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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excess or prevalence was reckoned at 20% among those in residential imbalance of energy.98:411–414 Malnutrition is a state in which a deficiency. Nevill Hall Hospital. 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. function and clinical hospital.21. it must have good sensitivity for detecting chronic disease.13.10 In 2002 the Royal College of Body mass index (BMI) Physicians highlighted the over-65s as a nutritionally vulnerable group.sagepub. UK 440. consistently normal in patients without protein- important are social factors such as poverty and isolation. energy malnutrition (high specificity).22 taste. needs to physiological decrease in appetite and food intake that be acceptable to patients and healthcare workers. it must have a National Health Service has been estimated at £260 million negative effect on outcomes. valid and a year.15–17 and seemingly these are independent of underlying disease WHAT IS THE EXTENT OF MALNUTRITION and disability. 2013 411 .20 Anorexia and weight loss are common in the elderly and the The process. nutrition-specific psychological factors such as depression and dementia.18 Malnourished older people are at increased IN THE ELDERLY POPULATION? risk of falls. 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. poor dental health and age-related achlorhydria.23 medication. looks for escalating frailty and physical dependence. and there DOES MALNUTRITION HAVE A NEGATIVE must be benefit from nutritional intervention in those EFFECT ON OUTCOME? identified by screening.5. postoperative complications.4. infections. the individuals identified can undergo full nutrition economic factors that also impact on nutritional status.10. However. and E-mail: dylangharris@hotmail.6 The World Health Organization categorizes underweight as BMI 518. and made normal by medical factors such as poor visual acuity and prescribed nutritional support. since its relation to morbidity and mortality is stronger than that of IS THERE A SUITABLE SCREENING TEST? obesity. undernutrition rather than respiratory function and may not identify significant unintentional weight loss if Downloaded from jrs.19 overnutrition is the main cause for concern. 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.1. malnutrition on physical and psychosocial outcomes. a simple. reliable. lengthy hospital stays and rehabilitation. in its various forms.7. as well as being quick and simple. The above question is difficult to answer in the absence of institutionalization. The risk both in those termed underweight and in those who are obese.4. poor wound healing. impaired muscle and In the older population. over- Departments of 1Geriatric Medicine and 2Medicine.2–7 pressure ulcers.5–24.1. normal 18. universally accepted criteria to define malnutrition.14 acceptable screening test must be available to detect those who are malnourished or at risk of malnutrition.12 Many of these are reversible or responsive to treatment. even if the specificity is lower.11 Also sensitivity).10.13 The College identified nutritional screening as an outcome. integral part of clinical practice.1 The complex characteristics associated with nutritional problems so that biological process of ageing is accompanied by many socio.9. and (unaffected by non-nutritional factors). obese 30–39. accompanies normal ageing can be augmented by acute and Furthermore. In this review we consider whether There is ample evidence of the adverse consequences of these conditions are satisfied by tests of various kinds. South Wales NP7 by guest on May 1.9 and extreme obesity Abergavenny. with 12% of those living in the Body mass index (weight[kg]/height[m2]) predicts disease community at high or medium risk of malnutrition.1 To justify screening for this state in the elderly.10 Contributing factors are altered smell/ treatable malnutrition.8 The prevalence of malnutrition increases with Nutritional screening. BMI may be unreliable in the presence Correspondence to: Dr Dylan Harris of confounding factors such as oedema or ascites.9 assessment and possible intervention.9. weight 25–29. in Ideally. protein and other nutrients causes accommodation and up to 40% in those admitted to adverse effects on body form.

Nutritional state. some criteria. others being outcome. riboflavin. social functioning.21. perioperative body mass index.17. Several different sites can was developed primarily for use in the community be used—subscapular.27 Furthermore.25. mortality and other outcomes (for example. differences between popula- is also important (including thiamine.5. chronic infection and hepatic disease. undernutrition since it encompasses physical and mental aspects of health. IS NUTRITIONAL INTERVENTION BENEFICIAL tion. however.8.16 In addition. morbidity and functional outcomes. 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.20. discharge the mass of the muscle group is proportional to its protein destination in orthopaedic patients). reliable Malnutrition screening tools measurement of height can be difficult in the elderly In view of the limitations of individual methods. In theory it gender and ethnicity. dietary supplementation does 412 identified by screening) and for monitoring.17.sagepub. is The MNA has predictive validity for adverse health not the only factor affecting these proteins. history of Skinfold thickness can be measured with standardized callipers unexplained weight loss and acute illness effect. JOURNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 98 September 2005 used as a single assessment. transferrin.33 The MNA has also shown itself malnutrition but is unreliable in conditions including practical and reliable. neuropsychological problems. pyridoxine. iron deficiency.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. some are unreliable in should be better at identifying frail elderly patients at risk of conditions that cause limb oedema.19. arm muscle Downloaded from jrs. serum mobility.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. protein and thyroxine-binding prealbumin.21. biceps. the long half-life stay. mortality in elderly wards.36 calcium.20. triceps.20 complications) in older by guest on May 1. likelihood of discharge to a nursing home and of albumin means that serum albumin does not respond to mortality. mortality and rate of visits to inflammation and infection. medium or high Anthropometry on the basis of three components—BMI.16 A low total lymphocyte count signifies a poor prognosis and is independent of low serum albumin.18 appear beneficial in terms of weight gain.21 Stratton et al. it detects risk of malnutrition at a time when albumin levels and BMI are Biochemical markers still normal. This limits their usefulness. B12. 422 cm minutes).23 Mid. retinol-binding months.14.29 but have to be interpreted in the light of age. females). loss of muscle tone fifty combinations have been tried. Their main value is in more detailed mortality. however. folate and ferritin).23 predictive validity in the hospital environment (length of Use of arm circumference depends on the assumption that hospital stay.6.35. 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.11 Malnutrition contributes to age-related immune dysregula. with different and postural changes. (where it predicts admission rates and need for general calf.30 content and also reflects total body muscle mass.8 validated. including decreased lymphocyte proliferation. scoring systems.26 Furthermore.21 A score of 11 or more on the screening short-term changes in protein and energy intake. psychological stress or acute disease in the albumin has been most widely adopted because it predicts preceding three months. supra-iliac. tions studied and diversity of outcome measures. over because of vertebral compression. intended users.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. The Malnutrition Universal Screening Tool (MUST) derives a score classifying malnutrition risk as low.6.14 On assessment (particularly risk stratification of patients existing evidence.6 Of these. weight loss during the preceding three months. thigh.8 MUST but requires a skilled technique.34 pregnancy. and screening tools use alternatives such as measurement acceptability. vitamin D. nursing homes and hospitals. the general practitioner as well as length of hospital especially in the acutely ill. 2013 .31 moreover. hypoxaemia.8 Below we discuss two that have been well of ulna length.27 For this reason. programmes. 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.16 Transferrin component of the MNA offers strong evidence that is a more sensitive indicator of early protein-energy malnutrition is absent.

Sinclair AJ. the Royal College of Nursing. London: King’s Fund. Clin Med J 2002. et al. Approach to the patient requiring nutritional adults. 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. Development and use of the ‘Malnutrition Universal Screening Tool’ (‘MUST’) dence. supported by the British Dietetic 21 Knodrup J. Am J Clin Nutr 1997. Oxford: CABI.306:969–72 use of the ‘‘Malnutrition Universal Screening Tool’’ (‘‘MUST’’) for 6 Alpers DH. Pennington CR. Amos SS. Pera G. Nutrition and patients: a doctor’s clearly defined patient groups.33:3 J 1999. 31 Salva A. Publ Health Nutr 2001.38 15 Whirter JP.14. Obesity: Preventing and Managing the Global Epidemic. Potter J. Paillaud E. Nutritional assessment: identifying patients’ needs. 2000 25 McKinlay J. 4th edn. Nutrition survey in an elderly population following admission to a tertiary care hospital.22:415–21 Enteral Nutrition. Murphy J. and one that attracts 2003. 18 Muhlethaler R. (WHO Tech Rep Ser 894). Assessment tools for nutritional status in the elderly. a significantly 9 Meydani M. ed. et al. Nutrition. Wolman SL. Clin Nutr 2002. Stuck AE. The prognostic Anthropometry and biochemical markers have drawbacks. the British Association for Parenteral and for nutrition screening 2002. Stroud M. J R REFERENCES Coll Physicians Edinb 2004.80:7–23 nursing homes. Clin Med 2004. Medicine 2005. eds. Lennard-Jones J. Plauth M. Uzan I. Age and the choice falls on ‘screening tools’ employing Ageing 2005. Jeejebhoy K. Nutrition support in clinical 551–9 practice: review of published data and recommendations for future research directions.92:799–808 supplementation. Getz M. Allison SP. 2003 dwelling elderly. ageing and ill health.161:511–15 29 Corish C.58:47–51 centile curves. Clin Nutr 2003. patients in hospital or 1998. 1992 in terms of hospital and nursing care. A Positive Approach to Nutrition as Treatment. Can Med Assoc 28 Macallan D. Cochrane Database of Systematic Weight gain is an outcome measure of particular Reviews 2005. length of hospital stay and mortality. Textbook of Gastroenterology. Proc sectional survey of Irish free-living elderly subjects with smoother Nutr Soc 1999. (WHO Tech Rep Ser 854). Nutritional assessment: a 30 Stratton RJ. Frey BM. those acutely unwell. 1984 24 World Health Organization. Clin Med 2004. Oxford: Blackwell Scientific. Value of body mass index in Based Approach to Treatment. J Hong Kong Geriatr Soc 2000. supplements for more than 11 Gariballa SE. concurrent validity and ease of Med 1982. College of Physicians. significance of protein-energy malnutrition in geriatric patients.5:365–7 wide support is MUST.36 Evidence has been responsibility.2:391–4 offered that nutritional support is cost-effective.36 In meta-analyses of the benefits of supplementation for Adults. Baker JP. Geneva: WHO. Kinney J. Minder CE.14. Elia M. Br J Clin Nutr 35 days.23: 2 Klein S. BMJ 1994. Br J Nutr 2004. Problems of nutritional assessment in the community.66:683–706 27 World Health Organization.17:1–7 people but there is no consensus on methods of detection.4:1375–8 Downloaded from jrs. Nutrition and older people: special considerations relating to nutrition and ageing.4:405–7 Registered Nursing Homes Association and the Royal 23 Buzby GP. Ferry PG. Disease Related Malnutrition: an Evidence 26 Campillo B. Nutritional status and well being. Toppan J. particularly 14 Leonard-Jones JE. Am J Clin Nutr CONCLUSION 1982. supplements of more than 10 Gariballa S. JOURNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 98 September 2005 circumference. Geneva: WHO.61:165–71 reduced mortality is seen in the following groups: patients defined as undernourished. 1995 3 Azad N. Klein S. et al. Vellas B. Mullen JL.24:193–7 combinations that can be applied without specific skills or 19 Davidson J.) Screening for Malnutrition: A Multidisciplinary Responsibility.35:1117–27 The importance of nutrition is now specified in documents 17 Balcombe NR. Critical evaluation of the role of clinical assessment and body composition studies in patients with malnutrition and after total parenteral nutrition. Hackston A.7 12 Woo J. age over 75. Protein and energy supplementation in elderly people at risk from malnutrition. 2013 413 . Wright R. Saweirs WM. Elia M. Nutritional Assessment. Longmore D. et al. Nutrition interventions in aging and age-associated disease.sagepub.3: Large multicentre randomized controlled trials are 15–18 needed to assess the benefits of nutritional intervention in 13 Kopelman P.35–37 7 Milne AC. the 22 Elia M. Nutrition and ageing: screening for malnutrition in Baltimore: Lippincott Williams & Wilkins. Malnutrition in hospital comparison of clinical judgement and objective measurements. Wesson DE. IMAJ be said for use of a single such tool. In Yamada T.34:28–31 1 Stratton RJ. Detsky AS. 2003 the detection of severe malnutrition: influence of the pathology and changes in anthropometric parameters. Elderly 2004. et al. Malnutrition and infection. Avenell A. (ed. Br J Nutr 2003. muscle function and functional indepen.308:945–8 16 Jeejeebhoy KN.24:53–68 In a particular hospital or community. Anthropometric measurements from a cross 4 Edington J. Nutritional risk and body composition in free- living elderly participating in congregate meal-site programs. Incidence and recognition of malnutrition in hospital. Physical Status: the Use and Interpretation of Anthropometry. In: Heymesfield S. ESPEN guidelines Association.pub2 importance since it correlates with improvements in 8 Elia M. Issue 1.89:137–45 5 Baker JP. immune function.4:411–14 400 kcal per day. Nutrition in the elderly. there is much to 20 Berner YN. Art No. Kennedy NP. N Engl J outpatients and inpatients: prevalence. BAPEN 2003 in elderly people at risk from malnutrition.: CD003288. J Nutr training. Analysis of nutritional assessment indices: prognostic equations and cluster analysis. Nutrition in acute care. Green CJ. Proc Nutr Soc by guest on May 1.

Jeandel C. Newbury JW. frail. Identifying the elderly at risk for 36 Potter J. The Mini Nutritional Assessment.23:1096–103 414 Downloaded from jrs. Malvy D. Chapman I. Review: oral protein and energy 38 Armand-Battandier F. Benefits of people. Clin Geriatr Med supplementation in adults: systematic review. Mitchell AM. elderly people: a prospective randomized community trial. Vellas BJ.8:82 a pharmaco-economic study. Evid Based supplements in malnourished elderly patients living in the community: Med 2003. Lauque S. Aust Fam Physician 2004. Routasalo P. Routine protein energy malnutrition. Boutier V. Roberts M.18:737–57 33 Visvanathan by guest on May 1. J Am Diet Nutritional Assessment in elderly home-care patients. BMJ 1998. undernourished 34 Soini H. et al. Malnutrition in older 37 Payette H. Gray-Donald K.sagepub.317:495–501 2002.58:64–70 35 Cheskin LJ. Use of oral supplements reduce all cause mortality in elderly people. Coulombe C. Clin Nutr 2004. Characteristics of the Mini. Eur J Clin Nutr Assoc 2002. Langhorne O. JOURNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 98 September 2005 32 Guigoz Y.33:799–805 nutritional supplementation in free-living.102:1088–95 2004. 2013 . Lagstrom H.

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