-mail: dylangharris@hotmail. postoperative complications. poor dental health and age-related achlorhydria. In this review we consider whether There is ample evidence of the adverse consequences of these conditions are satisfied by tests of various kinds.1 The complex characteristics associated with nutritional problems so that biological process of ageing is accompanied by many socio.11 Also sensitivity). accompanies normal ageing can be augmented by acute and Furthermore. weight 25–29. lengthy hospital stays and rehabilitation.5–24. integral part of clinical practice.9. the individuals identified can undergo full nutrition economic factors that also impact on nutritional status. obese 30–39. reliable. and made normal by medical factors such as poor visual acuity and prescribed nutritional support. looks for escalating frailty and physical dependence. energy malnutrition (high specificity). The above question is difficult to answer in the absence of institutionalization.9 and extreme obesity Abergavenny.14 acceptable screening test must be available to detect those who are malnourished or at risk of malnutrition. undernutrition rather than respiratory function and death.1. even if the specificity is lower. However.5.9.20 Anorexia and weight loss are common in the elderly and the The process. as well as being quick and simple.4.10 In 2002 the Royal College of Body mass index (BMI) Physicians highlighted the over-65s as a nutritionally vulnerable group. universally accepted criteria to define malnutrition.13 The College identified nutritional screening as an outcome.98:411–414 Malnutrition is a state in which a deficiency. and there DOES MALNUTRITION HAVE A NEGATIVE must be benefit from nutritional intervention in those EFFECT ON OUTCOME? identified by screening.2–7 pressure ulcers.23 may not identify significant unintentional weight loss if Downloaded from jrs. and (unaffected by non-nutritional factors). function and clinical hospital. 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. in its various forms. it must have good sensitivity for detecting chronic disease.18 Malnourished older people are at increased IN THE ELDERLY POPULATION? risk of falls.4. impaired muscle and In the older population. The risk both in those termed underweight and in those who are obese.10. infections. in Ideally. consistently normal in patients without protein- important are social factors such as poverty and isolation. since its relation to morbidity and mortality is stronger than that of IS THERE A SUITABLE SCREENING TEST? obesity.12 Many of these are reversible or responsive to treatment.1 To justify screening for this state in the elderly.

JOURNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 98 September 2005 used as a single assessment. riboflavin. some criteria. thigh. serum mobility. Their main value is in more detailed mortality.29 but have to be interpreted in the light of age.17. intended users. programmes. females).23 Mid.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. over because of vertebral compression. tions studied and diversity of outcome measures.31 moreover.27 For this reason. perioperative body mass index.8. IS NUTRITIONAL INTERVENTION BENEFICIAL tion. social functioning.8 MUST but requires a skilled technique. undernutrition since it encompasses physical and mental aspects of health.33 The MNA has also shown itself malnutrition but is unreliable in conditions including practical and reliable. discharge the mass of the muscle group is proportional to its protein destination in orthopaedic patients).11 Malnutrition contributes to age-related immune dysregula. arm muscle Downloaded from jrs.sagepub. likelihood of discharge to a nursing home and of albumin means that serum albumin does not respond to mortality.5. The Malnutrition Universal Screening Tool (MUST) derives a score classifying malnutrition risk as low. 2013 . Several different sites can was developed primarily for use in the community be used—subscapular. (where it predicts admission rates and need for general calf. 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. iron deficiency.23 predictive validity in the hospital environment (length of Use of arm circumference depends on the assumption that hospital stay. scoring systems.8 Below we discuss two that have been well of ulna length.16 In addition. the long half-life stay. history of Skinfold thickness can be measured with standardized callipers unexplained weight loss and acute illness effect. weight loss during the preceding three months.18 appear beneficial in terms of weight gain. folate and ferritin). biceps. with different and postural changes. 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.8 validated.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. Nutritional state.21.30 content and also reflects total body muscle mass. some are unreliable in should be better at identifying frail elderly patients at risk of conditions that cause limb oedema. 422 cm minutes).26 Furthermore. neuropsychological problems. reliable Malnutrition screening tools measurement of height can be difficult in the elderly In view of the limitations of individual methods. triceps. nursing homes and hospitals. In theory it gender and ethnicity.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. the general practitioner as well as length of hospital especially in the acutely ill.19. hypoxaemia.27 Furthermore.16 Transferrin component of the MNA offers strong evidence that is a more sensitive indicator of early protein-energy malnutrition is absent. mortality and rate of visits to inflammation and infection.20. including decreased lymphocyte proliferation. vitamin D. however. dietary supplementation does 412 identified by screening) and for monitoring. retinol-binding months. transferrin. morbidity and functional outcomes. protein and thyroxine-binding prealbumin. chronic infection and hepatic disease.17.21 A score of 11 or more on the screening short-term changes in protein and energy by guest on May 1. B12.35.21 Stratton et al. psychological stress or acute disease in the albumin has been most widely adopted because it predicts preceding three months.14.36 calcium. is The MNA has predictive validity for adverse health not the only factor affecting these proteins. loss of muscle tone fifty combinations have been tried.34 pregnancy. and screening tools use alternatives such as measurement acceptability.25. differences between popula- is also important (including thiamine. 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. however.6.20 complications) in older people. it detects risk of malnutrition at a time when albumin levels and BMI are Biochemical markers still normal.16 A low total lymphocyte count signifies a poor prognosis and is independent of low serum albumin. others being outcome.6 Of these. supra-iliac. pyridoxine. mortality in elderly wards. medium or high Anthropometry on the basis of three components—BMI.6.14 On assessment (particularly risk stratification of patients existing evidence. mortality and other outcomes (for example. This limits their usefulness.21.20.

Can Med Assoc 28 Macallan D. Frey BM. A Positive Approach to Nutrition as Treatment. Clin Nutr 2002.4:1375–8 Downloaded from jrs. concurrent validity and ease of Med 1982. supported by the British Dietetic 21 Knodrup J. et al. Sinclair AJ. (ed. Wright R. ageing and ill health. College of Physicians.35–37 7 Milne AC. Pennington CR. Problems of nutritional assessment in the community. Nutritional status and well being. Approach to the patient requiring nutritional adults. Longmore D. J Nutr training. Age and the choice falls on ‘screening tools’ employing Ageing 2005. Proc Nutr Soc 2002. Assessment tools for nutritional status in the elderly. 2013 413 . supplements for more than 11 Gariballa SE. Nutritional risk and body composition in free- living elderly participating in congregate meal-site programs.38 15 Whirter JP.308:945–8 16 Jeejeebhoy KN. Stroud M. Minder CE.) Screening for Malnutrition: A Multidisciplinary Responsibility. Malnutrition and infection. Critical evaluation of the role of clinical assessment and body composition studies in patients with malnutrition and after total parenteral nutrition. immune function.22:415–21 Enteral Nutrition. Clin Med 2004. Wolman SL. a significantly 9 Meydani M. Vellas B.: CD003288. Malnutrition in hospital comparison of clinical judgement and objective measurements. Toppan J. Nutrition and ageing: screening for malnutrition in Baltimore: Lippincott Williams & Wilkins. et al. Plauth M. Potter J. Am J Clin Nutr 1997. Elia M. 2003 the detection of severe malnutrition: influence of the pathology and changes in anthropometric parameters. Br J Nutr 2003. Clin Med 2004. Nutritional assessment: identifying patients’ needs. 2003 dwelling elderly.24:193–7 combinations that can be applied without specific skills or 19 Davidson J.4:405–7 Registered Nursing Homes Association and the Royal 23 Buzby GP. Proc sectional survey of Irish free-living elderly subjects with smoother Nutr Soc 1999. JOURNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 98 September 2005 circumference. (WHO Tech Rep Ser 894). 1992 in terms of hospital and nursing care. In: Heymesfield S. Am J Clin Nutr CONCLUSION 1982. et al.161:511–15 29 Corish C. Elderly 2004. 1995 3 Azad N. Nutritional Assessment. BMJ 1994. Medicine 2005. Jeejebhoy K.89:137–45 5 Baker JP.3: Large multicentre randomized controlled trials are 15–18 needed to assess the benefits of nutritional intervention in 13 Kopelman P. Saweirs WM. Br J Clin Nutr 35 days. The prognostic Anthropometry and biochemical markers have drawbacks.36 In meta-analyses of the benefits of supplementation for Adults.80:7–23 nursing homes. the Royal College of Nursing. Value of body mass index in Based Approach to Treatment. Nutrition in the elderly. Oxford: CABI. Klein S. IMAJ be said for use of a single such tool.23: 2 Klein S. 31 Salva A. Geneva: WHO. Disease Related Malnutrition: an Evidence 26 Campillo B.36 Evidence has been responsibility.14. Lennard-Jones J. Murphy J.33:3 J 1999. Incidence and recognition of malnutrition in hospital.58:47–51 centile curves. Nutrition interventions in aging and age-associated disease. (WHO Tech Rep Ser 854). ESPEN guidelines Association. Ferry PG. Elia M. Mullen JL.35:1117–27 The importance of nutrition is now specified in documents 17 Balcombe NR.14. patients in hospital or 1998. Stuck AE.24:53–68 In a particular hospital or community. 4th edn. Cochrane Database of Systematic Weight gain is an outcome measure of particular Reviews 2005. Is there a relationship between body mass index and the well- such as the UK National Service Framework for older being of older people? Curr Med Res Opin 2001.92:799–808 supplementation. Nutrition.5:365–7 wide support is MUST. Analysis of nutritional assessment indices: prognostic equations and cluster analysis. Getz M. et al. Development and use of the ‘Malnutrition Universal Screening Tool’ (‘MUST’) dence. Geneva: WHO. Nutrition and older people: special considerations relating to nutrition and ageing. Green CJ. Br J Nutr 2004. significance of protein-energy malnutrition in geriatric patients. those acutely unwell. length of hospital stay and mortality.4:411–14 400 kcal per day. ed. particularly 14 Leonard-Jones JE. N Engl J outpatients and inpatients: prevalence. Anthropometric measurements from a cross 4 Edington J. Detsky AS. Oxford: Blackwell Scientific.61:165–71 reduced mortality is seen in the following groups: patients defined as undernourished. Kinney J. et al.sagepub. Clin Med J 2002. and one that attracts 2003. the British Association for Parenteral and for nutrition screening 2002. Protein and energy supplementation in elderly people at risk from malnutrition.7 12 Woo J. Nutrition and patients: a doctor’s clearly defined patient groups. Pera G. London: King’s Fund. Uzan I. the 22 Elia M. Baker JP. J Hong Kong Geriatr Soc 2000. BAPEN 2003 in elderly people at risk from malnutrition. 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