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
REFERENCES
1. Tierney AJ. Undernutrition and elderly hospital patients: a review. Journal of Advanced Nursing 1996; 23:
228±246.
2. Vetta F, Ronzoni S, Taglieri G & Bollea MR. The impact of malnutrition on the quality of life in the
elderly. Clinical Nutrition 1999; 18: 259±267.
3. Adil A, Abbasi MD & Rudman D. Undernutrition in the nursing home: prevalence, consequences,
causes and prevention. Nutrition Reviews 1994; 52: 113±120.
4. Omran ML & Morley JE. Assessment of protein energy malnutrition in older persons, part I: history,
examination, body composition, and screening tools. Nutrition 2000; 16: 50±63.
5. Sullivan DH, Sun S & Walls RC. Protein-energy undernutrition among elderly hospitalised patients.
Journal of the American Medical Association 1999; 281: 2013±2019.
6. Keller HH. Malnutrition in institutionalised elderly: how and why? Journal of the American Geriatric
Society 1993; 41: 1212±1218.
7. Volkert D & Stehle P. Vitamin status of elderly people in Germany. International Journal of Vitamin and
Nutrient Research 1999; 69: 154±159.
8. Cunha DF, Cunha SFC, Unamuno MRL & Vannucchi H. Serum levels assessment of vitamin A, E, C, B2
and carotenoids in malnourished and non-malnourished hospitalised elderly patients. Clinical Nutrition
2001; 20: 167±170.
9. Corish CA, Flood P, Mulligan S & Kennedy NP. Apparent low frequency of undernutrition in Dublin
hospital in-patients: should we review the anthropometric thresholds for clinical practice? British Journal
of Nutrition 2000; 84: 325±335.
10. Bannerman E, Reilly JJ, MacLennan WJ et al. Evaluation of validity of British anthropometric reference
data for assessing nutritional state of elderly people in Edinburgh: cross sectional study. British Medical
Journal 1997; 315: 338±341.
11. Beck AM, Ovesen L & Osler M. The `Mini Nutritional Assessment' (MNA) and the `Determine Your
Nutritional Health' Checklist (NSI Checklist) as predictors of morbidity and mortality in an elderly
Danish population. British Journal of Nutrition 1999; 81: 31±36.
Nutrition in the Elderly 883
12. Mertz W, Tsui JC, Judd JT et al. What are people really eating? The relation between energy intake
derived from estimated diet records and intake determined to maintain body weight. American Journal of
Clinical Nutrition 1991; 54: 291±295.
13. Klein S, Kinney J, Jeejeebhoy K et al. Nutrition support in clinical practice: review of published data and
recommendations for future research directions. American Journal of Clinical Nutrition 1997; 66: 683±706.
14. Silver AJ, Morley JE, Storme LS et al. Nutritional status in an academic nursing home. Journal of the
American Geriatric Society 1988; 36: 487±491.
15. Dwyer JT, Coleman KA, Krall E et al. Changes in relative weight among institutionalised elderly adults.
Journal of Gerontology 1987; 42: 246±251.
16. Burr ML, Lennings CI & Milbank JE. The prognostic signi®cance of weight and of vitamin C status in the
elderly. Age and Ageing 1982; 11: 249±255.
17. Sullivan DH & Walls RC. The risk of life-threatening complications in a select population of geriatric
patients: the impact of nutritional status. Journal of the American College of Nutrition 1995; 14: 29±36.
18. Roubeno R, Roubeno RA, Preto J & Balke CW. Malnutrition among hospitalised patients. A problem
of physician awareness. Archives of Internal Medicine 1987; 147: 1462±1465.
19. McWhirter JP & Pennington CR. Incidence and recognition of malnutrition in hospital. British Medical
Journal 1994; 308: 945±948.
20. Flodin L, Svensson S & Cederholm T. Body mass index as a predictor of 1 year mortality in geriatric
patients. Clinical Nutrition 2000; 19: 121±125.
21. Pirlich M, SchuÈtz T, Spachos T et al. Bioelectrical impedance analysis is a useful bedside technique to
assess malnutrition in cirrhotic patients with and without cirrhosis. Hepatology 2000; 32: 1208±1215.
22. Gurney J & Jellie DB. Armanthropometry in nutritional assessment: nomogram for rapid calculation of
muscle circumference and cross-sectional muscle and fat mass. American Journal of Clinical Nutrition 1973;
26: 912±915.
23. Frisancho AR. New norms of upper limb fat and muscle areas for assessment of nutritional status.
American Journal of Clinical Nutrition 1981; 34: 2540±2545.
24. Campbell AJ, Spears GF, Brown JS et al. Anthropometric measurements as predictors of mortality in a
community population aged 70 years and over. Age and Ageing 1990; 19: 131±135.
25. Heyms®eld SB, Arteaga C, McManus C et al. Measurement of muscle mass in humans: validity of the 24-
hour urinary creatinine method. American Journal of Clinical Nutrition 1983; 3: 478±494.
26. Pirlich M, Selber O, BoÈker K et al. The creatinine approach to estimate skeletal muscle mass in patients
with cirrhosis. Hepatology 1996; 24: 1422±1427.
27. SuÈttmann U, Ockenga J, Selberg O et al. Incidence and prognostic value of malnutrition and wasting in
human immunode®ciency virus-infected outpatients. Journal of AIDS and Human Retrovirology 1995; 8:
239±246.
28. Selberg O, BoÈttcher J, Tusch G et al. Identi®cation of high- and low risk patients before liver
transplantation: a prospective cohort study of nutritional and metabolic parameters in 150 patients.
Hepatology 1997; 25: 652±657.
29. Pichard C, Kyle UG, Bracco D et al. Reference values of fat-free and fat masses by bioelectrical
impedance analysis in 3393 healthy subjects. Nutrition 2000; 16: 245±254.
30. De Lima JJ, Da Fonseca JA & Godoy AD. Baseline variables associated with early death and extended
survival on dialysis. Renal Failure 1998; 20: 581±587.
31. Gariballa SE, Parker SG, Taub N & Castleden CM. In¯uence of nutritional status on clinical outcome
after acute stroke. American Journal of Clinical Nutrition 1998; 68: 275±281.
32. Giner M, Laviano A, Meguid MM & Gleason RR. In 1995 a correlation between malnutrition and poor
outcome in critically ill patients still exists. Nutrition 1996; 12: 23±29.
33. Morley JE, Glick Z & Rubenstein LZ. Geriatric Nutrition: A Comprehensive Review. New York: Ravan Press,
1990.
34. Seiler WO & StaÈhelin HB. Aspects of malnutrition in geriatric medicine. Schweizer Medizinische
Wochenschrift 1995; 125: 149±158.
35. De Jong PCM, Wesdorp RICO, Volovics A et al. The value of objective measurements to select patients
who are malnourished. Clinical Nutrition 1985; 4: 61±66.
36. Detsky AS, McLaughlin JR, Baker JP et al. What is Subjective Global Assessment of nutritional status?
Journal of Parenteral and Enteral Nutrition 1987; 11: 8±13.
37. Buzby GP, Williford WO, Peterson OL et al. A randomised clinical trial of total parenteral nutrition in
malnourished surgical patients: the rationale and impact of previous clinical trials and pilot study on
protocol design. American Journal of Clinical Nutrition 1988; 47: 357±365.
38. Guigoz Y, Vellas B & Garry PJ. Assessing the nutritional status of the elderly: the Mini Nutritional
Assessment as part of the geriatric evaluation. Nutrition Reviews 1996; 54: 59±65.
39. Ek AC, Unosson M, Larsson J et al. Interrater variability and validity in subjective nutritional assessment
of elderly patients. Journal of Caring Sciences 1996; 10: 163±168.
884 M. Pirlich & H. Lochs
40. Lehmann AB, Bassey EJ, Morgan K & Dalosso HM. Normal values for weight, skeletal size and body mass
indices in 890 men and women aged over 65 years. Clinical Nutrition 1991; 10: 18±22.
41. Morley JE. Anorexia of ageing: physiologic and pathologic. American Journal of Clinical Nutrition 1997; 66:
760±773.
42. Volkert D. ErnaÈhrungsprobleme in der Geriatrie - MangelernaÈhrung bei geriatrischen Patienten. Aktuelle
ErnaÈhrungsmedizin 1996; 21: 200±202.
43. Watson R. Measuring feeding diculty in patients with dementia: perspectives and problems. Journal of
Advanced Nursing 1993; 18: 25±31.
44. Lew-Ting CA. Egg phobia in retirement homes: health risk perceptions among elderly Chinese. Culture
Medical Psychiatry 1997; 12: 27±51.
45. Trunet P, Legall JR, Lhoste F et al. The role of iatrogenic disease in admissions to intensive care. Journal of
the American Medical Association 1980; 244: 2617±2620.
46. Bowman BA, Rosenberg ICH & Hohnson MA. Gastrointestinal function in the elderly. In Munro HN &
Schierf G (eds) Nutrition of the Elderly, Nestle Nutrition Workshop Series, volume 29, pp. 43±50. New York:
Raven, 1992.
47. Russell RM. Changes in gastrointestinal function attributed to ageing. American Journal of Clinical
Nutrition 1992; 55: 1203S±1207S.
48. Brignoli R, Merki H, Miazza B & Beglinger C. Endoskopische Befunde bei Freiwilligen und dyspeptischen
Patienten. Schweizer Medizinische Wochenschrift 1994; 124: 1240±1247.
49. Sullivan DH & Walls RC. Impact of nutritional status on morbidity in a population of geriatric
rehabilitation patients. Journal of the American Geriatric Society 1994; 42: 471±477.
50. Cederholm T, JaÈgreÂn C & HellstroÈm K. Outcome of protein±energy malnutrition in elderly medical
patients. Journal of the American Medical Association 1995; 98: 67±74.
51. DaÂvalos A, Ricart W, Gonzalez-Huix F et al. Eect of malnutrition after acute stroke on clinical outcome.
Stroke 1996; 27: 1028±1032.
52. Jensen JE, Jensen TG, Smith TK et al. Nutrition in orthopaedic surgery. Journal of Bone and Joint Surgery
1982; 67: 884±886.
53. Wootton R, Brereton PJ, Clark MB et al. Fractured neck of the femur in the elderly: an attempt to
identify patients at risk. Clinical Science 1997; 57: 93±101.
54. Bastow MD, Rawlings J & Allison SP. Bene®ts of supplementary tube feeding after fractured neck of
femur: a randomised controlled trial. British Medical Journal 1983; 287: 1589±1592.
55. Barton AD, Beigg CL, MacDonald IA & Allison SP. High food wastage and low nutritional intakes in
hospital patients. Clinical Nutrition 2000; 19: 445±449.
56. Barton AD, Beigg CL, MacDonald IA & Allison SP. A recipe for improving food intakes in elderly
hospitalised patients. Clinical Nutrition 2000; 19: 451±454.
57. Gall MJ, Grible GK, Reeve NJ & Thomas SJ. Providing forti®ed meals and between-meal snacks
signi®cantly increases energy intake of hospital patients. Proceedings of the Nutrition Society 1998; 57: 94A.
58. Chapuy MC, Arlot ME, Buoeuf F et al. Vitamin D3 and calcium to prevent hip fractures in the elderly
woman. New England Journal of Medicine 1992; 327: 1637±1642.
59. Dawson-Hughes B, Harris SS, Krall EA & Dallal GE. Eect of calcium and Vitamin D supplementation on
bone density in men and women 65 years of age or older. New England Journal of Medicine 1997; 337:
670±676.
60. Bourdel-Marchasson I, Barateau M, Rondeau V et al. A multicenter trial of the eects of oral nutritional
supplementation in critically ill older inpatients. Nutrition 2000; 16: 1±5.
61. Finucane TE, Christmas C & Travis K. Tube feeding in patients with advanced dementia. A review of the
evidence. Journal of the American Medical Association 1999; 282: 1365±1370.