Jurnal Nutrisi 4
Jurnal Nutrisi 4
Jurnal Nutrisi 4
Matthias Pirlich MD
Assistant Professor
Herbert Lochs* MD
Professor, Head of Department
UniversitaÈtsklinikum ChariteÂ, Medizinische Klinik mit Schwerpunkt Gastroenterologie, Hepatologie und
Endokrinologie, Schumannstraûe 20/21, D-10117 Berlin, Germany
Malnutrition is more common in elderly persons than in younger adults. Ageing itself,
however, neither leads to malabsorption nor to malnutrition with the exception of a higher
frequency of atrophic gastritis in older persons. Malnutrition in elderly people is therefore a
consequence of somatic, psychic or social problems. Typical causes are chewing or swallowing
disorders, cardiac insuciency, depression, social deprivation and loneliness. Undernutrition
is associated with a worse prognosis and is an independent risk factor for morbidity and
mortality. Awareness of this problem is therefore important. For the evaluation of nutritional
status, it must be remembered that most normal values are derived from younger adults and
may not necessarily be suitable for elderly persons. Suitable tools for evaluating the nutritional
status of elderly persons are e.g. the body mass index, weight loss within the last 6 months,
the Mini Nutritional Assessment (MNA) or the Subjective Global Assessment (SGA). An
improvement in the nutritional status can be achieved by simple methods such as the
preparation of an adequate diet, hand feeding, additional sip feeding or enteral nutrition.
Key words: malnutrition; ageing; enteral nutrition; nutritional status; nutritional assessment.
INTRODUCTION
*All correspondence to: Prof. Dr. med. Herbert Lochs. Tel: 49 30 450 514 102; Fax: 49 30 450 514
923; E-mail: [email protected]
1521±6918/01/06086916 $35.00/00 *
c 2001 Harcourt Publishers Ltd.
870 M. Pirlich & H. Lochs
PREVALENCE OF UNDERNUTRITION
(e.g. excessive alcohol intake). In the following sections, we will focus on undernutrition
as the most prevalent state of malnutrition in the elderly.
The prevalence data on undernutrition in the geriatric population show a wide
range between dierent investigators depending on the population selected, the
institutional setting and the diagnostic criteria used for the de®nition. De®ning
undernutrition in the elderly poses speci®c problems, since the normal range of
nutritional parameters has usually been derived from values for younger adults. In
many instances it is dicult or impossible to distinguish whether a certain deviation
from this normal range, such as a reduction in body water, muscle mass, vitamin levels
or trace element levels, is a physiological phenomenon that occurs with age or a sign of
undernutrition. These considerations are also relevant for therapeutic strategies, since
it might not be desirable to treat an 80 year old patient so that their nutritional
parameters return to the levels of a 20 year old person.
Some authors have concluded that ageing itself does not aect nutritional status, but
that undernutrition in the elderly always re¯ects certain physical or social conditions
such as the inability to chew, poverty, or loneliness.1 If one accepts this approach, then
therapeutic consequences would always be warranted if undernutrition is diagnosed.
Other studies have correlated the deviation of certain nutritional parameters with
the prognosis of the patients and have concluded that undernutrition is a meaningful
term only if it is associated with a deterioration in prognosis.
Due to these uncertainities a number of investigations have dealt with the problem
of establishing nutritional parameters for the elderly.9±11 In the following sections
dierent methods for evaluating the nutritional state of the elderly and its relevance to
their prognosis will be discussed.
According to the general clinical evaluation of patients, one can distinguish two
main approaches for assessing the nutritional state: history-taking/observation and
physical or apparative examination.
History
The history regarding recent weight loss, chewing or swallowing diculties, physical
disability, mental confusion and drug regimens can provide important information on
the risk for undernutrition.1,4 Quantifying the nutritional intake can be carried out by
dierent methods and is best performed by a trained dietician.
24-hour recall
This is a commonly used method and is based on an interview, during which the
patient is asked to recall all of the food consumed over the previous 24 hours. As for
all dietary data the answers are prone to inaccuracy depending on the interviewer's
skills and the patient's memory, and the 24-hour recall cannot be used in persons with
dementia. Moreover, this approach has the disadvantage that data obtained from one
single day might not be representative of the patient's typical nutritional habits.
Food records
The patient is asked to record all of the foods and beverages consumed in terms of type
and amount for a period of time, usually 7 days. This approach is less in¯uenced by any
day-to-day variation in the dietary intake and is also less dependent on the patient's
872 M. Pirlich & H. Lochs
memory. However, food records might be invalid if the patient's notes are unreliable or
if the food intake is underestimated, as has been reported in obese subjects.12
Diet History
This is also not a practical screening method, since it is based on a very detailed and
time-consuming interview, with open-ended questions which should be administered
by a highly trained dietician.4
All of these methods are limited in the detection of small changes, which might
already be clinically important.
Physical examination
There are a large number of clinical signs that indicate nutritional de®ciencies (for an
excellent review see Omran & Morley.4 The general impression (wasted, thin),
alterations of the skin (dry, scaly, poor wound healing), the hair (thin, pluckability), the
nails (spooning, depigmentation), the eyes (night blindness, conjunctivitis), the mouth
(glossitis, bleeding gums) and the extremities (bone tenderness, joint pain, muscle
wasting, oedema) can be suggestive for protein±caloric undernutrition or de®ciencies
of vitamins, minerals and trace elements. However, the recognition of nutrient
de®ciencies is dependent on the examiner's awareness or the skills to see the link
between clinical signs and possible nutrient problems. There are several studies that
have reported an underestimation of nutritional problems by hospital sta, suggesting
that they need a better education in nutrition.18,19
Anthropometry
The basic anthropometric data of body weight and height are essential for each
nutritional assessment. Body weight can be compared with an ideal weight for height.
The body mass index (BMI weight/height2) allows for an approximate determination
of undernutrition and overnutrition. In a recent study on 532 patients with a mean age
of 81 years, a low BMI (420 kg/m2) was associated with an increased 1 year
mortality.20 However, in patients with ¯uid overload, the body weight or BMI might
be normal although a signi®cant loss of the whole body protein content (i.e. muscle
mass or body cell mass) may already be present.21 Thus, if a patient is suspected of
undernutrition and has a normal body weight, a further assessment is necessary.
Mid-arm circumference (MAC) and triceps skinfold thickness (TSF) provide a crude
measure of fat stores and muscle mass and are especially suitable for those patients
who cannot be weighed. MAC and TSF can also be used to calculate the mid-arm
muscle circumference and the mid-arm muscle area, which serve as more sensitive
indicators of muscle mass.4 The most commonly used standards for MAC and TSF are
those reported by Gurney & Jellie22 and Frisancho.23 However, these normal values
were obtained almost 30 years ago, and several studies have demonstrated that 20±30%
of healthy control subjects would be considered malnourished on the basis of these
standards.13 Nevertheless, a TSF of 55% has been shown to be a good predictor of
worse outcome in elderly people.24
Creatinine approach
The measurement of the 24-hour urinary creatinine excretion provides an index of lean
body or skeletal muscle mass25 and has been frequently used in clinical studies. The
method is based on two assumptions: (1) that creatine is found almost totally within the
skeletal and smooth muscle at a constant concentration per kilogram of muscle and (2)
that creatine is converted irreversibly to creatinine at a constant daily rate. However,
the accuracy of this method is limited by a high day-to-day variation, partly due to the
diculty of obtaining correct urine collections, which has been found to be about 12% in
non-geriatric patients.26 A complete urine collection might be even more dicult in
geriatric patients. Moreover, reduced renal function can cause a disproportionately low
urinary creatinine excretion level.26 Thus, the creatinine approach is probably more
suitable for groups of patients than for an individual nutritional assessment.
Laboratory tests
Serum albumin concentration is often considered to be a determinant of the nutritional
status, because protein±energy undernutrition causes a decrease in albumin synthesis.
Moreover, hypoalbuminaemia has been shown to be a good indicator for poor outcome
in a number of dierent clinical situations such as renal insuciency30, HIV-infection27,
stroke31 or in the critically ill patient.32 However, in sick patients there are several
causes of low serum albumin level, independent of undernutrition: albumin loss through
the gut is a frequent feature of gastrointestinal and some cardiac diseases; a decreased
albumin synthesis is observed in chronic liver disease or chronic in¯ammation; burns,
wounds and peritonitis cause albumin losses from the injured surfaces. The large
exchange between intravascular and extravascular albumin is increased in critically ill
patients due to the increased vascular permeability. In this situation the nutritional
in¯uence on serum albumin level is almost negligible. Therefore, in most clinical
situations albumin can not be considered to be a marker of undernutrition, but is
primarily a marker of organ dysfunction. Nevertheless, albumin is an important
parameter for the assessment of the clinical outcome and the severity of the disease and
should be part of each clinical assessment.
Serum proteins with a shorter half-life, such as prealbumin, transferrin or retinol-
binding protein are thought to give information on short-term changes in protein
intake. However, their clinical relevance in the elderly has not been adequately
investigated.
Total lymphocyte count is dependent on vitamin B12, folate or nicotinamide and can
be used to measure past nutrient de®ciency up to 2 months after therapy.33 A
lymphocyte count of 51500/mm3 is considered to be an indicator of undernutrition
and has been shown to identify patients at risk for poor outcome. Values of 5900/
mm3 are suggestive for severe malnutrition.34 Among micronutrients, de®ciencies in
iron and zinc levels are observed in up to 60% of geriatric patients34, as a result of low
meat intake. Measurement of serum electrolytes should be obligatory in all geriatric
patients. In the sick or undernourished patient, determination of vitamin status and
folic acid should be considered.
Screening tools
Since these multiple methods are not practical in the clinical suituation, screening tools
have been developed.
Commonly used screening tools for nutritional assessment are summarized in
Table 1. These scores are based on a combination of dierent parameters obtained
from history, subjective assessment, clinical examination, anthropometry or laboratory
tests, and are thought to be more sensitive than the use of isolated parameters.
Table 1. Clinical indices for classi®cation of undernutrition.
The MNA and the SCALES criteria were specially developed for geriatric patients.
Nutrition in the Elderly 875
876 M. Pirlich & H. Lochs
The Mini Nutritional Assessment (MNA) and the Malnutrition Risk Scale (SCALES)
were specially designed for geriatric patients and are highly correlated with each
other.4 The MNA test is composed of 18 items and can be performed in less than
15 minutes.4 The MNA has been shown to predict morbidity and mortality in a study
on an elderly Danish population.11 The SCALES test requires laboratory assessment of
serum cholesterol and albumin concentrations, but if these data are available SCALES
also takes only a few minutes to perform. The subjective Global Assessment (SGA)
relies primarily on physical signs of undernutrition and the patient's history and does
not incorporate any laboratory ®ndings.36 The SGA is probably the simplest screening
tool for undernutrition, requiring only a few minutes by a trained clinician. The SGA
has also been shown to be reliable in elderly outpatients.39
For clinical purposes the following diagnostic procedures are recommended for
evaluating the nutritional status in elderly patients:
. History: weight loss (410%/6 months); chewing or swallowing diculties, physical
disability, mental confusion, drug regimen, alcohol consumption, social environment,
gastrointestinal symptoms.
. Anthropometry: body weight and height; body mass index (520 kg/m2).
. Laboratory vitamins: albumin (53.5 g/l); iron, calcium, phosphorus, zinc, selenium,
B12, B1, B6, D, folic acid (below normal values).
. Screening tools: SGA or MNA.
Increasing age is not necessarily associated with an impaired nutritional health status.
However, age-related medical, psychological, social and economic problems increase
the likelihood of a poor nutritional state.40,41 Risk factors for undernutrition were
analysed by Volkert42 in 300 geriatric patients, and the results were compared with
those from 50 healthy elderly (Table 2).
age. The associated reduced acid secretion enhances the risk of bacterial overgrowth in
the small bowel and impairs the solubility and bioavailability of calcium, iron, folate,
vitamin B6 and protein-bound vitamin B12.46,47 Nevertheless, gastritis, oesophagitis and
ulcer disease may be underestimated in the elderly, because dyspeptic complaints are
less frequent in these persons.48 Like many other malignancies, the incidence of
gastrointestinal tumours increases with increasing age. Gastric and colorectal cancer
not only decrease the oral food intake because of obstruction or loss of appetite, but
can also impair digestion and absorption of nutrients. Dramatic progression of
undernutrition is a feature of pancreatic cancer and is attributed to loss of appetite,
maldigestion and tumour-induced increase of proteolysis. Of course other diseases,
which are not more frequent in the elderly, such as chronic in¯ammatory bowel
disease, short bowel syndrome, pancreatitis or coeliac disease can also impair the
digestion and/or absorption of nutrients. The chronic use of laxatives, which is not
always mentioned by the patient, can also cause malabsorption.
Hypermetabolism
An increased resting energy expenditure is observed in several diseases such as acute
infections of the respiratory or urinary tract, sepsis, liver cirrhosis, hyperthyroidism or
hyperactivity associated with dementia or Parkinson's disease. In some wasting
disorders (such as cardiac cachexia or chronic-obstructive lung disease) and in some
malignancies, hypermetabolism is associated with anorexia. An increase in resting
energy expenditure is well known in the post-operative period or after trauma and
burns or in patients with decubital ulcers. Incorrect treatment with thyroxine or
theophylline may also cause hypermetabolism.
Enteral nutrition
The basic principles of nutritional support are also valid in the elderly. Oral liquid
supplements with high energy density and high-quality protein are now available and
provide a valuable addition to the hospital diet. In many patients previously considered
for tube feeding, these liquid preparations represent a suitable alternative. Data from a
recent multicentre trial demonstrated that it was possible to increase the energy and
protein intake even in critically ill older patients using oral liquid supplements.60
However, enteral feeding is indicated in severely malnourished patients or if the medical
situation will not allow an adequate oral nutrient intake for more than 1 week. Naso-
gastric tube administration is appropriate in the majority of patients receiving enteral
nutrition for a circumscribed period of time. In some diseases when long-term enteral
feeding can be expected, such as head- and neck- or oesophageal cancer or in patients
with long-lasting swallowing diculties, the use of percutaneous endoscopic gastro-
stomy (PEG) is indicated. PEG feeding is also commonly used in patients with
neurological diseases or advanced dementia. However, the widespread practice of tube
feeding in patients with advanced dementia has recently been questioned. In an
excellent review, Finucane et al61 analysed data from 1966 through to March 1999 on the
risks and bene®ts of tube-feeding in advanced dementia. These authors stated that they
could not ®nd any published randomized trials that compared tube feeding with oral
feeding. Thus, a meta-analysis was not possible. However, in a summary of the data
available, they came to the very critical conclusion that there were no data to suggest
that tube feeding in patients with advanced dementia could prevent aspiration
pneumonia, prolong survival, reduce the risk of pressure sores or infections, improve
function, or provide palliation. In contrast, from a large number of clinical trials and
single reports, the authors concluded that all types of tube feeding in advanced
dementia were associated with an increased risk of aspiration pneumonia. Further
adverse eects reported were: systemic and local infections, gastric perforation, ®stula,
bleeding or increased gastro-oesophageal re¯ux and others. The authors stated that
they believed ``that a comprehensive, motivated, conscientious program of hand feeding
is the proper treatment. If the patient continues to decline in some clinically meaningful
way, tube feeding might be considered as empirical treatment''.
At this point it should be remembered that this somewhat discouraging analysis
refers to one speci®c ± although frequent ± indication for long-term enteral nutrition
in the elderly. As stated above, there are other indications for PEG feeding without
the alternative of hand feeding, unless we would tolerate long-term starvation.
However, the report by Finucane et al61 emphasizes the need for better designed
nutrition intervention studies to obtain evidence for therapeutic decisions.
882 M. Pirlich & H. Lochs
Practice points
. undernutrition is frequent in the elderly and indicates other diseases
. undernutrition is associated with a worse prognosis
. nutritional therapy can eectively improve the nutritional status of elderly
Research agenda
. the in¯uence of ageing on nutrition needs to be investigated
. the prevalence of undernutrition in dierent elderly populations needs to be
documented
. the eect of dierent nutritional therapies on nutritional status should be
evaluated
SUMMARY
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