Undernourishment in the
Elderly: Part I
(4/15/21)- The three Covid recovery packages included
substantial increases in funding for the Older Americans Act which supports
both group meals and individual meals programs such as Meals on Wheels.
The recently
passes stimulus package, known as the American Rescue Plan contains an
additional $750 million, which brings the total increase to $1.6 billion.
A 15% increase for everyone who
qualifies for food stamps, known as the Supplemental Nutritional Assistance
Program, will benefit an estimated 5.4 million individuals.
(6/11/15)- Studies and Reports
We received the following e-mail
from Roseanna Wheeler, for which we thank her for taking the time to correct
our error, and point out the site she is associated with: We apologize to her
for erroneously sending her a wrong e-mail. Take a look at her site, and decide
for yourself:
“ Roseanna Wheeler <info@
Hi Harold,
I do research for Katom.com, a website on
food equipment, and the
commercial food industry.. My name is Roseanna Wheeler.
I am
trying to get a hold of the person responsible for the above page.
There is a link on the page with the anchor text:
http://www.
We have worked very hard to put together a
complete resource on the USDA's My Plate that we think is now the best
on the internet.
https://www.katom.com/
It
contains everything from technical understanding of My Plate, a historical
comparison of past USDA recommended programs including the Food Pyramid,
commentary and analysis of the programs, and we believe is the
best starting point on the internet for research
in this area.
We are updating it
regularly to keep it very current.
I would
love you to consider placing a link on your page to
https://www.katom.com/
Many food
professionals, researchers and families could be helped by having this
info.
Thank You
So Much!
Roseanna Wheeler
info@restaurantsupplyresearch.
2248 Meridian Blvd.,
Suite H
Minden NV 89423 “
The following is the old item that Roseanna Wheeler was
referring to with an broken link that, thanks to her, has been deleted-
“According to a report on Nursing Home Residents Legal Center web site:
"Government statistics show that 47% of residents in nursing homes need
assistance with eating. 21% of the residents are completely dependent
for help." The University of Oklahoma Health Sciences Center report by Dr.
Sayed Rahman states "Studies of hospitalized elderly have confirmed that a
loss of 10% of body weight is associated with increased mortality while a
period of stable weight strongly suggests that a 6 month
survival is probable." McWhirter et. al. found that, in the United
Kingdom, the prevalence of undernourishment on admission to hospital is 40%. A
UC San Francisco study of nursing home residents with eating problems found
that inadequate staffing, lack of attention to food preferences and medical
problems all were factors in why people weren't eating”
General Information
(7/15/05)- The US Department of Health and Human
Services (HHS) has released the "Dietary Guidelines for Americans
2005", which promotes healthy habits and reducing the risk of chronic
disease through nutrition and physical activity. The guidelines and brochure
are available on line at http://www.health.gov/dietaryguidelines Thanks to Kelly Coleman for emailing us with
the corrected address:
(4/30/02)Undernutrition, due to
insufficient intake of food or lack of quality of food eaten, is a not uncommon
problem in the elderly. This is not to be confused with reduced calorie intake
that some studies associate with prolonging life.
Undernourishment is a serious,
potentially life-threatening situation in the elderly. The figures, according
to Silver, range from 5% to 12% of the community dwelling elderly, 30% to 61%
of hospitalized elderly, and 40% to 85% in those living in long-term care
institutions. When using a figure of ten percent underweight from the
Metropolitan Life Insurance index of weights, individuals over 75 show a 40%
rate of underweight.
Calle and colleagues, in a
study reported in the NEJM, showed that the lower the body mass index (BMI),
the greater the mortality rate. This has to be balanced with the concept that
studies of older adults have shown that a physiological change causing a linear
decrease in food intake occurs with increasing age. (Morley JE. Anorexia in
Aging: physiologic and pathogenic. Am J Clin Nut 1997; 66:
760-773.)
Introduction
The contributors to underweight
causes are multifactorial. This article will not explore the socio-economic
factors that may contribute to this problem. Well–developed (first world)
nations appear to have some fail-safe programs for elderly in need to get food i. e. meals on wheels, senior center feeding programs, food
stamps etc.
These programs have qualifying
standards/procedures that may scare off elderly people eligible for the
programs. There have been no reports of emergency rooms swamped with
individuals who show extreme symptoms of starvation, despite occasional reports
of elderly eating dog or cat food or "starving" children/adults that
may be due to specific situations. There are frequent reports of elderly who are
undernourished as result of medical conditions, dementia or other confused
states. This article will look at the medical causes of undernourishment and
attempt to show what the medical research literature is trying to do about this
condition.
Studies and Reports
We
received the following e-mail from Roseanna Wheeler, for which we thank her for
taking the time to correct our error, and point out the site she is associated
with:
“ Roseanna Wheeler <info@
Hi Harold,
I do
research for Katom.com, a website on food equipment, and the commercial food industry.. My name is
Roseanna Wheeler.
I am
trying to get a hold of the person responsible for the above page.
There is a link on the page with the anchor text:
http://www.
We have
worked very hard to put together a complete resource on the USDA's My
Plate that we think is now the best on the internet.
https://www.katom.com/
It
contains everything from technical understanding of My Plate, a historical
comparison of past USDA recommended programs including the Food Pyramid,
commentary and analysis of the programs, and we believe is the
best starting point on the internet for research
in this area.
We are
updating it regularly to keep it very current.
I would
love you to consider placing a link on your page to
https://www.katom.com/
Many food
professionals, researchers and families could be helped by having this
info.
Thank You
So Much!
Roseanna Wheeler
info@restaurantsupplyresearch.
2248
Meridian Blvd., Suite H
Minden NV 89423 “
According to a report on Nursing Home Residents Legal Center
web site (http://www.nursinghomeabuseresourcecenter.com/injured/malnutrition)
"Government statistics show that 47% of residents in nursing homes need
assistance with eating. 21% of the residents are completely dependent for
help." The University of Oklahoma Health Sciences Center report by Dr.
Sayed Rahman states "Studies of hospitalized elderly have confirmed that a
loss of 10% of body weight is associated with increased mortality while a
period of stable weight strongly suggests that a 6 month
survival is probable." McWhirter et. al. found that, in the United
Kingdom, the prevalence of undernourishment on admission to hospital is 40%. A
UC San Francisco study of nursing home residents with eating problems found
that inadequate staffing, lack of attention to food preferences and medical
problems all were factors in why people weren't eating.
Undernourishment and
Federal Action
The federal Department of
Health and Human Services in 1999 instituted new guidelines that dictate how
nursing home investigators should evaluate weight loss, malnutrition
and dehydration. They must review nursing home records (which must include any
weight loss of 5% within 30 days or 10% within six months), interview health
professionals and family members and personally observe at least two meals.
UCLA aging researchers have found in several related studies that about seven
out of 10 nursing home residents fail to finish 75% of their food--the federal
government's yardstick for measuring the risk of malnutrition. Caretakers or
family members can ask to see "care plans" for the resident which are
supposed to deal with any weight loss and also have
staff check the weight of the resident of nursing homes.
Nursing Home Record
Keeping and Undernourishment
Although nursing homes are
required to keep records of how much residents eat and drink and to track their
weight, it is difficult for researchers to determine how often inadequate food
and fluids play a role in their deaths. Death certificates rarely cite
dehydration or excessive weight loss. Tracking of amount eaten is a very
difficult task. In my over four years of visiting nursing homes, from New
England, Florida, and in the Southwest, I spent extended time with residents at
lunch and dinnertime.
I never saw anyone weigh the
food left over, nor continually observing the amount eaten on a consistent
basis unless a loved one specifically requested that this be don. Dieticians do spend time in the dining room and observe
the amount eaten by a resident. They often have to observe a number of people
and do not see residents exchange food, or spill food on to other trays or on
the floor, so the accuracy of their observations is highly questionable.
While nursing assistants
typically feed from five to 20 people in about an hour, UCLA researchers found
that it takes an average of 40 minutes for just one nursing home resident to
finish a meal. The typical scene in a nursing home is a resident waiting at
their table for extended periods of time to get their meals, being asked to eat
quickly and then ushered out of the dining room before completing the meal.
Some learn to eat quickly or pocket fruit, crackers etc. to be taken back to
their room. Most never finish their meal, nor completely drink the nutritional
supplement ordered by the dietician.
Nursing professor Jeanie Kayser-Jones of UCSF observed 100 residents of nursing
homes in the Pacific Northwest. Among her observations:
--"Nursing
home workers often were so rushed that they "shoveled" food into
residents' mouths, causing choking and coughing.
--The food,
while healthful, was sometimes served in unappetizing form: doled out in
indistinguishable scoopfuls or pureed and mixed into a glass of milk.
--Food trays
often were untouched by residents, and nutritional supplements weren't
consumed.
--Nurse
assistants placed water pitchers out of reach or failed to open drink
containers for residents with arthritic hands.
--Only one of
40 residents whose food and fluid intake she analyzed received the minimum
fluid requirement (at least six glasses daily).
--Some
residents went without liquids for as long as 24 hours, (according to Kayser-Jones), and some nursing assistants avoided giving
liquids to incontinent residents so that they wouldn't have to change clothes
and bedding as often."
Under these conditions, it is
not hard to see that undernourishment can be a big problem.
Further Studies
Simply providing three square
meals a day to an elderly resident doesn't mean the meals are eaten. That's
because the reasons someone won't eat can be complex. UCLA aging researchers
have found in several related studies that about seven out of 10 nursing home
residents fail to finish 75% of their food--the federal government's yardstick
for measuring the risk of malnutrition.
The researchers from UCLA's Borun Center on Aging tried to encourage poor eaters by
sitting with them at meals for extended periods over several days. Sometimes
they would even place the food on a fork for the nursing home residents. Even
so, only about half ate more than they had before, said Sandra Simmons, lead
author of a study on feeding assistance. "The picture is more complex than
people think," Simmons said.
The findings suggest that
inadequate staffing or poor quality care are not the only explanations for why
some elderly patients won't eat, said Jack Schnelle,
the Borun Center's director. Even when the staff uses
charm or persuasion to get older patients to eat, sometimes people "just
don't want the food." This symptom needs to be addressed by the staff in a
different manner than is in operation at this time. Specific intervention
techniques would seem in order that can target this issue. It would call for a
multidisciplinary approach because of the multifactorial nature of the problem,
not just making nutritional adjustments to the individual’s diet or ordering
some nutrient supplement to be taken by the resident.
Rahman in his study of
ambulatory geriatric patients (mean age of 76.8 years), concluded that
"Undernourished seniors had the following characteristics: they were more
likely to be female, be depressed, have lower educational levels, did not wear
dentures, received no help in meal preparation, were taking a large number of
medications and were less likely to follow up with medical care.
There was also a significant
correlation of decreased functional and mental status with undernourishment and
lower scores on the General and Perceived Health Scales of the Duke Health
Profile." What he did not mention was that the aging process itself can
dull one's sense of taste or hunger.
Other reasons for
undernourishment include illness and disability as well as a dislike of
institutional food. At greatest risk are frail seniors who must take multiple
medications daily--some known to be appetite-killers (see below). These people
tend to have trouble seeing, hearing and tasting, as well as swallowing and
chewing. They are vulnerable to depression and prone to forgetfulness and declining
mobility. About half of them have dementia, which requires extra care during
mealtime. Introduction of an eating specialist may preempt this problem and
save lives.
The range of nutritional
deficiency is broad with an apparent lack of large national studies and no
consensus on what health measures should be used. Based on observation, no
matter the measure, the problem exists even at some of the "best"--or
costliest--facilities
Depression and
Undernourishment
Medically, a major symptom of
depression is weight loss. Wilson and his group reported that 30% of older
medical outpatients had depression and weight loss. Morley et. al.'s study
indicated that depression is the most common cause of weight loss in nursing
home residents. Depression is a treatable disease, and successful treatment has
resulted in weight gain. However, first-onset depression in the elderly may be
more complicated etiologically than the general population depression. Gastointestinal hormones, especially cholecystokinin (CCK),
gastrin-releasing peptide and somatostatin, regulate how satiated an individual
feels when eating. Monitoring of some of these levels could be a red light for
undernourishment and could be followed with appropriate treatment, not only of
the depression but the elevated levels of the hormone.
Medication and
Undernourishment
Many of the medications
commonly prescribed to residents of nursing homes have adverse effects related
to anorexia. The following list can be used as a guideline to monitor potential
undereating. It is taken from a number of sources including ASCP Report, Guide
to Preferred Drugs in Long Term Care, RxList and
Clinical Pharmacology OnLine. Not all individuals
taking these medications will have the adverse effect. A difficulty with the
elderly is that many are taking multi-medications and they may have synergistic
effects resulting in killing of appetite. Medical staff needs to be consulted,
looking at the entire spectrum of reasons for weight loss and give weight to
the potential negative effect that these medications can have on nourishment..
Potential Adverse Drug
Effects on Nourishment
|
Generic
Name |
Brand
Name |
|
Amlodipine |
Norvasc |
|
Ciprofloxacin |
Cipro |
|
Cisapride |
Propulsid |
|
Conjugated estrogen |
Premarin |
|
Digoxin |
Lanoxin |
|
Enalapril maleate |
Vasotec |
|
Famotidine |
Pepcid |
|
Fentanyl transderm |
Duragesic |
|
Furosamide |
Lasix |
|
Ipratropium bromide |
Atrovent |
|
Levothyroxine sodium |
Synthroid |
|
Narcotic analgesic |
Propacet |
|
Nifedipine |
Procardia XL |
|
Nizatidine |
Axid |
|
Omerprazole |
Prilosec |
|
Paroxetine |
Paxil |
|
Phenytoin |
Dilantin |
|
Potassium replacement |
K-Dur |
|
Ranitidine HCL |
Zantac |
|
Sertraline HCL |
Zoloft |
|
Warfarin |
Coumadine |
Infections and
Undernourishment
Two common infections in the
elderly are upper respiratory infections (URIs) and urinary tract infections
(UTIs). According to Rudman and Fellar, 15% to 20% of
older persons suffer undernourishment due to both acute and chronic infections.
This may be due to a negative nitrogen balance.
A positive nitrogen balance
assures that the amount of protein being administered is sufficient to cover
the losses of endogenous protein occurring secondary to catabolism. Once
positive balance is achieved, protein replacement has been optimized. The urinary
urea nitrogen test is used to determine a patient's nitrogen balance.
If the urinary nitrogen balance is positive, the patient is ingesting
sufficient protein and nitrogen is excreted in the urine.
A urinary urea nitrogen value less
than zero indicates a negative nitrogen balance, which is an indication that
the patient needs a higher protein intake. When urinary urea nitrogen and
nitrogen balance are assessed, the dietician does a protein intake assessment
and the nurse is responsible for accurately recording all food intakes during
the 24 hours of the test period.
Normal urinary urea nitrogen
ranges between 6 and 17 gm in a 24-hour period. The value or urea nitrogen then
can alert the staff to a potential undernourishment problem. Measures to
counteract this undernourishment can be initiated to prevent serious medical
problems. The difficulty arises when the patient refuses to eat and someone
must spend time cajoling the patient to eat. Food, especially the kind given on
special diets can be bland and monotonous, especially when fat is left out.
Combine this with alteration in taste that happens as we get older and one can
see the magnitude of this problem. Undernourishment may be a consequence of the
treatment.
Cancer and Undernourishment
Cancer and its treatment are
the most obvious reason for weight loss. Anorexia is defined as a lack or severe loss of appetite. Many cancer patients develop
anorexia as a result of their disease process or as a result of a specific
treatment for their disease. Many cancer patients experience overwhelming
fatigue, lassitude, and generalized weakness (asthenia).
Again, like anorexia, this can
be due to the disease itself, or secondary to treatment such as radiation,
medicines, or chemotherapy. The actual state of malnutrition and wasting that
results from anorexia is called cachexia. Decrease in body weight is
characterized by significant loss of both adipose tissue and muscle mass that
makes weight gain especially difficult for patients with progressive cancer.
Cachexia can also be related to the disease itself or the effects of treatment.
Treatment of this situation is
problematic. Nutritional counseling is of course recommended and usually
consists of eating frequently, small meals, avoiding spicy foods, eat more in
the morning, avoid cooking aromas etc. Certain appetite stimulants may be
prescribed, but many have their side effects when chronically administered.
Examples of these stimulants
include progestational agents (megestrol acetate, medr-oxygesterone), corticosteroids (dexamethasone), and
such unproven drugs as dronbinol (Marinol),
branched-chain amino acids, metoclopramide and eicosapentaenoic
acid. The literature is replete with pilot studies of helpful drugs for
cachexia and hopefully new information will come available to deal with this
life-threatening symptom.
Presently, as we understand the
literature, no drug has long-term positive effects on this symptom, though they
may provide temporary relief. However, they appear reasonable to try. The
question remains whether a person can be "forced " to eat and also the indications that in cancer the nutrients may
provide stimulus for cancer growth compound the solution for this condition.
Dementia and
Undernourishment
In dementia, the individual may
not recognize the need to eat. Also, there is a symptom called apraxia for
swallowing, where the demented individual needs to be reminded to swallow when
eating. There are reports in the literature, without any scientific
corroboration, that Alzheimer’s disease patients have a faster metabolism,
which could contribute to undernourishment. These factors make it essential to
monitor weigh in demented patients.
Treatment of various symptoms
may help deal with the undernourishment i. e.
depression. Meal times need to be free of extraneous stimulation, regularly
scheduled, and need to last longer than the normal time spent eating. It takes
a lot of patience on the part of the caretaker, as well as creative approaches,
similar to child feeding to deal with this issue in demented patients.
Clinical Evaluations of
Protein-Caloric Undernourishment
When evaluating for protein-caloric
undernourishment, the physician looks for a number of signs as clues for a
diagnosis. The obvious clue is loss of weight. Other signs are muscle wasting
including temporalis muscle, calf muscle and the muscle between thumb and index
finger. Further indication would include subcutaneous loss of fat, sparse, dull
hair, orthostasis, edema, poor wound healing, decreased food intake, weak
cough, decreased grip strength, change in pallor, parotidmegaly,
and cognitive impairment. Biochemical tests are not specific in identifying
undernutrition.
Galanos et. al. suggest use of BMI (weight in kilograms divided by height in
meters squared) as an indicator of nutritional and mortality risk. The
suggested numbers are BMI below 19 in men and below 19.4 in women as a
definition of undernutrition. (In the study by Rahman mentioned above, a BMI of
less than 22 was used.)
We understand that some
physicians use a graded assessment to diagnose undernourishment. It may prove
helpful that this become a standard part of any evaluation of individuals in
nursing homes. The graded assessment is a gross measure and it is probable that
some action needs to be taken when rating is at grade B or grade C.
Grade A: minimal or no changes in food intake,
improving body weight and minimal change in function
Grade B: There is evidence of food restriction
and functional changes but minimal weight change.
Grade C: There are changes in dietary intake
and body mass (greater than 10% weight change over last 6 months) and poor
functional status.
White et al reported on a
nutrition screening initiative, which is felt to predict individuals at risk
for developing undernourishment. See J Am Diet Assoc. 1992; 92:163 for further
explanation of this screening device.
Recently, the American Dietetic
Association has introduced a Nutrition Screening Instrument (NSI) developed by
37 expert consensus panel that is undergoing research evaluation.
Please also see: Proper Nutrition and the Elderly-Part II
REFERENCES
- Dwyer
J., Gallo J., Reichel W. Assessing nutritional status in elderly patients.
American Family Physician 1993; 47:614.
- Galanos
AN, Pieper CF, Kussin PS, et al Relationship of body
mass index to subsequent mortality among seriously ill hospitalized
patients. Crit Care Med 1997; 25:1962.
- University
of Oklahoma Science Center, Oklahoma City, OK report of study by Rahman, Sayad. Impaired Nutritional Status in Geriatric
Population. No date.
- McWhirter
J., Pennington C. Incidence and recognition of malnutrition in hospital.
BJM 1994; 308:
- Rudman
D., Fellar AG. Protein-calorie undernutrition in
nursing home. J Am Geriatr Soc 1989; 37:173.
- Silver
AJ. Malnutrition. In: Beck JC, ed. Geriatrics Review Syllabus. A Core
Curriculum in Geriatric Medicine. Book1/Syllabus and Questions. New York:
American Geriatrics Society, 1991
- Thomas
DR., Morley JE. Nutritional Assessment and Indicators of Undernutrition in
the Elderly. Resident & Staff Physician. 2002; 48:47-55.
- White
JV., Dwyer JT., Posner BM et al. Nutrition screening initiative:
development and implementation of the public awareness checklist and
screening tools. J Am Diet Assoc. 1992; 92:163
FOR AN INFORMATIVE AND
PERSONAL ARTICLE ON PRACTICAL SUGGESTIONS WHEN SELECTING A NURSING HOME SEE OUR
ARTICLE
"How to Select a Nursing Home"
by Harold Rubin, MS, ABD, CRC,
Guest Lecturer
updated April 15, 2021
e-mail: harold.rubin255@gmail.com or allanrubin4@gmail.com
.