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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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weight 25–29. malnutrition on physical and psychosocial outcomes. 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 2005.11 Also sensitivity). it must have good sensitivity for detecting chronic disease.6 The World Health Organization categorizes underweight as BMI 518.5–24. accompanies normal ageing can be augmented by acute and Furthermore. and made normal by medical factors such as poor visual acuity and prescribed nutritional support. normal 18. poor dental health and age-related achlorhydria. nutrition-specific psychological factors such as depression and dementia. South Wales NP7 7EG. it must have a National Health Service has been estimated at £260 million negative effect on outcomes.8 The prevalence of malnutrition increases with Nutritional screening. lengthy hospital stays and rehabilitation.23 medication. infections. In this review we consider whether There is ample evidence of the adverse consequences of these conditions are satisfied by tests of various kinds. However. since its relation to morbidity and mortality is stronger than that of IS THERE A SUITABLE SCREENING TEST? obesity.98:411–414 Malnutrition is a state in which a deficiency. as well as being quick and simple. 2013 411 . function and clinical hospital. reliable.10. over- Departments of 1Geriatric Medicine and 2Medicine.18 Malnourished older people are at increased IN THE ELDERLY POPULATION? risk of falls. BMI may be unreliable in the presence Correspondence to: Dr Dylan Harris of confounding factors such as oedema or ascites. and E-mail: dylangharris@hotmail. energy malnutrition (high specificity). UK 440. even if the specificity is lower. 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.14 acceptable screening test must be available to detect those who are malnourished or at risk of malnutrition.1 To justify screening for this state in the elderly. consistently normal in patients without protein- important are social factors such as poverty and isolation.12 Many of these are reversible or responsive to treatment. universally accepted criteria to define malnutrition. needs to physiological decrease in appetite and food intake that be acceptable to patients and healthcare workers.4. protein and other nutrients causes accommodation and up to 40% in those admitted to adverse effects on body form. with 12% of those living in the Body mass index (weight[kg]/height[m2]) predicts disease community at high or medium risk of malnutrition. in its various forms. excess or prevalence was reckoned at 20% among those in residential imbalance of energy. in Ideally. a simple.sagepub. postoperative complications.10 Contributing factors are altered smell/ treatable malnutrition. the individuals identified can undergo full nutrition economic factors that also impact on nutritional status.22 taste.1.4. impaired muscle and In the older population.9 and extreme obesity Abergavenny. undernutrition rather than respiratory function and death. obese 30–39.20 Anorexia and weight loss are common in the elderly and the The process. Nevill Hall Hospital. valid and a year.19 overnutrition is the main cause for concern. The above question is difficult to answer in the absence of institutionalization.1. 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.10 In 2002 the Royal College of Body mass index (BMI) Physicians highlighted the over-65s as a nutritionally vulnerable group.2–7 pressure ulcers. The risk both in those termed underweight and in those who are obese. looks for escalating frailty and physical dependence.9 assessment and possible intervention.5. and (unaffected by non-nutritional factors). and there DOES MALNUTRITION HAVE A NEGATIVE must be benefit from nutritional intervention in those EFFECT ON OUTCOME? identified by screening.13.10.15–17 and seemingly these are independent of underlying disease WHAT IS THE EXTENT OF MALNUTRITION and disability.com by guest on May 1. poor wound healing.21.1 The complex characteristics associated with nutritional problems so that biological process of ageing is accompanied by many socio. integral part of clinical practice.13 The College identified nutritional screening as an outcome.9.com may not identify significant unintentional weight loss if Downloaded from jrs.9.7.

likelihood of discharge to a nursing home and of albumin means that serum albumin does not respond to mortality.26 Furthermore. it detects risk of malnutrition at a time when albumin levels and BMI are Biochemical markers still normal. perioperative body mass index. tions studied and diversity of outcome measures. retinol-binding months.19.34 pregnancy.16 A low total lymphocyte count signifies a poor prognosis and is independent of low serum albumin.17.21.27 Furthermore. morbidity and functional outcomes. including decreased lymphocyte proliferation. is The MNA has predictive validity for adverse health not the only factor affecting these proteins.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. others being outcome.21.6.sagepub.8 Below we discuss two that have been well of ulna length. vitamin D.8 MUST but requires a skilled technique. transferrin. and screening tools use alternatives such as measurement acceptability.31 moreover.5.8 validated.6 Of these. over because of vertebral compression. some are unreliable in should be better at identifying frail elderly patients at risk of conditions that cause limb oedema. thigh. psychological stress or acute disease in the albumin has been most widely adopted because it predicts preceding three months. undernutrition since it encompasses physical and mental aspects of health. neuropsychological problems.17.20.23 Mid. nursing homes and hospitals. loss of muscle tone fifty combinations have been tried.18 appear beneficial in terms of weight gain. 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. chronic infection and hepatic disease. JOURNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 98 September 2005 used as a single assessment. dietary supplementation does 412 identified by screening) and for monitoring. triceps.33 The MNA has also shown itself malnutrition but is unreliable in conditions including practical and reliable.27 For this reason. folate and ferritin).20 complications) in older people.16 Transferrin component of the MNA offers strong evidence that is a more sensitive indicator of early protein-energy malnutrition is absent. Nutritional state. IS NUTRITIONAL INTERVENTION BENEFICIAL tion.30 content and also reflects total body muscle mass. The Malnutrition Universal Screening Tool (MUST) derives a score classifying malnutrition risk as low. mortality in elderly wards. 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. mortality and rate of visits to inflammation and infection. This limits their usefulness. iron deficiency. 2013 . Their main value is in more detailed mortality. riboflavin. protein and thyroxine-binding prealbumin.14. In theory it gender and ethnicity.8. programmes. 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. supra-iliac. however. biceps. history of Skinfold thickness can be measured with standardized callipers unexplained weight loss and acute illness effect. however.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. mortality and other outcomes (for example.com by guest on May 1.21 Stratton et al.29 but have to be interpreted in the light of age. discharge the mass of the muscle group is proportional to its protein destination in orthopaedic patients). females).6. reliable Malnutrition screening tools measurement of height can be difficult in the elderly In view of the limitations of individual methods. the general practitioner as well as length of hospital especially in the acutely ill.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.25.35. the long half-life stay. (where it predicts admission rates and need for general calf. medium or high Anthropometry on the basis of three components—BMI.36 calcium. B12. hypoxaemia. Several different sites can was developed primarily for use in the community be used—subscapular.20. 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. serum mobility. differences between popula- is also important (including thiamine. scoring systems. intended users. weight loss during the preceding three months.21 A score of 11 or more on the screening short-term changes in protein and energy intake.16 In addition. pyridoxine.11 Malnutrition contributes to age-related immune dysregula.14 On assessment (particularly risk stratification of patients existing evidence. social functioning. 422 cm minutes). some criteria. with different and postural changes.

24:193–7 combinations that can be applied without specific skills or 19 Davidson J. Allison SP. Nutritional assessment: a 30 Stratton RJ.23: 2 Klein S. J Hong Kong Geriatr Soc 2000. 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. ageing and ill health. (ed.2:391–4 offered that nutritional support is cost-effective. muscle function and functional indepen. Obesity: Preventing and Managing the Global Epidemic.sagepub. Clin Nutr 2003.) Screening for Malnutrition: A Multidisciplinary Responsibility. College of Physicians. Protein and energy supplementation in elderly people at risk from malnutrition.80:7–23 nursing homes.33:3 J 1999. London: King’s Fund.35:1117–27 The importance of nutrition is now specified in documents 17 Balcombe NR. Nutritional assessment: identifying patients’ needs. In: Heymesfield S. Nutrition. Malnutrition and infection.3: Large multicentre randomized controlled trials are 15–18 needed to assess the benefits of nutritional intervention in 13 Kopelman P. Oxford: Blackwell Scientific. ed. Longmore D. supplements for more than 11 Gariballa SE. BMJ 1994. 2003 the detection of severe malnutrition: influence of the pathology and changes in anthropometric parameters.14. JOURNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 98 September 2005 circumference. Age and the choice falls on ‘screening tools’ employing Ageing 2005. Elia M.308:945–8 16 Jeejeebhoy KN. Potter J. Geneva: WHO. ESPEN guidelines Association.: CD003288.com by guest on May 1.92:799–808 supplementation. Geneva: WHO. Nutritional risk and body composition in free- living elderly participating in congregate meal-site programs. length of hospital stay and mortality. Disease Related Malnutrition: an Evidence 26 Campillo B.5:365–7 wide support is MUST. Nutrition and ageing: screening for malnutrition in Baltimore: Lippincott Williams & Wilkins.36 Evidence has been responsibility. Assessment tools for nutritional status in the elderly. particularly 14 Leonard-Jones JE. Minder CE. Nutrition in the elderly. those acutely unwell.4:1375–8 Downloaded from jrs. Pera G. immune function. Ferry PG. Mullen JL. Jeejebhoy K. Nutrition interventions in aging and age-associated disease. Textbook of Gastroenterology. the Royal College of Nursing. Clin Med J 2002.306:969–72 use of the ‘‘Malnutrition Universal Screening Tool’’ (‘‘MUST’’) for 6 Alpers DH. age over 75. Clin Med 2004. Pennington CR.34:28–31 1 Stratton RJ. concurrent validity and ease of Med 1982. Am J Clin Nutr CONCLUSION 1982. the 22 Elia M. Murphy J.17:1–7 people but there is no consensus on methods of detection. A Positive Approach to Nutrition as Treatment. et al. Wesson DE. Klein S. and one that attracts 2003. there is much to 20 Berner YN. Br J Nutr 2004. Value of body mass index in Based Approach to Treatment. 18 Muhlethaler R. (WHO Tech Rep Ser 854). N Engl J outpatients and inpatients: prevalence. Critical evaluation of the role of clinical assessment and body composition studies in patients with malnutrition and after total parenteral nutrition. Getz M.161:511–15 29 Corish C. Malnutrition in hospital comparison of clinical judgement and objective measurements. Development and use of the ‘Malnutrition Universal Screening Tool’ (‘MUST’) dence.pub2 importance since it correlates with improvements in 8 Elia M. Kinney J.4:405–7 Registered Nursing Homes Association and the Royal 23 Buzby GP. Hackston A. Nutrition and older people: special considerations relating to nutrition and ageing. Am J Clin Nutr 1997. Art No. 1995 3 Azad N. Can Med Assoc 28 Macallan D. IMAJ be said for use of a single such tool. J Nutr training. Problems of nutritional assessment in the community. 4th edn. Paillaud E. 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