Assessment of protein energy malnutrition in older persons, part I: History, examination, body composition, and screening tools

Protein-energy malnutrition is a prevalent problem in older persons. Its relation to increased morbidity and mortality has been well documented. Early recognition of malnutrition allows for a timely intervention. A large proportion of chronic diseases affecting older persons can be either prevented or significantly improved by improving nutrition, which underscores the importance of developing a screening system that can trigger a more comprehensive evaluation when indicated. Screening for malnutrition in older persons can be difficult because of the normal age-related changes in many of the commonly used parameters. A comprehensive nutritional evaluation includes a complete history and physical examination in addition to a more specific nutrition-oriented assessment. Specific nutritional assessment includes estimating food intake, anthropometric measurements, and evaluation of several biochemical parameters commonly affected by changes in nutritional status. In this article, we review the commonly used tools for nutritional assessment in older persons. The goal is to promote disease-free, active, and successful aging.     

Attention, psychomotor functions and age

Summary Nutrition might play an important role to ameliorate or to buffer age-related declines in attention and psychomotor functions. The assessment of nutritional effects in aged subjects has to take into account that attention and psychomotor functions can be subdivided in different functions that are differentially affected by age. This paper gives an overview of changes in different facets of attention and psychomotor functions beyond fifty as well as assessment methods for attention and psychomotor performance. It also provides a review of models to explain the pattern of changes with increasing age, and discusses the problems of high performance variance and of age related confounding variables like health status. Two different approaches are discussed that analyse a performance profile and an experimentally oriented functional microanalysis of changes in performance with respect to the effects of nutrition on attention and psychomotor functions. Addressed are examples of missing age-related deficits or even age-related superiority. Caffeine and Ginseng are considered as examples to enhance performance in older persons. Results are in accordance with data on the positive role of physical fitness for mental performance in older persons. Performance of older persons can well be enhanced by functional food components or nutritional supplementation. The effects are comparable to the effects obtained in younger groups, while there is only weak evidence for specific compensatory effects in aged persons. Finally the role of nutrition for the processes of healthy aging is discussed.     

Malnutrition in the institutionalized older adult.

Most older adults in the United States live at home and are well nourished. Approximately 5% to 6% reside in nursing homes, and this segment of the older population typically suffers from multiple diseases that contribute to a high incidence of malnutrition. Forty percent of hospital beds are occupied by older persons. This article addresses the causes of malnutrition in older persons institutionalized in long-term and acute-care facilities. The causes include changes in nutrient requirements secondary to disease processes and drug modalities in combination with low or marginal dietary intake. Infections are common and result in anorexia, poor dietary intake, and malnutrition, which predispose the patient to another infection. Occurrence of decubitus ulcers is related to nutritional status and presents a serious risk for older persons with limited mobility. Depression and dementia are commonly seen in older persons and are major contributors to poor appetite and malnutrition. Cancer cachexia accounts for about half of the cases of malnutrition in older institutionalized persons. Physiologic changes that occur with age and multiple drug use place older persons at a high risk for adverse drug reactions. Less body water in the older individual influences and complicates many aspects of treatment. Standards, methods, and interpretation of nutritional assessment measurements in older persons differ from those in younger adults. The nutrition care provider must carefully consider many complex physical, medical, and psychosocial factors to deliver individualized nutrition care.     

Helping Older Adults Meet Nutritional Challenges

ABSTRACT

Prevention of premature chronic diseases is an important component of healthy aging. Nutrition education can help to reduce the risk of premature chronic diseases in some older adults. Home delivered meals and congregate dining services assist vulnerable elderly persons by providing opportunities for nutritional and social support. Screening and assessment tools identify factors affecting nutritional health and can also provide specific directions for planning, implementation, and evaluation of tailored interventions. Dietitians and allied health professionals are well positioned to assist a heterogeneous population of older adults in securing nutritional adequacy.     

Demographic and nutritional trends among the elderly in developed and developing regions

Aging for an individual and aging for a population are related but not the same. For an individual, aging first involves survival to more advanced years, which will inevitably be accompanied by progressive changes in the structure and function of somatic tissues due to a programmed failure of the organism maximally to invest in their maintenance. For a population, aging means an increase in the median age, a dual function of longer survival of individuals and a decrease in fertility. In the wilds of nature, and for all but the recent decades for the human species, survival beyond the peak reproductive years is rare. The hostility of natural selection has its greatest impact on the young and the old. Only captive fowl and beasts, domesticated animal species and Homo sapiens achieve long survival. For humans, life expectancy from birth and from any age thereafter is increasing; median ages of populations and the percentage of persons over 60 y are rising. The affluent developed countries led the way, but developing countries are closing the gap. As of about 1966, a majority of the world's elderly live in developing societies. The rarity of growing old left a dearth of knowledge in the domain of gerontological nutrition, both for lack of motivation to learn and lack of individuals and populations to study. The convening of this workshop signifies that the polarity of interest has shifted 180 degrees. Social, economic, physiological and psychological changes with aging and growing older can both be influenced by diet and influence eating patterns and nutritional status. Many assumptions have been made about these changes, but only recently, with concerted metabolic studies of nutrient requirements in healthy elderly and carefully designed multi-center surveys of the health and nutrition of older segments of populations can a true portrait of the issues be delineated.     

Dénutrition chez le sujet âgé obèse

The aging population grows quickly, the prevalence of obesity increases in all age categories, and the prevalence of disease and disease related malnutrition is bound to increase with age. In subject aged 70 and older, the prevalence of obesity is 15 to 17 % and the prevalence of malnutrition is 4 to 10 %. The number of older persons both obese and malnourished has not been estimated, and there are no specific recommendations for nutritional care. Nevertheless, the obese older subjects can be frail, sarcopenic or malnourished and thus present a high risk for mobility disorders, falls, fractures, hospitalization and institutionalization. Data from the literature may help practitioners to diagnose and care for these older persons.     

Keeping the young-elderly healthy: is it too late to improve our health through nutrition?

Healthy older individuals can take several measures to preserve and improve their health. Even if past nutritional and lifestyle practices were not optimal, much can be done to reduce the risk of chronic disease and disability in future years. The first challenge is to recognize and address the profound changes in body composition that occur with aging. Older persons tend to accumulate relatively more body fat and less lean body mass, ie, muscle and bone. With a gain in body weight, which usually occurs, these changes are exaggerated. Because muscle tissue has a much higher metabolic rate than does fat tissue, older individuals generally develop lower metabolic rates. To avoid excess weight gain, older individuals must make major restrictions in caloric intake and increases in energy expenditure. Women experience changes in body composition similar to those in men, with changes becoming more prominent at menopause. Exercise improves body composition among healthy elderly, both by reducing fat mass and by increasing bone and muscle mass, thereby helping to restore higher metabolic rates. In men and women aged >/=65 y and taking calcium and vitamin D supplements for 3 y, the rate of bone loss slowed and the incidence of nonvertebral fractures was reduced. Several population studies of older persons show that following nutritional and lifestyle guidelines for cancer prevention reduces risk by one-third. Improving serum lipid concentrations in adults over 65 y of age with coronary artery disease decreases the risk of future cardiac events by as much as 45%. Furthermore, the greatest benefit from control of hypertension is in older individuals.     

Loss of skeletal muscle mass in aging: examining the relationship of starvation, sarcopenia and cachexia

A loss of body weight or skeletal muscle mass is common in older persons and is a harbinger of poor outcome. Involuntary weight loss can be categorized into three primary etiologies of starvation, sarcopenia, and cachexia. Starvation results in a loss of body fat and non-fat mass due to inadequate intake of protein and energy. Sarcopenia is associated with a reduction in muscle mass and strength occurring with normal aging, associated with a reduction in motor unit number and atrophy of muscle fibers, especially the type IIa fibers. The loss of muscle mass with aging is clinically important because it leads to diminished strength and exercise capacity. Cachexia is widely recognized as severe wasting accompanying disease states such as cancer or immunodeficiency disease, but does not have a universally accepted definition. The key clinical question is whether these changes in body composition are distinct entities or represent an interdependent continuum. The importance of defining the distinction lies in developing a targeted therapeutic approach to skeletal muscle loss and muscle strength in older persons. Failure to distinguish among these causes of skeletal muscle loss often results in frustration over the clinical response to therapeutic interventions.     

Aging and longevity: why knowing the difference is important to nutrition research

Life expectancies after the age of 70 and the number of individuals living with age-related chronic conditions that affect daily activities continue to increase. Age-specific nutritional recommendations may help to decrease the incidence or severity of age-related debilitating chronic disorders. However, research in this area has seen limited success in identifying nutrition-related mechanisms that underlie the functional loss and chronic conditions that occur as a function of time. We believe that the limited success in establishing age-specific nutrition recommendations for the older population reflects, at least in part, research designs that fail to consider the evolutionary and biological bases of aging and longevity. Longevity has evolved as a by-product of genes selected for their contribution in helping the organism survive to the age of reproduction. As such, the principle of genetic determinism provides an appropriate underlying theory for research designs evaluating nutritional factors involved with life span. Aging is not a product of evolution and reflects stochastic and/or random events that most likely begin during the early, reproductively-active years. The genetic determinism model by which young (normal, control) are compared to old (abnormal, experimental) groups will not be effective in identifying underlying mechanisms and nutritional factors that impact aging. The purpose of this commentary is to briefly discuss the difference between aging and longevity and why knowing the difference is important to nutrition research and to establishing the most precise nutritional recommendations possible for the older population.     

Problems of nutritional assessment in the acute setting.

Surveys have shown that 20-50% of hospital admissions suffer from nutritional depletion and that there is failure to recognize its existence and significance. More emphasis must be placed in clinical medicine on identifying subjects who are at high risk of developing disease-related malnutrition. There is a need to screen patients on admission to hospital to identify those at risk of nutrition-related complications. More formal determination of nutritional status should be carried out to define the nutritional status of the patient and to monitor changes in nutritional status during nutritional support. The most frequently used tests of nutritional status include dietary, anthropometric, biochemical and functional indices of nutritional status. It is important, and indeed is the skill of the nutritional care team (particularly the dietitian) to be able to evaluate these measurements, as many of them are affected by non-nutritional factors. There is no consensus on the best method for the accurate assessment of nutritional status. Practical difficulties arise with individual measurements and in their interpretation in the acute setting. The aim of the present paper is to identify the most relevant variables to measure in clinical medicine, and to discuss the limitations of their use in the acute setting.     

Rural and Urban Older African Caregivers Coping With HIV/AIDS are Nutritionally Compromised

This article describes the nutritional status of a group of rural and urban free living African older surrogate parents caring for HIV/AIDS orphans and grandchildren. Multiple sources of data collection were used, including anthropometry, biochemical analyses, and quantitative questionnaires. The diets of these older participants were marginal. The rural to urban geographical transition in these older persons is characterized by a better micronutrient and trace element intake; however, urban dwellers also had higher fat intakes, increasing the risk for cardiovascular disease. These results suggest that to be a surrogate grandparent provides a special meaning to the life of men that needs to be better understood. However, the diets of these older people caring for HIV/AIDS-affected children were more compromised than those of non-caregivers.     

Rural and urban older African caregivers coping with HIV/AIDS are nutritionally compromised

This article describes the nutritional status of a group of rural and urban free living African older surrogate parents caring for HIV/AIDS orphans and grandchildren. Multiple sources of data collection were used, including anthropometry, biochemical analyses, and quantitative questionnaires. The diets of these older participants were marginal. The rural to urban geographical transition in these older persons is characterized by a better micronutrient and trace element intake; however, urban dwellers also had higher fat intakes, increasing the risk for cardiovascular disease. These results suggest that to be a surrogate grandparent provides a special meaning to the life of men that needs to be better understood. However, the diets of these older people caring for HIV/AIDS-affected children were more compromised than those of non-caregivers.     

Nutrition for Older Athletes: Focus on Sex-Differences

Regular physical exercise and a healthy diet are major determinants of a healthy lifespan. Although aging is associated with declining endurance performance and muscle function, these components can favorably be modified by regular physical activity and especially by exercise training at all ages in both sexes. In addition, age-related changes in body composition and metabolism, which affect even highly trained masters athletes, can in part be compensated for by higher exercise metabolic efficiency in active individuals. Accordingly, masters athletes are often considered as a role model for healthy aging and their physical capacities are an impressive example of what is possible in aging individuals. In the present review, we first discuss physiological changes, performance and trainability of older athletes with a focus on sex differences. Second, we describe the most important hormonal alterations occurring during aging pertaining regulation of appetite, glucose homeostasis and energy expenditure and the modulatory role of exercise training. The third part highlights nutritional aspects that may support health and physical performance for older athletes. Key nutrition-related concerns include the need for adequate energy and protein intake for preventing low bone and muscle mass and a higher demand for specific nutrients (e.g., vitamin D and probiotics) that may reduce the infection burden in masters athletes. Fourth, we present important research findings on the association between exercise, nutrition and the microbiota, which represents a rapidly developing field in sports nutrition.     

Facilitated feeding in disabled elderly

Nutrition and health are major concerns to older individuals. Whereas illness associated with overnutrition has been well characterized, poor health associated with undernutrition has received less attention. Malnutrition continues to plague the elderly in developed and underdeveloped countries alike, and is becoming of more concern as global demographic changes predict increasing proportions of elderly in all societies. Nutrition influences many chronic disease processes affecting older individuals. In addition, changes in physiology, metabolism, and function accompanying aging result in altered nutritional requirements. The enhancement and maintenance of health and function are now more possible with the new knowledge of nutritional needs in old age. Designing nutritional therapy to treat malnutrition associated with illness in older patients requires an understanding of the aging processes, a careful setting of treatment goals, and multidisciplinary collaboration.     

Anthropometric measurements as indicators of nutritional status of the elderly

This review contains details on anthropometric measurements required for assessment of nutritional status in the elderly. These measurements provide indicators of fat tissue content or body composition and evaluate trends in nutritional status. Anthropometric measurements in the elderly are similar to these in other groups of population but they have to be adopted according to changes in constitution and posture of elderly and disabled people. The following measurements are presented: stature, weight, skinfold thickness and mid upper-arm, waist and hip circumferences. Derived measurements and indices of nutritional status are also discussed.     

Effects of dietary supplements on depressive symptoms in older patients: a randomised double-blind placebo-controlled trial

BACKGROUND & AIMS: The effect of nutritional supplements on mental health in older patients has received little attention so far. The aims of this trial were therefore to test the effect of nutritional support on older patient's depressive symptoms and cognitive function. METHODS: In this prospective, double-blind, placebo-controlled study, we randomly assigned 225 hospitalised acutely ill older patients to receive either normal hospital diet plus 400 mL oral nutritional supplements (106 subjects) or normal hospital diet plus a placebo (119 subjects) daily for 6 weeks. The composition of the supplement was such as to provide 995 kcal for energy and 100% of the Reference Nutrient Intakes for a healthy old person for vitamins and minerals. Outcome measures were 6 weeks and 6 months changes in nutritional status, depressive symptoms and cognitive state. RESULTS: Randomisation to the supplement group led to a significant increase in red-cell folate and plasma vitamin B12 concentrations, in contrast to a decrease seen in the placebo group. There were significant differences in symptoms of depression scores in the supplement group compared with the placebo group at 6 months (p = 0.021 for between groups difference). The effect of supplement was seen in all patient groups including those with no symptoms of depression, mild depression and those with severe depression (p = 0.007). There was no evidence of a difference in cognitive function scores at 6 months. CONCLUSION: Oral nutritional supplementation of hospitalised acutely ill older patients led to a statistically significant benefit on depressive symptoms.     

The relationship between delayed hypersensitivity response, nutritional status and clinical outcome in surgical patients referred for nutritional support

Delayed hypersensitivity responses to recall antigens were measured in 125 surgical patients referred for nutritional assessment and support. On initial testing 57 patients were skin test positive and 68 were anergic each of these patient groups being closely matched in terms of surgical conditions. There was a mortality of 4 in the skin test positive group and 26 in the anergic group. The anergic patients were significantly older and in biochemical and anthropometric terms were in poorer nutritional status than the skin test positive group. Of 33 anergic patients who were repeat tested, 15 remained anergic and 18 converted to a positive response. Conversion from anergy to a positive response was not associated with changes in the measured indices of nutritional status and did not improve clinical outcome. The value of repeat skin testing is therefore in doubt.     

Nutrition et insuffisance rénale chronique de l'enfant

The nutritional management of the uremic child depends on the residual glomerular filtration rate. When it has dropped to 25% of the normal range, one can observe decreased growth velocity, anemia, hyperparathyroidism, poor tolerance to changes in water and sodium intake and anorexia. The assessment of the nutritional status is based on anthropometric measurements by using standard deviation scores — i.e. body weight, height, growth velocity, head circumference and skinfold thickness —, on some biochemical parameter — i.e. serum proteins, calcium, phosphorus, parathyroid hormone and urea: creatinine ratio — and sometimes on biophysical methods (dual energy X ray absorptiometry). The current nutritional practices of the uremic child are less restrictive than in adults due to energy and protein requirements for both cerebral maturation and statural growth. Such uremic children should therefore be fed according to recommended dietary allowances, that often require tube feeding in infants. In addition to diet, some other treatments have a nutritional impact, like recombinant human growth hormone and erythropoietin. Such strategies should be adapted to the type of treatment — i.e. conservative, transplantation, haemodialysis, peritoneal dialysis.     

Nutritional status of a brain-injured population in a long-stay rehabilitation unit: a pilot study

Background: Studies elsewhere have shown a high incidence of malnutrition in brain-injured people and in in-patient populations. Objectives: To investigate the incidence of malnutrition in long-term rehabilitation at the National Centre for Brain Injury Rehabilitation and to evaluate the usefulness of a range of measures of nutritional status. Methods: All (n=33) patients were invited to participate. Anthropometric, dietary, haematological and biochemical measurements were made. Result: The incidence of malnutrition was nil. The incidence of obesity was comparable to the ‘normal’ population. Subjects consumed a nutritionally adequate diet, except for NSP (fibre). Conclusion: The result was not only better than that of other therapeutic communities, it was better than the ‘normal’ population. Useful tools for assessment of nutritional status were found to be BMI, arm anthropometry, biochemistry, haematology and food diaries. Further study of the nutritional status of all admissions will identify the changes which can occur during long-term rehabilitation.