This chapter addresses the following Geriatric Fellowship Curriculum Milestones: #29, #42, #49, #72, #73
Describe common factors contributing to undernutrition in older adults.
Identify the three most common causes of weight loss in older adults.
Determine appropriate nutritional support interventions for persons with protein-energy malnutrition (PEM).
Key Clinical Points
Weight loss of 5% or more of baseline body weight over 6 to 12 months is associated with increased morbidity and mortality and should prompt clinical investigation.
When malignancy is the cause of weight loss, the diagnosis is usually readily made with standard evaluations that include a careful history, physical examination, and basic laboratory tests.
High-protein, high-calorie oral nutritional supplements may reduce morbidity and mortality when provided to hospitalized, malnourished patients age 75 or older.
Enteral nutrition (EN) is preferred over parenteral nutrition (PN) for patients who are in need of nutritional support and have a functional gastrointestinal (GI) tract.
Protein-energy malnutrition (PEM) is present when insufficient energy and/or protein is available to meet metabolic demands. PEM may develop because of poor dietary protein or caloric intake, increased metabolic demands as a result of illness or trauma, or increased nutrient losses. Proposed clinical criteria from the Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition to diagnose adult malnutrition are listed in Table 35-1.
TABLE 35-1CLINICAL CHARACTERISTICS RECOMMENDED FOR THE DIAGNOSIS OF ADULT MALNUTRITIONa |Favorite Table|Download (.pdf) TABLE 35-1 CLINICAL CHARACTERISTICS RECOMMENDED FOR THE DIAGNOSIS OF ADULT MALNUTRITIONa
Insufficient energy intake
Loss of muscle mass (eg, temporal wasting, reduced pectoralis, deltoid, quadriceps, other muscle)
Loss of subcutaneous fat (eg, orbital, triceps, fat overlying ribs)
Localized or generalized fluid accumulation (eg, extremity or genital edema, ascites)
Decreased functional status as measured by reduced handgrip strength
Prevalence data, relying on a variety of measures of nutritional adequacy, suggest that deficiencies in macronutrients (protein-energy) and micronutrients (vitamins and minerals) are very common among older adults. National survey data indicate that 40% to 50% of noninstitutionalized older adults are at moderate to high risk for nutritional problems, and up to 40% have diets deficient in three or more nutrients. Prevalence estimates in selected populations over 65 years indicate that 9% to 15% of older persons seen in outpatient clinics, 12% to 50% of hospitalized older persons, and 25% to 60% of older persons residing in institutional settings have one or more nutritional inadequacies—with PEM being the most common. Physical and psychosocial factors that may lead to inadequate nutrition are listed in Table 35-2.
TABLE 35-2FACTORS CONTRIBUTING TO INADEQUATE NUTRITION IN ...