Breaking Down Malnutrition – Causes, Diagnosis and Treatments

Our elderly population can be diverse, ranging from healthy, active, and healthy octogenarians to extremely frail, totally dependent people with chronic disease and severe disabilities. As people age, their body composition changes, which has an impact on their nutritional status. Malnutrition is a common problem among elderly individuals, which is defined as the state of being poorly nourished.

What do you mean by Malnutrition – Malnutrition Definition

Malnutrition or poor nutrition leads to serious health problems such as anemia, osteoporosis, impaired immune function, non-healing wounds, and prolonged time to recover from illnesses. It may be caused by the lack of one or more nutrients (undernutrition) or an excess (overnutrition). Weight loss and malnourishment come in the elderly population in different forms.

1. Wasting: An involuntary weight loss primarily caused by inadequate dietary intake. It may be attributable to disease and psychosocial factors and occurs with a background of cachexia, sarcopenia, or both.
2. Sarcopenia: An involuntary loss of muscle mass, a natural element of aging rather than a disease affecting older people.
3. Cachexia: An involuntary loss of fat-free mass caused by catabolism and changes in body composition. It is characterized by a raised metabolic rate and increased protein degradation. Cachexia is often accompanied by anorexia, fatigue, and muscle weakness. It can be caused by chronic conditions such as cancer, HIV/AIDS, rheumatoid arthritis, heart failure, and COPD.

What are the causes of malnutrition?

One can be at high risk for malnourishment due to multiple factors ranging from a poor appetite/ inadequate energy intake and nutrients, difficulty chewing or swallowing, and certain medications/ polypharmacy. It is easier to simplify the causes of malnutrition based on medical, lifestyle, and psychological factors.

 Medical factors:

1. Poor appetite.
2. Loss of taste and smell.
3. Respiratory, gastrointestinal, endocrine, neurological disorders, and other disease conditions.
4. Infections (urinary tract infection, chest infection).
5. Physical disability (arthritis, poor mobility).
6. Drug interactions (digoxin, metformin, antibiotics)/polypharmacy interaction leading to Nausea, Vomiting, and loss of appetite.
7. With old age- anemia, asthenia, and anorexia may be associated with underlying cancers (Gastric, colon).

 Lifestyle and social factors:

1. Lack of knowledge about fresh food, cooking, and nutrition
2. Isolation/loneliness
3. Poverty
4. Inability to shop or prepare fresh food
5. Ongoing smoking and substance abuse
6. Lack of transportation
7. Limited income
8. Poverty
9. Social isolation/ Physical limitations

Psychological factors:

1. Confusion
2. Anxiety
3. Dementia
4. Depression
5. Bereavement

How is malnutrition diagnosed?

There are no generally accepted criteria for diagnosing malnourishment in the elderly. Your doctor may do a quick Mini Nutritional Assessment (MNA) and Nutritional Risk Screening (NRS) to identify malnutrition in the clinic quickly. Your doctor will focus on the following points to evaluate the nutrition degree.

• Record your history

  ○     Low body weight or changes in appetite/ Significant weight loss. e.g., 10 lbs in the last month.

  ○     Reasons for a diminished nutritional intake.

• Physical examination

  ○   Anthropometric values: Body Mass Index (BMI) of less than 20 kg/m2 and calf circumference of less than 31 cm. You can use this user family BMI calculator from National Heart, Lung, and Blood Institute(Calculate Your BMI – Standard BMI Calculator (nih.gov).

  ○      Evaluate if you have problems with swallowing.

  ○      General muscular atrophy, loss of subcutaneous fat, muscle wasting.

                          
• Documentation of oral intake

How will your doctor treat malnutrition?

Malnutrition treatment is a step-by-step process. Your doctor will ask why you have a poor intake or what is the reason behind losing muscles despite good intake. The treatment involves:

• Dietary counseling with or without oral nutritional supplements. You might benefit from protein-rich supplements- and it comes in different flavors.

• Supportive intervention: A pleasant eating environment in institutions, sharing mealtimes with others, nutritional information and education, and food security.

• Nutritional counseling: Usually with a nutritionist or a registered dietitian

• Food modification: Food fortification, texture-modification of food.

What are the signs to look for malnutrition in the elderly?

• Involuntary weight loss

• Fatigue

• Muscle weakness

• Decreased ability to fight off infections.

• Low body mass index

•   Muscle wasting

   

How can we prevent malnutrition in the elderly population?

Elderly people with poor nutrition are at a higher risk for malnutrition and physical health problems, which can further contribute to their decline in mental health. Adequate nutrition is essential for brain health systems and function and a diet lacking in essential nutrients such as vitamins B12, folate, and omega-3 fatty acids can contribute to depression, anxiety, and other symptoms including mental health problems. Some strategies that can help prevent malnourishment in this population include:

• Encourage a healthy diet: Consume a well-balanced diet that consists of a range of nutrient-rich foods, such as fruits, vegetables, lean meats, and whole grains.

• Make meals more appealing: Make meals more appealing by attractively serving them, using colorful plates and garnishes. Offer a variety of fresh food to make mealtime more enjoyable.

• Keep meals simple: Avoid overly complicated recipes or dishes that may be difficult to chew or swallow.

• Small, frequent meals: Instead of three large meals, distribute smaller, more frequent meals throughout the day. This may be simpler for the person to handle and prevent hunger.

• Make sure the individual has access to healthy fresh food: Ensure that the individual has easy access to healthy, nutrient-dense foods, and consider delivering meals if necessary.

• Address any physical or cognitive challenges: If the individual has physical or cognitive challenges that make eating difficult, work with a healthcare professional or occupational therapist to find ways to overcome these challenges.

•  Monitor the individual’s weight: Regularly monitoring the individual’s weight can help to identify any potential malnourishment early on so that it can be addressed promptly.

Myths on malnutrition

• All older adults need the same type of diet.

• Older adults should avoid all dairy products.

• Supplements can replace a healthy diet.

• Older Adults need to eat less as they get older.

• Malnutrition is a normal part of the aging process.

• Weight loss is healthy.

   

5 Facts you need to know about malnutrition

• Body fat mass increases at about 75 years of age and then decreases or remains stable.
• The pattern of fat distribution has been linked with an increased risk of stroke, diabetes, hyperlipidemia, heart disease, and hypertension, all of which are common conditions that affect the elderly.
• The central accumulation of fat increases with aging while appendicular fat mass decreases.
• The impact of malnourishment appears to be more severe than in younger adults.

   

5 Tips for nutritional support at home- Let’s avoid malnutrition risk factors 

• Add dried fruit, chopped nuts, bacon pieces, cheese, mayonnaise, and avocado as a topping, and use butter or olive oil when cooking which will increase calorie intake without increasing volume.

• Spread meals into several small ones throughout the day rather than just three large ones.

• Those who experience the taste and odor alterations can also benefit from eating more often throughout the day.

• Drinking liquid is frequently much simpler than eating, especially if you have a limited appetite. 

• Higher-calorie beverages such as whole milk, shakes, smoothies, and oral nutritional supplements can be taken between meals instead of alongside meals.

Things to note if you have an elderly at home

• Appetite pattern: Age-related physiological changes and the individual’s environment, temperament, current health, and pharmaceutical regimen can affect hunger.
• Dehydration: Dehydration can lead to seizures, low blood volume, low blood pressure, increased thirst, decreased urination, dark urine color, dizziness, weariness, and confusion.
• Dentition: Chewing becomes more challenging as people age; hence, older people may become hungry earlier and eat less.
• Taste and smell changes: Favorite foods can sometimes taste “too salty,” “too sweet,” or “too bland,” which makes people less interested in eating them.
• Difficulty in swallowing: Some older adults may cough more frequently while eating, which can indicate swallowing issues and cause them to eat less.

Questions for your doctor

1. What is causing my malnutrition?
2. What treatment options are available?
3. How can I improve my nutritional intake?
4. Are there any supplements or medications that can help to improve my nutritional status?
5. How can I make meals more appealing and easier to eat?
6. Are there any resources available to help me access healthy, nutrient-dense fresh food?
7. How often should I follow up with you to monitor my progress?
8. Are there any potential complications that I should be aware of?
9. How can I prevent malnutrition in the future?

References

Hickson, M. (2006). Malnutrition and aging. The postgraduate medical journal, 82(963), 2-8.

Norman, K., Haß, U., & Pirlich, M. (2021). Malnutrition in older adults—recent advances and remaining challenges. Nutrients, 13(8), 2764.

Ervin RB. Healthy Eating Index scores among adults, 60 years of age and over, by sociodemographic and health characteristics: United States, 1999–2002. Advance data from vital and health statistics; no 395. Hyattsville, MD: National Center for Health Statistics. 2008

Malnutrition in Older Adults: What to Watch for and How to Help. (n.d.). ASA Generations. https://generations.asaging.org/malnutrition-elders-how-help

Bauer, J. M., Volkert, D., Wirth, R., Vellas, B., Thomas, D., Kondrup, J., … & Sieber, C. C. (2006). Diagnosing malnutrition in the elderly. Deutsche Medizinische Wochenschrift (1946), 131(5), 223-227.

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