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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13 The College identified nutritional screening as an outcome.98:411–414 Malnutrition is a state in which a deficiency.14 acceptable screening test must be available to detect those who are malnourished or at risk of malnutrition.7. it must have good sensitivity for detecting chronic disease. postoperative complications.9 and extreme obesity Abergavenny. and E-mail: dylangharris@hotmail. In this review we consider whether There is ample evidence of the adverse consequences of these conditions are satisfied by tests of various kinds. energy malnutrition (high specificity). and (unaffected by non-nutritional factors). function and clinical hospital. BMI may be unreliable in the presence Correspondence to: Dr Dylan Harris of confounding factors such as oedema or ascites.11 Also sensitivity). it must have a National Health Service has been estimated at £260 million negative effect on outcomes. accompanies normal ageing can be augmented by acute and Furthermore.10 In 2002 the Royal College of Body mass index (BMI) Physicians highlighted the over-65s as a nutritionally vulnerable group.23 medication. 2013 411 . excess or prevalence was reckoned at 20% among those in residential imbalance of energy.5–24. undernutrition rather than respiratory function and death.4. The risk both in those termed underweight and in those who are obese. poor dental health and age-related achlorhydria.1.19 overnutrition is the main cause for concern. integral part of clinical practice.12 Many of these are reversible or responsive to treatment.9. malnutrition on physical and psychosocial outcomes.13.1 The complex characteristics associated with nutritional problems so that biological process of ageing is accompanied by many socio. nutrition-specific psychological factors such as depression and dementia. in Ideally. valid and a year.8 The prevalence of malnutrition increases with Nutritional screening.9 assessment and possible intervention. the individuals identified can undergo full nutrition economic factors that also impact on nutritional status.18 Malnourished older people are at increased IN THE ELDERLY POPULATION? risk of falls. in its various forms. weight 25–29.2–7 pressure ulcers.sagepub. lengthy hospital stays and rehabilitation. over- Departments of 1Geriatric Medicine and 2Medicine. poor wound healing. 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. universally accepted criteria to define malnutrition. needs to physiological decrease in appetite and food intake that be acceptable to patients and healthcare workers.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.10.20 Anorexia and weight loss are common in the elderly and the The process. as well as being quick and simple. impaired muscle and In the older population.22 taste. The above question is difficult to answer in the absence of institutionalization.21. a simple. reliable. even if the specificity is lower. However.10. since its relation to morbidity and mortality is stronger than that of IS THERE A SUITABLE SCREENING TEST? obesity. and there DOES MALNUTRITION HAVE A NEGATIVE must be benefit from nutritional intervention in those EFFECT ON OUTCOME? identified by screening. consistently normal in patients without protein- important are social factors such as poverty and isolation.1.4.15–17 and seemingly these are independent of underlying disease WHAT IS THE EXTENT OF MALNUTRITION and may not identify significant unintentional weight loss if Downloaded from jrs. looks for escalating frailty and physical dependence. and made normal by medical factors such as poor visual acuity and prescribed nutritional support. infections.10 Contributing factors are altered smell/ treatable malnutrition. protein and other nutrients causes accommodation and up to 40% in those admitted to adverse effects on body form.5. normal 18. 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.1 To justify screening for this state in the elderly. with 12% of those living in the Body mass index (weight[kg]/height[m2]) predicts disease community at high or medium risk of by guest on May 1. UK 440. obese 30–39. South Wales NP7 7EG.9. Nevill Hall Hospital.

2013 .30 content and also reflects total body muscle mass. and screening tools use alternatives such as measurement acceptability.11 Malnutrition contributes to age-related immune dysregula. medium or high Anthropometry on the basis of three components—BMI. reliable Malnutrition screening tools measurement of height can be difficult in the elderly In view of the limitations of individual methods. mortality in elderly wards.35.10 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. supra-iliac. triceps.25. retinol-binding months. however.31 moreover.16 A low total lymphocyte count signifies a poor prognosis and is independent of low serum albumin.21 Stratton et al. with different and postural changes.sagepub.29 but have to be interpreted in the light of age.27 For this reason. chronic infection and hepatic disease. IS NUTRITIONAL INTERVENTION BENEFICIAL tion. Nutritional state. scoring systems.14 On assessment (particularly risk stratification of patients existing evidence. the general practitioner as well as length of hospital especially in the acutely ill.5. arm muscle Downloaded from jrs. 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. including decreased lymphocyte proliferation.23 predictive validity in the hospital environment (length of Use of arm circumference depends on the assumption that hospital stay. mortality and other outcomes (for example.6. dietary supplementation does 412 identified by screening) and for monitoring.6 Of these. riboflavin. history of Skinfold thickness can be measured with standardized callipers unexplained weight loss and acute illness effect. hypoxaemia.8.36 calcium. protein and thyroxine-binding prealbumin.17.32 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. 422 cm minutes). B12. Their main value is in more detailed mortality. Several different sites can was developed primarily for use in the community be used—subscapular.27 Furthermore. folate and ferritin). serum mobility. others being outcome. over because of vertebral compression. pyridoxine.8 validated.19. morbidity and functional outcomes. 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. likelihood of discharge to a nursing home and of albumin means that serum albumin does not respond to mortality. JOURNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 98 September 2005 used as a single assessment. females). the long half-life stay. weight loss during the preceding three months. In theory it gender and ethnicity. vitamin D.8 MUST but requires a skilled technique. is The MNA has predictive validity for adverse health not the only factor affecting these proteins. some criteria. (where it predicts admission rates and need for general calf.20. perioperative body mass index. undernutrition since it encompasses physical and mental aspects of health.20.18 appear beneficial in terms of weight gain. differences between popula- is also important (including thiamine.17.23 Mid.14.26 Furthermore.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. some are unreliable in should be better at identifying frail elderly patients at risk of conditions that cause limb oedema. however. The Malnutrition Universal Screening Tool (MUST) derives a score classifying malnutrition risk as low.33 The MNA has also shown itself malnutrition but is unreliable in conditions including practical and reliable.20 complications) in older people. programmes. intended users.8 Below we discuss two that have been well of ulna length. mortality and rate of visits to inflammation and infection. biceps.6. discharge the mass of the muscle group is proportional to its protein destination in orthopaedic patients).21. This limits their usefulness. thigh. 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. transferrin. social functioning. iron deficiency. neuropsychological problems. tions studied and diversity of outcome measures.16 In addition. it detects risk of malnutrition at a time when albumin levels and BMI are Biochemical markers still normal.16 Transferrin component of the MNA offers strong evidence that is a more sensitive indicator of early protein-energy malnutrition is absent.21. nursing homes and hospitals.34 by guest on May 1. psychological stress or acute disease in the albumin has been most widely adopted because it predicts preceding three months. loss of muscle tone fifty combinations have been tried.21 A score of 11 or more on the screening short-term changes in protein and energy intake.

Allison SP.66:683–706 27 World Health Organization. et al. In: Heymesfield S. Art No. age over 75. The prognostic Anthropometry and biochemical markers have drawbacks. Analysis of nutritional assessment indices: prognostic equations and cluster analysis. Wolman SL. ageing and ill health. 1992 in terms of hospital and nursing care. College of Physicians. JOURNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 98 September 2005 circumference. Vellas B. concurrent validity and ease of Med 1982. et al. Lennard-Jones J.) Screening for Malnutrition: A Multidisciplinary Responsibility. 4th edn. BAPEN 2003 in elderly people at risk from malnutrition. 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. 2000 25 McKinlay J. Nutrition survey in an elderly population following admission to a tertiary care hospital. Elia M. supplements for more than 11 Gariballa SE. 18 Muhlethaler R. 2003 dwelling elderly.34:28–31 1 Stratton RJ. Malnutrition in hospital comparison of clinical judgement and objective measurements. J Hong Kong Geriatr Soc 2000. BMJ 1994.17:1–7 people but there is no consensus on methods of detection. Kinney J.pub2 importance since it correlates with improvements in 8 Elia M.22:415–21 Enteral Nutrition. Br J Clin Nutr 35 days. Frey BM.58:47–51 centile curves. Pennington CR. Avenell by guest on May 1. (WHO Tech Rep Ser 894). Approach to the patient requiring nutritional adults. eds. Amos SS. J R REFERENCES Coll Physicians Edinb 2004. Proc Nutr Soc 2002. the Royal College of Nursing. et al. Textbook of Gastroenterology. N Engl J outpatients and inpatients: prevalence.306:969–72 use of the ‘‘Malnutrition Universal Screening Tool’’ (‘‘MUST’’) for 6 Alpers DH.14.4:411–14 400 kcal per day.38 15 Whirter JP. Mullen JL. Publ Health Nutr 2001. 2003 the detection of severe malnutrition: influence of the pathology and changes in anthropometric parameters. Development and use of the ‘Malnutrition Universal Screening Tool’ (‘MUST’) dence. Detsky AS. Nutrition and older people: special considerations relating to nutrition and ageing. A Positive Approach to Nutrition as Treatment. Clin Med 2004. ESPEN guidelines Association. Nutritional risk and body composition in free- living elderly participating in congregate meal-site programs.80:7–23 nursing homes.33:3 J 1999. a significantly 9 Meydani M. Nutrition in acute care. Nutritional status and well being. Obesity: Preventing and Managing the Global Epidemic. Physical Status: the Use and Interpretation of Anthropometry. Oxford: CABI. Nutrition in the elderly. Minder CE.5:365–7 wide support is MUST. there is much to 20 Berner YN. Disease Related Malnutrition: an Evidence 26 Campillo B. ed.24:193–7 combinations that can be applied without specific skills or 19 Davidson J. Elderly 2004. supported by the British Dietetic 21 Knodrup J. patients in hospital or 1998. the 22 Elia M. Anthropometric measurements from a cross 4 Edington J. 31 Salva A. Paillaud E. Nutritional Assessment. J Nutr training. Clin Med J 2002.35:1117–27 The importance of nutrition is now specified in documents 17 Balcombe NR. Medicine 2005.36 In meta-analyses of the benefits of supplementation for Adults. significance of protein-energy malnutrition in geriatric patients. Stuck AE. Malnutrition and infection. Murphy J. Wesson DE. Potter J.: CD003288. Br J Nutr 2003. Protein and energy supplementation in elderly people at risk from malnutrition. Nutritional assessment: identifying patients’ needs. Problems of nutritional assessment in the community. et al. Klein S. Nutritional assessment: a 30 Stratton RJ. Assessment tools for nutritional status in the elderly. Nutrition and patients: a doctor’s clearly defined patient groups. Longmore D. immune function. Can Med Assoc 28 Macallan D. Green CJ.89:137–45 5 Baker JP. Nutrition support in clinical 551–9 practice: review of published data and recommendations for future research directions. 1995 3 Azad N. Critical evaluation of the role of clinical assessment and body composition studies in patients with malnutrition and after total parenteral nutrition. Pera G. (ed. London: King’s Fund.35–37 7 Milne AC. the British Association for Parenteral and for nutrition screening 2002.4:405–7 Registered Nursing Homes Association and the Royal 23 Buzby GP. length of hospital stay and mortality. Kennedy NP.14. Wright R.161:511–15 29 Corish C.24:53–68 In a particular hospital or community. Ferry PG. Nutrition interventions in aging and age-associated disease. supplements of more than 10 Gariballa S. Value of body mass index in Based Approach to Treatment. those acutely unwell. Am J Clin Nutr CONCLUSION 1982. Stroud M. Hackston A. Proc sectional survey of Irish free-living elderly subjects with smoother Nutr Soc 1999. et al. Br J Nutr 2004.36 Evidence has been responsibility. Getz M. Clin Nutr 2002.4:1375–8 Downloaded from jrs.7 12 Woo J.2:391–4 offered that nutritional support is cost-effective. Uzan I.sagepub. Clin Nutr 2003. Issue 1.23: 2 Klein S. Oxford: Blackwell Scientific. particularly 14 Leonard-Jones JE. Geneva: WHO. and one that attracts 2003.3: Large multicentre randomized controlled trials are 15–18 needed to assess the benefits of nutritional intervention in 13 Kopelman P. In Yamada T. Sinclair AJ.92:799–808 supplementation. Incidence and recognition of malnutrition in hospital. Nutrition and ageing: screening for malnutrition in Baltimore: Lippincott Williams & Wilkins. 2013 413 . Age and the choice falls on ‘screening tools’ employing Ageing 2005.61:165–71 reduced mortality is seen in the following groups: patients defined as undernourished. (WHO Tech Rep Ser 854). Plauth M. Am J Clin Nutr 1997. Clin Med 2004. Cochrane Database of Systematic Weight gain is an outcome measure of particular Reviews 2005. Baker JP. muscle function and functional indepen. 1984 24 World Health Organization. Elia M.308:945–8 16 Jeejeebhoy KN. Nutrition. Geneva: WHO. Saweirs WM. IMAJ be said for use of a single such tool. Toppan J. Jeejebhoy K.

Routasalo P. Malnutrition in older 37 Payette H. JOURNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 98 September 2005 32 Guigoz Y. et al. undernourished 34 Soini H.18:737–57 33 Visvanathan R. J Am Diet Nutritional Assessment in elderly home-care patients.23:1096–103 414 Downloaded from jrs.102:1088–95 2004. Clin Geriatr Med supplementation in adults: systematic review. Malvy D. Boutier V. BMJ 1998. Routine protein energy malnutrition. Aust Fam Physician 2004. The Mini Nutritional Assessment. Eur J Clin Nutr Assoc 2002. Clin Nutr 2004. Langhorne O. Use of oral supplements reduce all cause mortality in elderly by guest on May 1. Coulombe C. frail. Benefits of people. Roberts M. Characteristics of the Mini. Lagstrom H. Vellas BJ.33:799–805 nutritional supplementation in free-living.sagepub.317:495–501 2002. 2013 . Evid Based supplements in malnourished elderly patients living in the community: Med 2003. elderly people: a prospective randomized community trial.58:64–70 35 Cheskin LJ. Identifying the elderly at risk for 36 Potter J. Jeandel C. Lauque S. Review: oral protein and energy 38 Armand-Battandier F. Gray-Donald K. Mitchell AM.8:82 a pharmaco-economic study. Chapman I. Newbury JW.

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