Best Practice & Research Clinical Gastroenterology

Vol. 15, No. 6, pp. 869±884, 2001

doi:10.1053/bega.2001.0246, available online at http://www.idealibrary.com on

Nutrition in the elderly

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 insuciency, 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

In Western societies the demographic transition and the consecutively increasing

number of elderly (individuals aged 4 65 years) present challenges to those concerned
with their physical and emotional well-being. However, the elderly are not a
homogeneous group of individuals, but have widely varying capabilities and levels of
function. Nutrition is an important factor contributing to health and functional ability,
and the impact of the nutritional state on physical and psychological well-being is
especially high in the elderly. Moreover, elderly persons are more likely than younger
adults to be in an impaired nutritional state, and to be at higher risk for frank
nutritional de®ciency in times of health care problems. There is evidence that

*All correspondence to: Prof. Dr. med. Herbert Lochs. Tel: ‡‡49 30 450 514 102; Fax: ‡ ‡49 30 450 514
923; E-mail: herbert.lochs@charite.de
1521±6918/01/060869‡16 $35.00/00 *
c 2001 Harcourt Publishers Ltd.
870 M. Pirlich & H. Lochs

malnutrition is common in the geriatric population but is underestimated in diagnostic

and therapeutic procedures.1,2
The cause of this malnutrition is not always clear. The question is whether ageing
alone leads to dysfunction of the gastrointestinal tract and consequently to malnutrition,
or whether malnutrition in elderly people often indicates another disease.
This chapter will review the prevalence and aetiology, the clinical impact and
diagnosis of undernutrition in the elderly and will discuss possible therapeutic
strategies in di€erent clinical situations.

PREVALENCE OF UNDERNUTRITION

Data on the prevalence of malnutrition in the elderly di€er considerably according to

the population investigated and the de®nitions used.
Using a broad de®nition of undernutrition ± the presence of one or more abnormal
nutritional parameters ± Adil et al3 reported, in a review of 18 di€erent studies, a
prevalence of 1±83% in institutionalized geriatric patients and of 2±32% in otherwise
`healthy' subjects living at home. When de®ned as protein±energy undernutrition, the
prevalence ranges from 30±65% in hospitalized patients4,5 and from 25±60% in patients
living in nursing homes or other long-term care institutions.4,6
With regard to vitamin status, Volkert & Stehle7 analysed four di€erent studies in
healthy elderly persons and geriatric patients performed in Germany in the 1980s.
They concluded that healthy elderly people were not at higher risk for vitamin
de®ciency compared to younger adults. In general only 5% of the healthy study
populations showed low blood levels, and the daily vitamin intakes almost covered the
actual recommendations for daily intake. The only exception was seen in a high
prevalence of low vitamin B12 values in 12% of males, which was assumed to be caused
most probably by atrophic gastritis. In contrast, an abnormal status for at least one of
the ®ve vitamins A, C, B1, B2 or B6 was observed in two-thirds of patients con-
secutively admitted to a geriatric ward. These patients were multi-morbid with
cardiovascular disease, diabetes mellitus, pulmonary disease and gastrointestinal
disease as the most prevalent diagnoses. Half of the patients were housebound before
admission and two-thirds showed signs of mental deterioration at hospital admission.
Thus, an impaired vitamin status in the elderly is not an isolated phenomenon, but is
strongly associated with morbidity. Moreover, a recent study on the status of water-
soluble vitamins in geriatric patients from Brazil8 demonstrated that an impaired
vitamin status is signi®cantly more frequent in protein±energy undernourished than in
well nourished patients. Summarizing these data one can conclude that elderly patients
who have severe medical problems are at high risk for developing protein±energy
undernutrition and also for having micronutrient de®ciencies.

DEFINITION AND DIAGNOSIS OF UNDERNUTRITION IN THE

ELDERLY

According to Keller6 `malnutrition' is an overall term, which is used for di€erent

deviations from the normal nutritional state. Malnutrition might refer to a state of
undernutrition (protein±energy malnutrition, vitamin and mineral de®ciency), to a
state of overnutrition (obesity), or to an imbalance due to disproportionate intake
 Nutrition in the Elderly 871

(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 di€erent 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 dicult 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 a€ect 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
di€erent 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 diculties, 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
di€erent 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

Food Frequency Questionnaire

This is used to explore the dietary intake over a long period of time (up to 1 year)
with a large number of questions, but is probably more suitable for the evaluation of
groups rather than of individuals.4

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.

Unintentional weight loss

However, unintentional weight loss is one of the best nutritional parameters indicating
a worse clinical outcome, and a weight loss of 410% within the previous 6 months is
associated with increased post-operative complications.13 In the elderly, unintentional
weight loss is associated with increased morbidity14 and mortality.15±17

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

Body composition analysis

An increasing number of modern technologies allow direct or indirect body com-
position analysis. Most methods that allow a direct measurement of a single or several
body compartments (such as magnetic resonance imaging (MRI), computed tomo-
graphy (CT), neutron activation, underwater weight densitometry), are expensive,
time-consuming or invasive. Thus, while they might give more precise estimates of
body compartments than simpler or indirect methods, these technologies are not
suitable for use as screening tools or, in general, for clinical practice.4,13
 Nutrition in the Elderly 873

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 ˆ 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 & Jelli€e22 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
diculty 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 dicult 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.

Bioelectrical impedance analysis

The bioelectrical impedance analysis (BIA) is a simple, non-invasive, inexpensive and
quick method for estimating total body water, extracellular water, fat free mass and
body cell mass. The method refers to the measurement of the whole body impedance,
which is composed of two vectors, the resistance and the reactance. Resistance is the
pure opposition of a conductor to an alternating current. Reactance is the component
that results from the additional opposition to an alternating current produced by the
capacitant e€ect of cell membranes and tissue interfaces. There are a large number of
di€erent equations for the calculation of body compartments from resistance and
reactance, and there is some controversy regarding the validity of the method and of
the speci®c equations for estimating fat free mass in di€erent clinical situations,
especially in patients with obesity or with ¯uid overload. However, several studies
have demonstrated the prognostic impact of a low body cell mass as measured by BIA
874 M. Pirlich & H. Lochs

in malnourished patients.27,28 Using anthropometric data, a recent study has tried to

obtain reference values of fat free and fat masses using BIA in 3393 healthy subjects.29
Unfortunately, the upper age included in this analysis was 64 years, so that no
reference values were obtained for the elderly. Since there is a lack of reference values,
interpretation of BIA data in the elderly is dicult. Therefore, despite its possible
value in detecting malnutrition, BIA should primarily be used for scienti®c purposes
and, at least at present, BIA can not be recommended as a diagnostic tool in the clinical
evaluation of the elderly.

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 di€erent clinical situations such as renal insuciency30, 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 di€erent 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.

Index Parameters/formula Classi®cation

Maastricht Index35 20.68 (0.24  serum albumin (g/l)) (19.21  prealbumin (g/l)) (1.86  lymphocyte count (106/ 4 0 malnutrition
l)) (0.04  ideal body weight)
Subjective Global History (changes of weight and dietary intake, gastrointestinal symptoms, functional capacity, nutritional A, well nourished.
Assessment36 requirements)
Physical (loss of fat mass, muscle wasting, oedema, ascites) B, moderately (or suspected of
Subjective classi®cation according to the recommendations given by the authors being) malnourished.
C, Severely malnourished.
Nutritional Risk Index37 (1.489  serum albumin (g/l)) ‡ 41.7  (actual/usual weight), where `usual weight' ˆ stable weight 6 months 4100, no malnutrition
before admission 97.5±100, mild malnutrition
83.5±97.5, moderate
malnutrition
483.5, severe malnutrition
Mini Nutritional Anthropometry (weight, height, loss of weight) 5 24, well nourished
Assessment38 Global assessment (life-style, medication, mobility) 17±24, risk for malnutrition
Dietary history (number of meals, food and ¯uid intake, ability to self-feed), self assessment of the health and 5 17, malnourished
nutrition status
Answers/results are transferred into a score
Malnutrition Risk Scale S, sadness; C, cholesterol; A, albumin 5 40 g/l, L, loss of weight; E, eating problems (cognitive or physical; 5 3, high risk for malnutrition
(SCALES)4 S, shopping problems or inability to prepare a meal
Each element represent one point to transfer into a summed score

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 diculties, 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.

CAUSES OF UNDERNUTRITION IN THE ELDERLY

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).

Decreased food intake

The main cause of undernutrition in the elderly is decreased food intake, which may
be caused by several, often combined, conditions. A loss of appetite is frequently
observed and is associated with low physical activity or immobilization, pain, social

Table 2. Risk factors for undernutrition in the elderly.

Geriatric patients Healthy elderly

Loss of appetite 26 14
Masticatory problems 46 20
Dysphagia 18 10
Problems preparing food 44 16
Immobility 49 ±
Dementia 20 ±
Depression 13 8
Social isolation 27 ±
Stressful life event 23 34

Modi®ed from Volkert42

 Nutrition in the Elderly 877

isolation and a number of diseases such as malignancies, depression or dementia. In

dementia, eating disturbances per se are a feature of the early disease stages.43
Furthermore, a deterioration in the sense of taste or of smell is commonly observed
with increasing age and may also contribute to reduced appetite. In some otherwise
healthy patients, beliefs concerning dietary restriction and longevity or cholesterol
phobia may result in inappropriate food intake.44
Reduced physical activity, immobilization, hemiplegia as well as visual problems or
severe tremor in persons su€ering from Parkinson's disease can decrease their ability
to prepare food. Stroke patients are at high risk for having a low food intake due to
dysphagia and impaired self-feeding ability.1 Other frequent causes of reduced food
intake are oral problems such as dry mouth, sores or masticatory problems due to
tooth loss or inappropriate dental care.4
Iatrogenic reasons for decreased food intake are monotony or unattractive food in
health care institutions and insucient nursing care and help in eating. In a recent
study, Sullivan et al5 demonstrated that hospitalization (or the carelessness of the
hospital sta€) is a risk factor for an inadequate nutrient intake in geriatric patients: 21%
of 497 patients studied had an average daily in-hospital nutrient intake of less than 50%
of their calculated energy requirements. These authors also reported that patients
were frequently ordered to have nothing by mouth, but did not receive adequate
nutritional support by another route. Another iatrogenic reason for a low food intake
is polypharmacy, which has been estimated to contribute to 10% of all cases of
hospitalization among the elderly.45 Several drugs reduce the food intake due to loss of
appetite and taste, nausea, or mental dysfunction. In patients receiving chemotherapy,
mucositis, loss of appetite, nausea and vomiting can also accelerate the poor nutritional
status caused by the tumour itself. Table 3 lists several drugs that have possible side-
e€ects that may cause a decreased food intake.

Gastrointestinal diseases, maldigestion and malabsorption

It is obvious that digestive diseases are a risk factor for the development of a poor
nutritional state. Diarrhoea in general may be associated with malabsorption and, in
some patients, diarrhoea is also associated with decreased food intake as an avoidance
strategy. However, there are only a few gastrointestinal diseases that develop
speci®cally in the elderly.
In general, absorption does not deteriorate by a clinically relevant amount with age.
However, achlorhydria is more frequent in the elderly. Atrophic gastritis has been
proven to be a common cause of malabsorption, since its prevalence increases with

Table 3. Selected side e€ects of drugs causing decreased food intake.

Side e€ect Drug

Loss of appetite
Decreased/altered taste
Dry mouth (Xerostomie)
Nausea
Mental dysfunction
Digoxin, captopril, non-steroidals, antibiotics, anti-histamines, sedatives,
neuroleptics, tricyclic anti-depressants
Captopril, penicillin, anti-hypertensives, analgesics, anti-diabetics,
psychopharmaceuticals, cytostatics, vasodilatators
Anti-parkinsonians, anti-depressants, anti-histamines, anti-cholinergics
Cytostatics, anti-hypertensives
Psychopharmaceuticals
878 M. Pirlich & H. Lochs

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.

CLINICAL IMPACT OF MALNUTRITION IN THE ELDERLY

In general, there is a strong association between undernutrition, disease and disease

complications, but the cause and e€ect relationship may sometimes be indistinguishable.
The link between undernutrition and worse outcome of a medical condition is not easy
to establish, because the criteria of undernutrition are unclear or imprecise (which also
explains the wide range in prevalence data) and there may be a problem in di€er-
entiating between the in¯uence of the underlying disease and the in¯uence of the
nutritional state.13 This needs to be studied using large and well characterized
populations, a clear de®nition of outcome criteria and a careful statistical analysis of the
data to avoid bias or misinterpretation. There have been quite a few studies in the
elderly that allow an analysis of cause and e€ect of undernutrition and disease. For
example, Sullivan & Walls49studied 350 randomly selected patients admitted to the
geriatric rehabilitation unit of a Veterans Administration hospital and analysed the
impact of their nutritional status and in-hospital nutrient intake on in-hospital
morbidity. As expected, 99% of the patients were male, and the average age was 76 years.
A total of 96 di€erent variables relating to the medical, functional, neuro-psychological,
socio-economic and nutritional status were analysed. The strongest predictor of
subsequent complications was the Katz Index of Activities of Daily Living (ADL) score,
followed by serum albumin concentration, usual weight percent, number of
prescription medications, presence of renal disease, individual income, the presence
of decubiti, dysphagia and mid-arm muscle circumference. In a subsequently performed
logistic regression analysis, these investigators demonstrated that protein±energy
 Nutrition in the Elderly 879

undernutrition was a strong independent risk factor for in-hospital morbidity. In

contrast, in-hospital nutrient intake could not be identi®ed as a signi®cant risk factor for
complications. In a further analysis of this study published separately17, the authors
focused on life-threatening morbidity during hospitalization. Using the same 96
variables they demonstrated that the best predictors for the development of at least one
life-threatening complication were serum albumin concentration, body mass index, the
presence of renal disease, the Katz Index and the amount of weight loss in the year prior
to admission. Here again the logistic regression analysis indicated that protein±energy
undernutrition is an independent risk factor for life-threatening morbidity during the
hospital course of geriatric patients.
The long-term outcome of protein±energy undernutrition in elderly medical
patients was studied by Cederholm et al.50 The study comprised 205 consecutively
admitted patients (on an emergency basis) without cancer, aged 75 years; 41 patients
were identi®ed as undernourished by having at least three nutritional variables (which
included weight index, triceps skinfold thickness, arm muscle circumference, serum
albumin concentration and delayed cutaneous hypersensitivity reaction) below the
reference range. The cumulative mortality 9 months after admission was signi®cantly
higher in the undernourished patients than in the normally nourished patients (44%
versus 18%, P 5 0.001). Multivariate analysis revealed congestive heart failure, multiple
organ disease and protein±energy undernutrition to be predictors of death. Consider-
ing the interaction between disease and protein±energy undernutrition, the
prognostic relevance of undernutrition remained among the patients with cardiac
congestion. The mortality of undernourished patients with cardiac congestion (n ˆ 10)
was 80%, while only 22.5% of normal nourished patients with cardiac congestion
(n ˆ 40) died within the observation period. In contrast, patients with multiple organ
disease (n ˆ 58) tended to have a higher undernutrition index than patients with
other diagnoses, but there was no relationship between mortality and protein-
undernutrition in this patient group. The authors concluded that protein±energy
undernutrition seems to be causally related to mortality mainly in patients with
congestive heart failure. However, this study also demonstrated that in complex
medical conditions such as multiple organ disease it might be impossible to distinguish
the prognostic impact of impaired nutritional status from the prognostic impact of the
underlying disease.
The prognostic impact of undernutrition has also been studied in acute onset
diseases: DaÂvalos et al51 studied 104 patients with an acute stroke. On admission 16.3%
of patients had signs of protein±energy undernutrition, and the percentage rose to
26.4% after the ®rst week with a signi®cant decrease in fat and visceral proteins.
Undernourished patients had an increased frequency of infections and bedsores, and
undernutrition after 1 week was an independent risk factor for poor outcome on day
30 (death or a Barthel Index score of 450). A deterioration in the nutritional status
during the hospital stay was also reported in 201 patients with acute stroke who were
studied by Gariballa et al.31 In this study only the serum albumin concentration was
associated with various outcome measures: hypoalbuminaemia had a greater risk of
infective complications, poor functional outcome during hospital stay and increased
mortality at 3 months after acute stroke.
The nutritional implications in elderly patients with hip fracture are more complex.
In general, poor nutritional state is a main risk factor for developing hip fractures in
the elderly.52,53 Also, severely undernourished hip fracture patients have a higher
mortality than adequately nourished patients.54
880 M. Pirlich & H. Lochs

Summarizing these studies, undernutrition appears to be an independent risk factor

for disease, disease complications and mortality, but there is also evidence that co-
morbidity has a prime role in in¯uencing health status.50

NUTRITIONAL THERAPY IN THE ELDERLY

Increasing the oral intake
As described above, oral nutritional intake is frequently decreased in elderly patients.
Therefore, the primary nutrition strategy in the elderly should be aimed at improving
the oral food intake. A recent study in hospitalized patients, from di€erent specialities,
demonstrated that more than 40% of hospital food was wasted55, resulting in energy and
protein intakes that were less than 80% of that recommended. Interestingly, among
elderly patients 42% said that food portion sizes were too large. In a further study by the
same group, elderly patients were randomized to receive either a normal or a reduced
portion size forti®ed menu, which provided 14% more energy than the normal menu.56
Nutritional intakes were 25% higher on the forti®ed menu, indicating that simple
modi®cation of the hospital menu can result in food intakes that approximate require-
ments. Another study using a forti®ed menu demonstrated that between-meal snacks
were also suitable for achieving improved energy intakes in the elderly.57
However, as stated above, there are several other medical, social and psychological
factors that contribute to low oral food intake. In many cases advising and motivating
the patient and their relatives to use simple strategies to improve food intake may be
bene®cial. In elderly persons living in health care institutions the ecacy of nutritional
support is largely dependent on the awareness and motivation of the institutional sta€.
In some cases additional support from speech therapists, physical therapists or other
professionals may be necessary to improve the patient's ability to eat. Some risk factors
for undernutrition and possible intervention strategies are summarized in Table 4.

Table 4. Possible strategies to improve oral nutrient intake.

Risk factor Intervention strategies

Loss of appetite Check drug prescription
Personally chosen food
Forti®ed menu
Appetizer
Chewing problems Dental care
Oral hygiene
Mushy food
Swallowing problems Speech therapy
Tube-feeding/PEG
Diculties preparing food Physical therapy
Nursing assistance
Immobility Physical therapy
Feeding assistance
Chronic pain Analgesics
Depression Check medication
Medical treatment
Social isolation Social service
Meals on wheels
 Nutrition in the Elderly 881

Supplementation of speci®c nutrients

In patients with proven de®ciencies of micronutrients, supplementation is strongly
recommended to improve clinical outcome. Several studies have demonstrated a
positive e€ect of calcium and vitamin D supplementation on the incidence of hip
fracture.58,59 The frequently observed low serum vitamin B12 concentration requires
correction. Low iron or zinc intake can be prevented by an increased intake of meat or
dairy products. Pharmaceutical supplementation might be necessary in a number of
patients who will not meet the recommended oral intake. Since, in clinical practice,
micronutrient de®ciency may be dicult to diagnose, supplementation should be
liberally instituted.

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 diculties, 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 e€ects 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 e€ectively improve the nutritional status of elderly

Research agenda
. the in¯uence of ageing on nutrition needs to be investigated
. the prevalence of undernutrition in di€erent elderly populations needs to be
documented
. the e€ect of di€erent nutritional therapies on nutritional status should be
evaluated

SUMMARY

In summary, although the prevalence of undernutrition in the elderly population

di€ers according to health status and living conditions, there are clearly groups who
are at a high risk for undernutrition, which by itself poses a risk for higher morbidity
and mortality. It is therefore especially important to evaluate the nutritional status of
elderly patients and to install nutritional therapy to improve their prognosis.

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