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Abstract
Acknowledgment
First of all I thank Allah the most gracious and the most merciful.
I offer my deep appreciation and sincere thanks to Prof. Dr. Amany Hussein Refaat, professor of community Medicine, Faculty of Medicine, Suez Canal University, for her continuous encouragement and precious advice throughout the supervision of this work.
My sincere thanks and appreciation goes to, Prof. Dr. Mohammed Mohammady Awad Diab ,Professor of family medicine , Suez Canal University, for his enthusiastic support, encouragement, helpful notes and guidance throughout this work.
I wish to extend my thanks to Dr . Seham Ahmed Abd El Hameed , Lecturer of Family Medicine, Suez Canal University, for her generous support during this study.
Also I wish to express my deep thanks for all participants in this study for their patience and cooperation .
Last but not least, my deepest love, appreciation goes to all of my family members for their support and kind assistance.
Conclusion
This study found that Malnutrition is prevalent in our rural society (19%), risk for malnutrition is about 45% and has multiple risk factors as female gender , increasing age , decrease in number of meals daily ,deficient diet regarding fruit and vegetables and proteins ,decrease in number of fluid intake daily ,current psycho and mental problems ,presence of anxiety or depression in last three months .
Recommendations
1- For physicians , they should be aware with the importance of the nutritional assessment for elderly group and should also educate their patients about the importance of balanced diet and what is a balanced diet required for them and motivate patients to participate in screening and if required in investigation to check their nutritional status .
2- For the ministry of health , they should arrange for training programs for primary care physicians about nutritional needs and assessment specially for this valuable group and arrange for mass education of the community about nutrition and nutritional problems for various groups of age .
3- For elderly group individuals , they should ask about their nutritional needs from their physicians and check for their nutritional status routinely.
4- for the research authority , they should investigate various types of tools of screening and assessment of nutritional status and choose the most simple and useful ones to be recommended for field work by physicians .
Discussion
The fastest growing segment of the population in most industrialized countries is the elderly; and too often this is also a group most susceptible to many health risks from a nutrient poor diet. Evidence from numerous sources indicates that a significant number of elderly fails to get the amounts and types of food necessary to meet essential energy and nutrient needs. There are a wide range of reasons why older individuals might not be eating the most nutritious diet which is all the more reason why health professionals and care providers need to be constantly aware of the necessity for maintaining an optimal nutritional health status in the elderly.( enc@enc.online.org ).
This study is a cross sectional household study aimed to assess the prevalence of malnutrition among elderly in Abou Khalifa village which is a rural area in Ismailia and determine the most important risk factors affecting malnutrition using the Mini Nutritional Assessment questionnaire (MNA) and included 300 elderly .
Prevalence of malnutrition ,In this study according to Mini Nutritional Assessment questionnaire (MNA) ,19 % are malnourished , 45 % are at risk and 36% are well nourished .
Kabir1 et al, (2007) found According to MNA categorization in a household elderly , the prevalence of malnutrition and risk of malnutrition in their sample was 26% and 62% respectively and 10% are well nourished and these percentage are near to ours .however according to Hengstermann et al, (2007) using also MNA, 15% of patients were well-nourished, 65% at risk of malnutrition and 20% were malnourished in a multi morbid elderly which refers to the higher prevalence of malnutrition and also the risk of malnutrition in persons with either one current disease or multiple diseases.
Soini et al, (2004) found in their study 11% of the nursing homes (NH) residents and 3% of long term care setting (LT) patients were well nourished. Of NH residents 60 % were at risk of malnutrition and 29 % were malnourished. The respective figures for LT patients were 40 % and 57 %. which is much greater than home living in our study .this may indicate that nursing homes predispose to malnutrition more than home care .this hypothesis is supported by Gazzotti et al.,(2000) who reported that patients originating from nursing homes had a poorer nutritional status than those living at home (MNA: 18.4 against 22.3, P <.001). the same also reported by Gonzalez et al.(2007)who found that the occurrence of undernutrition can be low among elders living freely in the community, but it might affect a vast number of those seeking medical assistance at the public health institutions .this is also may be explained by that elderly who need public health institutions assistance are those who had any morbidity or are not well so they seek help.
Guigoz et al.,2002 reported that In more than 10,000 elderly persons, the prevalence of undernutrition assessed by the MNA is 1% to 5% in community-dwelling elderly persons and outpatients, 20% in hospitalized older patients, and 37% in institutionalized elderly patients.
Malnutrition and gender in the current study , women represent 75% of malnourished , 70% of those at risk and 40% of those well nourished with highly significant relation with malnutrition ( p < 0.001) which is matched with Kabir et al,(2007) who found that women had a significantly lower mean MNA score (17.2) than men (18.1) also Morillas et al,(2006) found in Murcia Significant differences (p < 0.05) in malnutrition risk by gender, being higher in females as compared to men . Griep et al.,(2000 ) found also women had slightly, but significantly, lower MNA scores than men (respectively, 23.4, SD = 2.8; and 24.6, SD = 2.6; p = .048). in the other hand Gazzotti C et al, (2000) found that There was no association between MNA and gender .
Malnutrition and age, In this study there is highly statistical significant relation between malnutrition and increasing age (p <0.01).Kabir et al,(2007) found that the prevalence of malnourishment is higher in the older population than younger adults. Baweja et al,(2008) also reported that as the age increases, malnutrition and risk of malnutrition increase. When we compared elderly of >75 years with those of <75 of age, more were malnourished (7.24% v/s 6.66%) and at risk of malnutrition (56.52 % v/s 46.87%) and less were well nourished (36.24% v/s 46.47 %). Shum et al,(2005) found that The age distribution of malnourished patients (mean, 86.2 years )was significantly different to those nourished (79.1 years ) ,higher in those malnourished .They found that The distribution of malnourished and nourished subjects among the young-old, old, and old-old groups were 0/9, 3/43, and 17/48, respectively meaning that it is higher in old old . However Gazzotti C et al (2000) found that There was no association between MNA and age .
Malnutrition and current psycho mental status , In our study there is highly significant relation between malnutrition and current psycho mental problems (p <0.01). also Brocker et al,(2003) found in their study that under nutrition is more frequently associated with low mini mental state examinations (p < 0.001).
Malnutrition and body mass index , In the current study there is negative relation between BMI and malnutrition ( p<0.1) which matched with results of previous studies, Inoue et al,(2007) found That MNA score related with anthropometric measurements ( P < 0.01) .also Morillas et al, (2006) found in Murcia 17%of the studied home living elder people have a likely risk for malnutrition, with 3% of malnourished patients. BMI and malnutrition risk are negatively correlated (p < 0.01). Baweja et al,(2008) found that among elderly having BMI <19 significantly higher (p < 0.001) was the prevalence of malnutrition (18.7%) than those having BMI 19 to < 23 (1.4%) or >23 (0.8%) . At risk of malnutrition were also more among those having BMI < 19 (72.3%) than those with BMI 19 to < 23 (57.8%) or > 23 (25%). But it is noticed that the percentage of low body mass index is much less than the percentage of malnutrition resulted from the assessment by MNA this may indicate that MNA is an earlier indicator for malnutrition than body mass index MNA is more sensitive than body mass index .
Malnutrition and depression or anxiety, In our study there is highly significant relation between malnutrition and depression or anxiety in last three months ( p <0.01) and this is supported by scientific review which reported that mood changes strongly affect the eating habits . also Johnson (2005) found 17% of participants were at risk of malnutrition. Compared with those who had adequate nutrition, at-risk participants had significantly higher levels of depression (p<0.04). Antoni Salva and Guillem Pera (2001) reported that depression has been correlated with weight loss in many studies.
Malnutrition and type of movement , in this study there is highly significant relation between movement and malnutrition (p <0.01).which means that inability to reach sources of food and inability to prepare food is strongly affect the nutritional status .Wylie et al,(1999) also concluded that elderly people living in the community with restricted mobility may be unable to consume an optimum nutritional intake due to the health and social factors which affect their food choices and nutritional intake. Baweja et al,(2008) found that prevalence of malnutrition and at risk of malnutrition was significantly higher in home bound elderly (25% and 68.05%) in comparison to persons who were functionally active and going out (5.71% and 49.92%).
malnutrition and pressure ulcers , in this study there is highly significant relation between malnutrition and presence of bed sores (p < 0.01), matched with previous results pnchofsky-DevinGD et al , (1986) found that there was a significant difference (P less than 0.001) between the nutritional status of pressure sore patients and the malnourished patients. It appears that the development of pressure sores correlates with nutritional deficiencies. Hengstermann et al,(2007) found according to MNA, 39.5% of the pressure ulcer (PU) patients were malnourished, and 2.5% were well nourished. By contrast, 16.6% of the non-PU patients were malnourished, and 23.6% were well nourished.. these results may be explained by Connie et al,(2004) who concluded that both micronutrients (vitamins and minerals) and macronutrients (carbohydrates, fats, and protein) are intrinsic or essential factors in the wound healing cascade of inflammation, proliferation, and remodeling. Pressure ulcer development or the presence of a chronic non healing ulcer places increased metabolic demands on the individual and initiates a cascade of catabolic events that includes an increase in the release of catabolic hormones (eg, cortisol and catecholamine) and a simultaneous down-regulation of the anabolic hormones .Catabolism also can be a response to stress, malnourishment, trauma, or infection. These factors can occur simultaneously, each contributing to the catabolic state, and also with inter-related cause and effect, causing a spiral of malnutrition that impacts the wound healing process.
Malnutrition and food intake , In our results there is highly significant relation (p <0.01) between malnutrition and type of food lacking of proteins and diminished fruits and vegetables intake daily. Also Yap KB et al,(2007) found that The most common contributions to nutritional risks were: changing food intake due to illness (40.3 percent), taking three or more different medications daily (25.0 percent), eating alone (14.5 percent) and consuming insufficient amount of fruits, vegetables or milk products on a daily basis (9.0 percent). Feldblum et al,(2007) found that lower dietary score indicating lower intake of vegetables fruits and fluid, poor appetite and difficulties in eating distinguished between malnourished and at-risk populations with the highest sensitivity and specificity as compare with the anthropometric, global, and self-assessment of nutritional status parts of the MNA .Guigoz (2006) found that Malnutrition is associated with functional and cognitive impairment and difficulties eating. The MNA detects risk of malnutrition before severe change in weight or serum proteins occurs .
Malnutrition and appetite and polypharmacy, in the current study It is found that a significant relation between malnutrition and taking more than three drugs daily (p <0.01)is present .The Marin County Department of Health & Human Services, Division of Aging(2002)concluded that problems with dental health, loss of appetite and interactions between medications and nutrients are some of the challenges that cause older adults to be at nutritional risk . Griep et al.,(2000) also found a significant negative relation between number of drugs taken and the MNA score . in the other hand Shum et al,(2005) found in their study in china that some risk factors for malnutrition did not differ significantly between nourished and malnourished patients: depression , moderately or severely impaired cognitive function ,polypharmacy and living alone.
Malnutrition and weight loss , In our study subjective answer about weight loss in last three months is highly significant (p< 0.01) related with malnutrition .Antoni Salva et al,(2001) found that weight loss greater than 10% within a 6-month period has been considered an indicator for under nutrition.
Malnutrition and number of meals , Wylie(1999), concluded that there was an infrequent consumption of cooked meals in malnourished patients. The highest proportion of the well-nourished group took three full meals per day and a third of the undernourished group survived on one meal a day (P , 0.001). .In our study there is highly significant negative relation between malnutrition and number of meals (p <0.01)increasing in malnutrition with decreasing number of meals taken daily , although there is a big percent of malnourished taking two and three meals daily but this may reflect the poor content of meals .
Malnutrition and socioeconomic state , The Marin County Department of Health & Human Services, Division of Aging(2002) concluded that low-income older adults are at particularly high risk of malnutrition but in the current study we found that there is no statistical significant relation between malnutrition and socioeconomic status .
List of figures
figure (1) recommended food guide pyramid for elderly people……….51
figure (2) shows the prevalence of malnutrition ……………………….62
figure (3) Shows distribution of socio. Economic status among participants……………………………………………………………..63
figure (4) relation between malnutrition and body mass index………..65
figure (5) relation between malnutrition and weight loss in last 3 months………………………………………………………………....68
Figure (6) the relation between malnutrition and current psycho and mental problems ……………………………………………………….71
Figure (7) relation between malnutrition and number of meals……….72
figure (8) the relation between malnutrition and decrease In food intake in last 3 months…………………………………………………………74
Figure (9) shows the relation between malnutrition and feeding……….76
figure (10) the relation between malnutrition and how the patient compare his health with others……………………………………………………77
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Summary
The number of persons 65 years of age and older continues to increase dramatically. Comprehensive health maintenance screening of this population is becoming an important task for primary care physicians. As outlined by the U.S. Preventive Services Task Force, assessment categories unique to elderly patients (Karl et al,2000).
Malnutrition in older people is not only common, but frequently overlooked. It can result in multiple medical complications, hospitalization and even death.( Visvanathan et al,2004)
Kabir et al study for detection of hyponutrition in elderly persons in a rural area in Bangaladish found that BMI<18.5 kg m), indicating chronic energy deficiency, was found in 50% of the population and . MNA revealed prevalence of 26% for protein-energy malnutrition and 62% for risk of malnutrition. (Kabir et al,2006 ).
Patients and methods
This study aiming at assessment of the prevalence and the most common risk factors affecting malnutrition among elderly groups in Abou Khalifa village ,a rural village in Ismailia ,
It is a cross sectional study .
The study carried out in abou khalifa village on 300 elderly whose 65 years and older , home based chosen randomly,
The study used the Mini Nutritional Assessment questionnaire as a screening tool for the nutritional status among elderly and used the Amenities and Possessions Index (API)as an index for the socio economic status .
Results
About 19% of participants are malnourished ,45% are at risk and 35% only are well nourished . also the study found that the most common risk factors affecting malnutrition are female gender , increasing age , decrease in number of meals daily ,deficient diet regarding fruit and vegetables and proteins ,decrease in number of fluid intake daily ,current psycho and mental problems ,presence of anxiety or depression in last three months , inability to move , taking more than three drugs daily and decrease in food intake in last three months but the socio economic status found not to affect the nutritional status .
Summary
The number of persons 65 years of age and older continues to increase dramatically. Comprehensive health maintenance screening of this population is becoming an important task for primary care physicians. As outlined by the U.S. Preventive Services Task Force, assessment categories unique to elderly patients (Karl et al,2000).
Malnutrition in older people is not only common, but frequently overlooked. It can result in multiple medical complications, hospitalization and even death.( Visvanathan et al,2004)
Kabir et al study for detection of hyponutrition in elderly persons in a rural area in Bangaladish found that BMI<18.5 kg m), indicating chronic energy deficiency, was found in 50% of the population and . MNA revealed prevalence of 26% for protein-energy malnutrition and 62% for risk of malnutrition. (Kabir et al,2006 ).
Patients and methods
This study aiming at assessment of the prevalence and the most common risk factors affecting malnutrition among elderly groups in Abou Khalifa village ,a rural village in Ismailia ,
It is a cross sectional study .
The study carried out in abou khalifa village on 300 elderly whose 65 years and older , home based chosen randomly,
The study used the Mini Nutritional Assessment questionnaire as a screening tool for the nutritional status among elderly and used the Amenities and Possessions Index (API)as an index for the socio economic status .
Results
About 19% of participants are malnourished ,45% are at risk and 35% only are well nourished . also the study found that the most common risk factors affecting malnutrition are female gender , increasing age , decrease in number of meals daily ,deficient diet regarding fruit and vegetables and proteins ,decrease in number of fluid intake daily ,current psycho and mental problems ,presence of anxiety or depression in last three months , inability to move , taking more than three drugs daily and decrease in food intake in last three months but the socio economic status found not to affect the nutritional status .
Aim of the
To improve nutritional health in elderly
Objectives
(1) To assess the prevalence of malnutrition in elderly in Abou Khalifa village.
(2) To screen for the major risk factors for malnutrition in elderly in Abou Khalifa village.
Research question
What is the prevalence of malnutrition in elderly in Abou Khalifa village and what are the most common risk factors for malnutrition ?
The hypothesis
Malnutrition has a high prevalence among elderly in Abou Khalifa village.
Contents
Contents…….………............................................ ........................ I
List of Tables ……………………………………………………. III
List of figures………………………………………... …………. V
List of Abbreviations ……………….………………… ……….. VI
Abstract ………………………………………………………… VII
Page
Chapter1-Introduction …………………………………………… 1
- Aim of the work ………………………………………. 9
Chapter 2: Review of Literature
● Definition of malnutrition……………………… ………………… 11
●Prevalence of malnutrition…………………… ………………. 13
● causes and risk factors of malnutrition……………………….. 16
● Effects of malnutrition………………………………………… 26
● Diagnosing malnutrition………………………………………. 30
● Management of elderly malnutrition …………………………. 41
● Nutritional needs of the elderly……………… ………………. 48
● Role of family physicians in managing malnutrition in elderly … 52
Chapter3: Subjects & Methods------------------------------------------- 56
Chapter 4: Results---------------------------------------------------------- 61
Chapter5 :Discussion------------------------------------------------------- 80
Chapter6 : Conclusion & Recommendations --------------------------- 89
Summary --------------------------------------------------------------------- 91
References------------------------------------------------------------------- 93
Appendices------------------------------------------------------------------ 101
Arabic summary------------------------------------------------------------ 1
In stating the Millennium Development Goals, the United Nations aimed to halve malnutrition around the world by 2015. Nutritional status of the elderly population in low-income countries is seldom focused upon.( Kabir et al., 2006) .
The number of persons 65 years of age and older continues to increase dramatically . Comprehensive health maintenance screening of this population is becoming an important task for primary care physicians. As outlined by the U.S. Preventive Services Task Force, assessment categories unique to elderly patients (Karl et al., 2000).
The fastest growing segment of the population in most industrialized countries is the elderly; and too often this is also a group most susceptible to many health risks from a nutrient poor diet. Evidence from numerous sources indicates that a significant number of elderly fails to get the amounts and types of food necessary to meet essential energy and nutrient needs. There is a wide range of reasons why older individuals might not be eating the most nutritious diet which is all the more reason why health professionals and care providers need to be constantly aware of the necessity for maintaining an optimal nutritional health status in the elderly. Physiological, psychological and economical changes in the later years can all contribute to poor nutrition among the elderly, and accordingly establishment of healthy nutritional habits often requires a multifaceted intervention approach to address the wide range of factors contributing to suboptimal nutrient intakes.( enc@enc.online.org )
The world health organization (WHO) defines malnutrition as ”the cellular imbalance between the supply of nutrients and energy and the body demand for them to ensure growth, maintenance ,and specific function”(Noah SScheinfeld,2007)
Clinical manifestation in adults generally losing weight ,although , in some cases ,edema can mask weight loss. Patients may describe restlessness, easy fatigability ,and a sensation of coldness. Global impairment of system function is present . in elderly persons , an indicative sign of malnutrition is delayed healing and an increased presence of decubitus ulcers . biochemical markers of malnutrition include certain serum proteins ,synthesized by liver namely : albumin ,transferrin ,retinol binding protein and thyrotoxine binding prealbumin . although these proteins are decreased by protein energy malnutrition related effects (decrease in liver mass and diminished hepatic protein synthesis ) there are also a number of other factors , which contribute , for example , infection. A total lymphocyte count is independently a poor prognostic indicator and is often associated with a low serum albumin .it is known that malnutrition contribute to age –related immune dysregulation including decreased lymphocyte proliferation .a low total cholesterol has also been correlated with risk of malnutrition and assessment of vitamin and trace element status is also important as mentioned previously (including b1 thiamine ,b2 riboflavine ,b6 pyrodixine ,calcium, vitamin D, folate and ferritin).(Nadim Haboubi and Dylan Harris ,2006)
Malnutrition in older people is not only common, but frequently overlooked. It can result in multiple medical complications, hospitalization and even death.( Visvanathan et al.,2004)
Undernutrition is an important public health issue which is frequently undetected and untreated. Disease and illness are the major causes of undernutrition, and older people are a particularly vulnerable group. Effective screening is needed to reduce the prevalence of malnutrition in older people and when this is established, action can then be taken to address the problem .( Todorovic ,2001)
Kabir et al study for detection of hyponutrition in elderly persons in a rural area in Bangaladish found that BMI<18.5 kg m(-2), indicating chronic energy deficiency, was found in 50% of the population and .Mini Nutritional Assessment (MNA )revealed prevalence of 26% for protein-energy malnutrition and 62% for risk of malnutrition. (Kabir et al., 2006 ).
An inadequate food intake in the elderly increases immunological system vulnerability, the risk for infections, and it also leads to muscle atrophy, high sugar and fat plasma levels, fatigue, apathy, greater risk for bone fractures, and lower response to medication. Physiological and pathological changes related to aging bring about changes in dietary habits and organ body use of nutrients. The main consequence is an increase in the prevalence of individuals with global or nutrient-specific hypo nutrition (Morillas Jet al.,2006)
Regulation of food intake changes with increasing age, leading to what has been called a ”physiologic anorexia of aging.” The amount of circulating cholecystokinin, a satiating hormone, increases in the circulation.9 Other substances are also thought to cause satiety.10,11 A role for cytokines, including cachectin (or tumor necrosis factor), interleukin-1 and interleukin-6, has also been postulated.1 Physiologic changes in food intake regulation occur even in the presence of the increased body fat and increased rates of obesity that occur with age, some of which can be explained by altered patterns of physical activity.12 Loss of lean body mass is common with increased age.2 Advancing age is also associated with a decrease in the basal metabolic rate, as well as changes in the senses of taste and smell.13 By the age of 65 years, approximately 50 percent of Americans have lost teeth, and resultant chewing problems can affect food intake. Lower socioeconomic status and functional disabilities can also contribute to involuntary weight loss in older patients.4 Elderly patients with dementing illnesses who are dependent on others for daily care are more likely to suffer unintended weight loss than are those who are demented but less dependent or those who are not demented. (Grace Brooke Huffman et al., 2002).
Other causes and risk factors of malnutrition :
Elderly persons often develop malnutrition ,common causes of which include decreased appetite , dependency on help for eating , impaired cognition and/or communication , poor positioning ,frequent acute illnesses with gastrointestinal losses, medications that decrease appetite or increase nutrient losses , polypharmacy, decreases thirst response, decreased ability to concentrate urine , intentional fluid restriction due to fear of incontinence or choking if dysphagic, psychosocial factors such as isolation and depression , monotony of diet ,higher nutrient density requirements, and other demands of age ,illnesses, and disease on the body . patients with liver cirrhosis are also at risk for protein energy malnutrition(PEM), which is a risk factor that portends a poor prognosis for survival . This risk correlates with the degree of liver injury and the etiology of liver disease , with the risk of PEM being more severe in persons with alcoholic cirrhosis than in those with nonalcoholic cirrhosis . patients on long term hemodialysis also may develop PEM ;this is associated with increased morbidity and mortality. Patients with squamous cell carcinoma of the esophagus are at risk for PEM. (NIH Guide ,1994)
Although 13% of the elderly’s diets are poor and about two-thirds need improvement by the HEI, this is still better than younger adults who score 18% as poor and 70% as needing improvement. However, as people age past 74 years, their diet quality slowly declines.( nutritionnewsfocus.com ).
In Egypt 16.7% of the population– almost 11.7 million – live below the poverty line . poverty ,food insecurity ,malnutrition and gender disparities are still significant problems at the regional level . in upper Egypt 36% or 9.5 million people consume less than the recommended minimum level of dietary energy .( Regional bureau ,2007)
A study prepared by the National Research Center in Egypt found that 32% of Egypt’s children suffer from malnutrition because of a inadequate intake of protein and calories.( ArabicNews.com ,2007)
In Murcia 17% of analyzed elderly people have a likely risk for malnutrition and 2% are malnourished .( Morillas et al.,2006).
Malnutrition is an independent predictor of mortality in older adults .( Verdery et al., 1991)
Assessment of malnutrition involves a dietary history that includes daily caloric intake, the availability of food, the use of nutritional or herbal supplements, and the adequacy of the patient’s diet as quantified through the amount of food intake, the number of meals, and the balance of nutrients. Body weight, weight trend, and muscle wasting that is found on physical examination and confirmed by laboratory data (such as serum albumin and total cholesterol levels, and lymphocyte count) should be included.( Grace Brooke Huffman et al., 2002)
Medications associated with malnutrition include digoxin, diuretics, anti-inflammatory agents, antacids, H2-blockers, antidepressants, anticonvulsants, anti-neoplastic agents, hypoglycemic agents and major tranquilizers; they can produce this effect by causing anorexia, nausea, vomiting, diarrhea, cognitive disturbance or increased metabolism.( Thomas, 1999).
While there are many physical and clinical factors that lead to malnutrition, many elderly experience social, family and economic changes. In the UK, almost two million pensioners live in poverty and are facing ill health because of an inadequate diet. 8 Social isolation, loneliness, depression, minority status, caregiver burnout, lack of cooking and shopping skills and economic concerns can place older people at moderate to high nutritional risk. (International council of nurses ,2007)
The Mini Nutritional Assessment (MNA), a validated tool for measuring nutritional risk in elderly persons that combines anthropometric measures and dietary history, is easy to use in the office setting. Patients also should be assessed for oral pathology, ill-fitting dentures, problems with speech or swallowing, medication use that might cause anorexia or dysgeusia, and financial and social problems that may be contributors to malnutrition.(Grace Brooke Huffman et al., 2002)
Rational of the study
Despite being preventable and treatable, malnutrition remains a problem in the developing world and the nutritional needs of many older people are not met.. However, research is still needed into the detection, prevalence, cause and effects of malnutrition and maintenance of optimum nutrition; and to address the lack of training and education among those caring for older peoples.(Cowan et al.,2004)
List of tables
Table (1) Frequency of occurrence of all items of MNA questionnaire………61
Table (2) prevalence of malnutrition ………………………………………......62
Table (3) Relation between malnutrition and gender……………………………64
Table (4) Relation between malnutrition and age groups ……………………….66
Table (5) The relation between malnutrition and mid arm circumference………66
Table (6) The relation between malnutrition and mid calf circumference……….67
Table (7) Relation between malnutrition and taking more than 3 drugs daily……69
Table (8) The relation between malnutrition and depression or anxiety in last 3 months…………………………………………….. ………………………… ...69
Table(9) The relation between malnutrition and type of movement ………………70
Table (10) The relation between malnutrition and current psycho mental problems……………………………………………………………………… ……70
Table (11) The relation between malnutrition and presence of bed sores . ………...71
Table (12) The relation between malnutrition and type of food …………………….73
Table(13) The relation between malnutrition and fruits and vegetables eaten
daily………………………………………………………………………………….73
Table (14) Relation between malnutrition and fluid intake daily …………………...75
Table (15) The relation between malnutrition and elderly perception about his nutritional status ……………………………………………………………………..75
Table (16) The relation between malnutrition and socioeconomic status …………...78
Table (17) The relation between type of food and body mass index ……………….78
Table (18) Multiple regression between variables and malnutrition………………..79
RESULTS
Table (1)
Frequency of occurrence of all items of MNA questionnaire
N %
gender male 118 39.3%
female 182 60.7%
age 65 -< 70 230 76.7%
70 -< 80 56 18.7%
>= 80 14 4.7%
Body mass index < 19 8 2.7%
19 –< 21 10 3.3%
21 - <23 29 9.7%
> = 23 253 84.3%
Take more than three drugs yes 69 23.0%
no 231 77.0%
Depression or anxiety in last 3 months yes 180 60.0%
no 120 40.0%
Number of meals one 25 8.3%
two 67 22.3%
three 208 69.3%
Fruits and vegetable intake daily yes 34 11.3%
no 266 88.7%
Decrease in food intake in last 3 months sever 111 37.0%
mild 65 21.7%
no 124 41.3%
Number of fluid cups daily < 3 26 8.7%
3-5 96 32.0%
>5 178 59.3%
How patient think about his nutritional status has big problem 45 15.0%
moderate problem 50 16.7%
no problem 205 68.3%
Malnutrition score < 17 56 18.7%
17- 23,5 137 45.7%
>= 24 107 35.7%
socio. economic status high 16 5.3%
medium high 201 67.0%
medium 80 26.7%
low 3 1.0%
Table (1) shows percentage of occurrence of all items of the Mini Nutritional Assessment (MNA) questionnaire .
Table (2) prevalence of malnutrition
Malnutrition score
NO %
malnutrition < 17 56 18.7
At risk 17- 23,5 137 45.7
Well nourished >= 24 107 35.7
Total 300 100.0
shows prevalence of malnutrition among elderly :malnourished : 18.7% ,
at risk :45.7% and well nourished :35.7% .
Figure (2) shows the prevalence of malnutrition
figure (2) shows the prevalence of malnutrition
Figure (3) Shows distribution of socio. Economic status among participants
figure (3) Shows distribution of socio. Economic status among participants according to the Amenities and Possessions Index (API) .
Table (3)relation between malnutrition and gender
score Total
Malnourished At risk Well nourished
N % N % N % N %
gender male 14 25.0% 41 29.9% 63 58.9% 118 39.3%
female 42 75.0% 96 70.1% 44 41.1% 182 60.7%
Total
56 100.0% 137 100.0% 107 100.0% 300 100.0%
P= 0.000**
shows highly significant relation between malnutrition and gender: female participants shows more prevalence in malnutrition and at risk of malnutrition .
Figure (4) relation between malnutrition and body mass index
figure (4) relation between malnutrition and body mass index.
Shows highly significant relation between malnutrition and body mass index giving negative correlation between them .
Table (4) relation between malnutrition and age groups .
score Total
< 17 17- 23,5 >= 24 < 17
N % N % N % N %
Age Groups 65-<70 39 69.6% 114 83.2% 77 72.0% 230 76.7%
70-80 9 16.1% 20 14.6% 27 25.2% 56 18.7%
> 80 8 14.3% 3 2.2% 3 2.8% 14 4.7%
Total 56 100.0% 137 100.0% 107 100.0% 300 100.0%
p= .001**
The table shows highly statistical significant relation between malnutrition and increasing age
Table (5) the relation between malnutrition and mid arm circumference
score Total
Malnourished At risk Well nourished
N % N % N % N %
Mid arm circumference < 21 1 1.8% 3 2.2% 0 .0% 4 1.3%
21- 22 5 8.9% 5 3.6% 0 .0% 10 3.3%
>= 22 50 89.3% 129 94.2% 107 100.0% 286 95.3%
Total
56 100.0% 137 100.0% 107 100.0% 300 100.0%
P= 0.020*
shows significant negative relation between malnutrition and mid arm circumference .
Table (6) the relation between malnutrition and mid calf circumference
score Total
Malnourished At risk Well nourished
N % N % N % N %
Mid calf circumference < 31 26 46.4% 12 8.8% 2 1.9% 40 13.3%
>= 31 30 53.6% 125 91.2% 105 98.1% 260 86.7%
Total
56 100.0% 137 100.0% 107 100.0% 300 100.0%
P= 0.000**
shows highly significant negative relation between malnutrition and mid calf circumference .
Figure (5) relation between malnutrition and weight loss in last 3 months
figure (5) relation between malnutrition and weight loss in last 3 months Showing highly significant relation between malnutrition and weight loss in last 3 months with positive correlation .
Table (7) relation between malnutrition and taking more than 3 drugs daily
score Total
Malnourished At risk Well nourished
N % N % N % N %
More than 3 drugs daily yes 27 48.2% 27 19.7% 15 14.0% 69 23.0%
no 29 51.8% 110 80.3% 92 86.0% 231 77.0%
Total 56 100.0% 137 100.0% 107 100.0% 300 100.0%
P= 0.000**
Shows highly significant relation between malnutrition and taking more than 3 drugs daily
Table (8) the relation between malnutrition and depression or anxiety in last 3 months
score Total
malnourished At risk Well nourished
N % N % N % N %
Depression or anxiety in last 3 months yes 51 91.1% 97 70.8% 32 29.9% 180 60.0%
no 5 8.9% 40 29.2% 75 70.1% 120 40.0%
Total 56 100.0% 137 100.0% 107 100.0% 300 100.0%
P= 0.000**
Shows highly significant positive relation between malnutrition and depression or anxiety in last three months.
Table(9) shows the relation between malnutrition and type of movement
score Total
Malnourished At risk Well nourished
N % N % N % N %
movement No movement 0 .0% 2 1.5% 0 .0% 2 .7%
move but don’t go out door 8 14.3% 11 8.0% 0 .0% 19 6.3%
move and go out door 48 85.7% 124 90.5% 107 100.0% 279 93.0%
Total
56 100.0% 137 100.0% 107 100.0% 300 100.0%
P= 0.003**
Shows highly significant correlation between type of movement and malnutrition .
Table (10) the relation between malnutrition and current psycho mental problems
score Total
Malnourished At risk Well nourished
N % N % N % N %
Psycho mental problems sever dementia 46 82.1% 46 33.6% 9 8.4% 101 33.7%
mild dementia 7 12.5% 41 29.9% 11 10.3% 59 19.7%
no problems 3 5.4% 50 36.5% 87 81.3% 140 46.7%
Total 56 100.0% 137 100.0% 107 100.0% 300 100.0%
P= 0.000**
Table shows highly significant relation between malnutrition and current psycho mental problems
Figure (6) the relation between malnutrition and current psycho and mental problems .
figure(6) shows the relation between malnutrition and current psycho and mental problems with significant relation, increasing in malnutrition with presence of dementia .
Table (11)shows the relation between malnutrition and presence of bed sores .
score Total
Malnourished At risk Well nourished
N % N % N % N %
Bed sores yes 15 26.8% 6 4.4% 2 1.9% 23 7.7%
no 41 73.2% 131 95.6% 105 98.1% 277 92.3%
Total 56 100.0% 137 100.0% 107 100.0% 300 100.0%
P= 0.000**
Shows highly significant relation between malnutrition and presence of bed sores
Figure (7) relation between malnutrition and number of meals
figure (7) shows the relation between malnutrition and number of meals daily , highly significant relation between decreasing number of meals and increasing malnutrition
Table (12) shows the relation between malnutrition and type of food
Type of food
- at least one of (milk –cheese – yogurt)
- two or more of eggs every day
-meats or fish
score Total
Malnourished At risk Well nourished
N % N % N % N %
Type of food if all three types 20 35.7% 16 11.7% 3 2.8% 39 13.0%
if only two types 19 33.9% 39 28.5% 20 18.7% 78 26.0%
if only one type or none 17 30.4% 82 59.9% 84 78.5% 183 61.0%
Total 56 100.0% 137 100.0% 107 100.0% 300 100.0%
P= 0.000**
Shows highly statistical significant relation between malnutrition and type of food increasing in malnutrition with defect of type of food taken daily .
Table(13) the relation between malnutrition and fruits and vegetables eaten daily
score Total
Malnourished At risk Well nourished
N % N % N % N %
Fruit and vegetables daily yes 20 35.7% 13 9.5% 1 .9% 34 11.3%
no 36 64.3% 124 90.5% 106 99.1% 266 88.7%
Total
P= 0.000** 56 100.0% 137 100.0% 107 100.0% 300 100.0%
Shows highly significant relation between malnutrition and not taking fruits and vegetables daily .
Figure (8) the relation between malnutrition and decrease In food intake in last 3 months
figure (8) the relation between malnutrition and decrease In food intake in last 3 months showing that malnutrition increase with decrease in appetite in last three months .
- sever – sever loss of appetite .
- mild --- mild loss of appetite .
- no ---- no loss of appetite .
Table (14) relation between malnutrition and fluid intake daily
score Total
Malnourished At risk Well nourished
N % N % N % N %
Number of fluid intake daily < 3 cups 15 26.8% 4 2.9% 7 6.5% 26 8.7%
3-5 26 46.4% 57 41.6% 13 12.1% 96 32.0%
>5 15 26.8% 76 55.5% 87 81.3% 178 59.3%
Total 56 100.0% 137 100.0% 107 100.0% 300 100.0%
P= 0.000**
Shows highly significant negative relation between malnutrition and fluid intake daily , malnutrition increases with decrease in number of fluid cups taken daily .
Table (15) the relation between malnutrition and elderly perception about his nutritional status .
score Total
malnourished At risk Well nourished
N % N % N % N %
Thinking about nutritional status has big problem 32 57.1% 13 9.5% 0 .0% 45 15.0%
moderate problem 12 21.4% 37 27.0% 1 .9% 50 16.7%
no problem 12 21.4% 87 63.5% 106 99.1% 205 68.3%
56 100.0% 137 100.0% 107 100.0% 300 100.0%
P= 0.000**
The table shows highly significant relation between malnutrition and how the patient think about his nutritional status , malnutrition increase with thinking of the patient that he has a big problem .
Figure (9) shows the relation between malnutrition and feeding
Figure (9) shows the relation between malnutrition and feeding, malnutrition increase with difficulty in feeding .
Figure (10) the relation between malnutrition and how the patient compare his health with others
figure (10) shows the relation between malnutrition and how the patient compare his health with others . malnutrition increase with low self assessment in comparison with others with highly statistical significance .
Table (16) the relation between malnutrition and socioeconomic status
score Total
Malnourished At risk Well nourished
N % N % N % N %
Socio .economic status high 0 .0% 8 5.8% 8 7.5% 16 5.3%
medium high 41 73.2% 89 65.0% 71 66.4% 201 67.0%
medium 14 25.0% 38 27.7% 28 26.2% 80 26.7%
low 1 1.8% 2 1.5% 0 .0% 3 1.0%
Total 56 100.0% 137 100.0% 107 100.0% 300 100.0%
P= 0.399
Table shows that the relation between malnutrition and socioeconomic status is not significant .
Table (17) the relation between type of food and body mass index
Type of food
- at least one of (milk –cheese – yogurt) daily
- two or more of eggs every day
-meats or fish daily
Body mass index Total
<19 19 – 21 21 - <23 > = 23 <19
N % N % N % N % N %
if all three types 1 12.5% 0 .0% 1 3.4% 37 14.6% 39 13.0%
if only two types 4 50.0% 2 20.0% 4 13.8% 68 26.9% 78 26.0%
if only one type or none 3 37.5% 8 80.0% 24 82.8% 148 58.5% 183 61.0%
Total p=0. 039* 8 100.0% 10 100.0% 29 100.0% 253 100.0% 300 100.0%
The table shows significant relation between type of food and body mass index with DEcrease in BODY MASS INDEX with decrease in important types taken daily .
*statistical significant at the 0.05 level.
** Highly statistical significant at the 0.01 level.
Table (18) Multiple regression between variables and malnutrition
parameters Model Fitting Criteria Likelihood Ratio Tests
-2 Log Likelihood of Reduced Model Chi-Square df P value
gender 3071.327 185.217 1 .000 **
age 11265.692 8379.581 18 .001**
Body mass index 4947.451 2061.340 3 .000 **
Mid arm circumference 3150.050 263.939 2
0.020*
Take more than three drugs 6898.884 4012.774 1 .000 **
Depression or anxiety in last 3 months 9796.491 6910.381 1 .000 **
Number of meals 24528.984 21642.874 2 .000 **
Fruits and vegetable intake daily 9844.210 6958.100 1 .000 **
Decrease in food intake in last 3 months 3567.762 681.652 2 .000 **
Number of fluid cups daily 15595.168 12709.058 2 .000 **
How patient think about his health 12296.592 9410.481 2 .000 **
score 16801.029 13914.919 2 .000 **
Socio . economic level 4871.401 1985.290 3
0.399
The table shows that gender ,age ,decreased body mass index ,decreased mid arm circumference ,polypharmacy , depression or anxiety in last three months, decreased number of meals ,deficient fruits and vegetables daily, decreased food intake in last three months ,decreased fluid intake daily ,and the negative perception of the individual towards his nutritional status can be considered as indicators for malnutrition and all have significant relation with malnutrition . but socioeconomic status cannot be considered as an indicator as there is statistical insignificant relation .
معدل انتشار و عوامل الخطورة لسوء التغذية عند كبار السن بقرية أبو خليفة بالإسماعيلية
توطئة لدرجة الماجستير في طب الأسرة رسالة
مقدمة من
الطبيبة / شريفة سيد حسن سيد
بكالوريوس الطب و الجراحة 2002 م
معيدة طب أسرة
كلية الطب البشرى, جامعة قناة السويس
المشـرفـون
د/ أمانى حسين رفعت ا. د/محمد محمدى عواد دياب ا.
أستاذ طب المجتمع استاذ طب الأسرة
كلية الطب البشرى كلية الطب البشرى
جامعة قناة السويس جامعة قناة السويس
د. سهام أحمد عبد الحميدد
مدرس طب الأسرة
كلية الطب البشرى
جامعة قناة السويس
كلية الطب البشرى
جامعة قناة السويس
2008
Abstract
Introduction ;The number of persons 65 years of age and older continues to increase dramatically . and too often this is also a group most susceptible to many health risks from a nutrient poor diet .Comprehensive health maintenance screening of this population is becoming an important task for primary care physicians.
Aim of this study ;was to assess the nutritional status among elderly and the most common risk factors affecting malnutrition in Abou Khalifa village ,Ismailia governorate ,Egypt.
Subjects and methods ; The number of participants was 300 elders ,house hold ,chosen randomly ,descriptive The study used the Mini Nutritional Assessment questionnaire as a screening tool for the nutritional status among elderly and used the Amenities and Possessions Index (API)as an index for the socio economic status .
Results .the study found ;About 19% of participants are malnourished ,45% are at risk and 35% only are well nourished . also the study found that the most common risk factors affecting malnutrition are female gender , increasing age , decrease in number of meals daily ,deficient diet regarding fruit and vegetables and proteins ,decrease in number of fluid intake daily ,current psycho and mental problems ,presence of anxiety or depression in last three months , inability to move ,taking more than three drugs daily and decrease in food intake in last three months but the socio economic status found not to affect the nutritional status. Recommendations ; the study recommended that more effort should be done in screening for malnutrition in elderly ,more training for physicians for more awareness for health maintenance in elderly and increase awareness of elderly groups regarding nutrition .
Appendices
Appendix (1)
Definition of categories of the Amenities and Possessions Index (API)
Individuals are assigned the following values of the API index according to whether their household has the specified combination of basic amenities and consumer durables:
HIGH API: Bottled water or water piped into residence (or property, where relevant) for both drinking and non-drinking purposes; own (not shared) flush toilet, electricity, all four consumer durables namely radio, television, refrigerator and car.
MEDIUM-HIGH API: Any kind of drinking and non-drinking water source other than surface water; any kind of flush or pit toilet latrine or ”other” toilet facilities; may or may not have electricity; at least two of the four consumer durables;
MEDIUM API (The residual category): Any kind of drinking or non-drinking water source including surface water and ”other” water sources; any kind of toilet facility including those listed under no facility and ”other”; may or may not have electricity; any combination of the four consumer durables including none;
LOW API: Only surface water for drinking and non-drinking purposes; no toilet facility ; no electricity; none of the four consumer durables.
Appendix (2)
Mini Nutritional Assessment
Last name:__________ First name:__________ Middle initial:____ Sex:____ Date:________ Age:____ Weight (kg):____ Height (cm):____
Complete the form by writing the points in the boxes. Add the points in the boxes, and compare the total assessment to the malnutrition indicator score.*
Anthropometric assessment Points Points
1. Body mass index (weight in kg ÷ height in m2):
a. <19 = 0 points
b. 19 to <21 = 1 point
c. 21 to <23 = 2 points
d. >23 = 3 points
2. Mid arm circumference:
a. <21 cm = 0 points
b. 21 to <=22 cm = 0.5 point
c. >22 cm = 1 point
3. Calf circumference:
a. <31 cm = 0 points
b. >=31 cm = 1 point
4. Weight loss during past 3 months:
a. >3 kg = 0 points
b. Does not know = 1 point
c. 1 to 3 kg = 2 points
d. No weight loss = 3 points
General assessment
5. Lives independently (not in a nursing home or hospital):
a. No = 0 points
b. Yes = 1 point
6. Takes more than three prescription drugs per day:
a. Yes = 0 points
b. No = 1 point
7. Has suffered psycho logic stress or acute disease in the past 3 months:
a. Yes = 0 points
b. No = 1 point
8. Mobility:
a. Bed-bound or chair-bound = 0 points
b. Able to get out of bed or chair, but does not go out = 1 point
c. Goes out = 2 points
9. Neuropsychological problems:
a. Severe dementia or depression = 0 points
b. Mild dementia = 1 point
c. No psycho logic problems = 2 points
10. Pressure sores or skin ulcers:
a. Yes = 0 points
b. No = 1 point
Dietary assessment
11. How many full meals does the patient eat daily?
a. One meal = 0 points
b. Two meals = 1 point
c. Three meals = 2 points
12. Selected consumption markers for protein intake:
a. At least one serving of dairy products (milk, cheese, yogurt) per day:
Yes No
b. Two or more servings of legumes or eggs
per week:
Yes No
c. Meat, fish or poultry every day:
Yes No
0 or 1 yes answers = 0 points
2 yes answers = 0.5 point
3 yes answers = 1 point
13. Consumes two or more servings of fruits or vegetables per day:
a. No = 0 points
b. Yes = 1 point
14. Decline in food intake over the past 3 months because of loss of appetite, digestive problems, or chewing or swallowing difficulties:
a. Severe loss of appetite = 0 points
b. Moderate loss of appetite = 1 point
c. No loss of appetite = 2 points
15. Cups of fluid (e.g., water, juice, coffee, tea, milk) consumed per day (1 cup = 8 oz):
a. <3 cups = 0 points
b. 3 to 5 cups = 0.5 point
c. >5 cups = 1 point
16. Mode of feeding:
a. Needs assistance to eat = 0 points
b. Self-fed with some difficulty = 1 point
c. Self-fed with no problems = 2 points
Self-assessment
17. Does the patient think that he or she has nutritional problems?
a. Major malnutrition = 0 points
b. Moderate malnutrition = 1 point
c. No nutritional problem = 2 points
18. How does the patient view his or her health status compared with the health status of other people of the same age?
a. Not as good = 0 points
b. Does not know = 0.5 point
c. As good = 1 point
d. Better = 2 points
Assessment total (maximum of 30 points): *
*--Malnutrition indicator score: >=24 points = well nourished; 17 to 23.5 points = at risk for malnutrition; <17 points = malnourished.
FIGURE 1. Mini Nutritional Assessment.
Adapted with permission from Guigoz Y, Vellas B, Garry PJ. Assessing the nutritional status of the elderly: the Mini Nutritional Assessment as part of the geriatric evaluation. Nutr Rev 1996;54:S59-65.
ِ
Prevalence and risk factors of malnutrition among elderly in Abou Khalifa village , Ismailia governorate
Thesis submitted for partial fulfillment
of the master degree in family medicine
BY
Sherifa Sayed Hassan Sayed
M . B . B. CH .(2002 )
Suez Canal University
Demonstrator of family medicine department
Supervisors
Prof. Amany Hussein Refaat Prof.Mohammed M .Awad Diab
Professor of community medicine Professor of family medicine
Faculty of medicine faculty of medicine
Suez Canal University Suez Canal University
And
Dr: Seham Ahmed Abd El Hameed
Lecturer of family medicine
Faculty of medicine Suez canal university
Faculty of medicine
Suez Canal University
2008
List of abbreviations
ACBS …….. Advisory Committee on Borderline Substances
ADL……… activities of daily living
AIDS ………. Acquired immunodeficiency syndrome
BMI ……….. body mass index
DTH ……….. delayed-type hypersensitivity
FPs ….. family physicians
GI ……. Gastrointestinal
GP ………… general practice
HANES…..……..Health and Nutrition Examination Survey
HIV…………Human Immuno Deficiency virus
INA ………. The Instant Nutritional Assessment
IV ………… intravenous
LT …..long term care
MAG…….. Malnutrition Advisory Group
MNA…… Mini Nutritional Assessment
NHANES III -- Third National Health and Nutrition Examination Survey
NICE ……National Institute for Clinical Excellence
NS …..Nursing setting
NSAIDs …… non-steroidal anti-inflammatory drugs
P ……. P value
PEM…… protein energy malnutrition
PU…… pressure ulcer
RDA ….. recommended daily allowance
SD ….. standard deviation
SGA ............ The Subjective Global Assessment
TLC ……… Total lymphocyte count
UK……….. United kingdom
US …………United states
WHO ………The world health organization
Definition of malnutrition in the elderly
Faulty or inadequate nutritional status; undernourishment characterized by insufficient dietary intake, poor appetite, muscle wasting and weight loss. In the elderly, malnutrition is an ominous sign. Without intervention, it presents as a downward trajectory leading to poor health and decreased quality of life. Malnutrition in the elderly is a multidimensional concept encompassing physical and psychological elements. It is precipitated by loss, dependency, loneliness and chronic illness and potentially impacts morbidity, mortality and quality of life.( Chen et al., 2001).
Malnourished subjects were identified as having at least three nutritional variables (which included weight index, triceps skin fold thickness, arm muscle circumference, serum albumin, and delayed cutaneous hypersensitivity reaction) below the reference range .(Cederholm et al., 1995) .
Malnutrition is a nutrient deficiency state, whether of protein, energy or micronutrients (vitamins and minerals) , This causes measurable harm to body composition, function or clinical outcomes. (NICE guidelines, 2006)
Malnutrition is a common, potentially serious, and frequently under-diagnosed condition among elderly individuals. Age-related physiologic changes in combination with organic and psychological disease processes contribute to the development of malnutrition in older adults. Profound malnutrition and serious illnesses often present concurrently, and each can accelerate the progression of the other. (Ramzi et al. ,2004)
World-wide, the elderly population is increasing, and with it, the pre-valence of malnutrition. Malnutrition is associated with significantly increased morbidity and mortality in independently living older people , as well as in nursing home residents and hospitalized patients.(Bienia ,1982).
The World Health Organization (WHO)1 defines malnutrition as ”the cellular imbalance between the supply of nutrients and energy and the body’s demand for them to ensure growth, maintenance, and specific functions.” (Noah et al , 2008)
Prevalence and burden of malnutrition
One in seven people aged over 65 in the UK are malnourished, or at severe risk of malnutrition, according to the Malnutrition Advisory Group (MAG). The North West is hardest hit, with one in five over-65s in the region under-nourished. There is a clear north-south divide, with a 71% greater prevalence amongst over 65s in the north compared to the south. Professor Marinos Elia, chairman of the MAG, part of the British Association for Parenteral and Enteral Nutrition, told BBC News Online: ”Malnutrition is a public health problem. but when you look at vulnerable groups, such as the elderly, malnutrition is a serious problem. In the UK malnutrition is a major health problem and older people are particularly at risk ” . (Health ,2001)
’’In a conservative estimate, 15 percent to 20 percent of those over 65 in North America are malnourished,’’ said Dr. Ranjit K. Chandra of the Memorial University of Newfoundland, Canada. ’’For those at special risk - those with chronic diseases or who have lost their spouses or are poor - the rate is higher.’’ Among the affluent and happy, he said, the proportion of malnourished is much lower, perhaps less than 5 percent. (Erik Eckholm,1985)
Globally, malnutrition is the most important risk factor for illness and death. Amongst the elderly: malnutrition affects 1% healthy individuals in the community, 4-5% patient receiving home help living at home, 20% in hospital patients, and 37% in institutionalized individuals (Swiss study). (Guigoz et al ,2002)
Although only 1% of older adults who are independent and healthy are malnourished, the Health and Nutrition Examination Survey (HANES) data indicated that 16% of community-dwelling Americans older than 65 years consumed fewer than 1000 calories per day--a statistic that would place these persons at high risk for undernutrition. (Wallace et al.,1999- Endoy,2005)
The nutritional risk increases in the community-dwelling elderly who are sick, poor, homebound, and have limited access to medical care. Malnutrition can become a major concern. The incidence of malnutrition ranges from 12% to 50% among the hospitalized elderly population and from 23% to 60% among institutionalized older adults . (Wallace et al.,1999- Endoy,2005 – Ennis et al., 2001)
The prevalence of PEM varies greatly with the population studied and the criteria used to define malnutrition. It is estimated that up to 15% of community-dwelling and ambulatory elderly persons, and 5% to 44% of homebound patients are malnourished. The prevalence increases to 20% to 65% in hospitalized patients and 23% to 85% in nursing home residents. The point prevalence of PEM on admission to a long-term care facility was estimated at 54% in one study , and 60% of residents showed a net weight loss following admission to an academic nursing home. Blaum et al .report that approximately 10% of nursing home residents lost 5% of their weight within one month of admission, or 10% of their weight within six months. Nutritional compromise, however, need not be a necessary consequence of long-term care. Abbasi et al. report that nursing homes with aggressive evaluation and treatment policies for malnutrition had lower prevalence and fewer complications of PEM compared to nursing homes without such policies. Nutritional supplementation has been shown to improve the prevalence and outcome of PEM in long-term care facilities, with 50% of malnourished residents gaining weight and 63% showing improvement in PEM diagnostic criteria.( Ramzi et al. ,2004)
Protein-energy malnutrition in non cancer medical patients is associated with an excess mortality in those with congestive heart failure. Improvement of PEM is accompanied by a decline in inflammatory activity. (Cederholm et al. 1995)
In some studies, the PEM prevalence among elderly persons is estimated to be as high as 4% for those living in the community, 50% for those hospitalized in acute care units or geriatric rehabilitation units, and 30-40% for those in long-term care facilities. PEM has also been found to be a primary factor of poor prognosis in elderly persons. (Noah ,2008)
In a study in Jerusalem Based on MNA found that > 24, 91% of the study population were in good nutritional state, 8.3% were at risk of undernutrition, and 0.7% were malnourished. (Maaravi et al.,2000)
Causes and risk factors of malnutrition in elderly
Malnutrition is often due to one or more of the following factors: inadequate food intake; food choices that lead to dietary deficiencies; and illness that causes increased nutrient requirements, increased nutrient loss, poor nutrient absorption, or a combination of these factors .(Demling and DeSanti, 2005)
Nutritional inadequacy in the elderly can be the result of one or more factors--physiologic, pathologic, sociologic, and psychologic .The difficulty for the clinician is in identifying the underlying factors contributing to the problem and how to intervene effectively.
A physiologic decline in food intake has been seen in people as they age regardless of chronic illness and disease. Physiologic changes that decrease food intake--often referred to as the anorexia of aging--involve alterations in neurotransmitters and hormones that affect the central feeding drive and the peripheral satiation system .(Endoy, 2005- Morley,2002 - Huffman ,2002)
Loss of lean body mass and the decreased basal metabolic rate observed in persons of advanced age also may influence appetite and food intake. Sensory decline in both olfaction and taste decreases the enjoyment of food, leads to decreased dietary variety, and promotes increased dietary use of salt and sugar to compensate for these declines . (Morley,2002)
Underlying pathology and medical treatment can directly cause anorexia and malnutrition. Disorders of the gastrointestinal system--ranging from problems with dentition and swallowing to dyspepsia, esophageal reflux, constipation, and diarrhea--are related to poor intake and malabsorption of nutrients. Many diseases (eg, thyroid, cardiovascular, and pulmonary disease) often lead to unintentional weight loss through increased metabolic demand and decreased appetite and caloric intake .(Bouras et al.,2001)
Chronic illnesses such as diabetes, hypertension, congestive heart failure, and coronary artery disease are treated with dietary restrictions and with medication that affects food intake. Because sugar, salt, and fat contribute to the taste of food, dietary restrictions may make food unpalatable. Drugs affect nutritional status through side effects (eg, anorexia, nausea, and altered taste perception) and through alteration of nutrient absorption, metabolism, and excretion(J Adv Nurs , 2001).
Socioeconomic status and functional ability are often major indicators of nutritional status. The cost of housing and medical expenses (most notably, medication) often competes with the money needed for food. When financial concerns are present, meals are often skipped and food that is purchased may not provide a nutritionally adequate diet. Declines in functional status both physical and cognitive, affect a person’s ability to shop for food and to prepare meals. Loss of instrumental skills related to activities of daily living (eg, shopping, transportation, meal preparation, housekeeping, taking medications, managing finances, using the telephone) leads to dependence on others. Nutritional problems are further compromised by inadequate social support networks and by resultant social isolation, which commonly leads to apathy about food and therefore decreased intake.
Late life can be a time of multiple losses. The older person has experienced change and loss through retirement, disability and death of friends and family as well as change in financial, social, and physical health status. These changes may lead to depression, a well-known cause of anorexia and weight loss. Even transient depressed mood (as with bereavement) can cause clinically significant weight loss. Depression is often unrecognized in older persons, many of whom are seen for distinctly somatic complaints. Malnutrition may be a presenting symptom of depression in the elderly .(Morley,2002)
Changes in Food Intake and Body Composition with Aging
There is evidence from both cross-sectional[ 44 , 45 , 46 ] and longitudinal[ 47 , 48 ] studies that there is an increase in lean body mass and percentage of body fat in both men and women up to the age of 70 years. This is followed by a decline in both lean body mass and body fat. Data from the third National Health and Nutrition Examination Survey (NHANES III)[ 49 ] as well as other studies[ 50 , 51 , 52 , 53 ] clearly demonstrate a linear decline in food intake from the age of 20 to 80 years in both men and women. The average decrease in food intake was 1321 calories in males and 629 calories in females.[ 54 ] This decrease in food intake was predominantly due to a decrease in fat intake.[ 44 ] In the study by Wurtman et al,[ 52 ] older persons ate 55% less fat and 40% less carbohydrate than younger individuals. Protein consumption was equivalent in both age groups. Older persons were also less likely to snack between meals. Rolls et al[ 54 ] found that older persons consumed less calories over a single meal compared to younger persons. However, when given a yogurt preload, older subjects were likely to overeat compared to younger subjects, suggesting a failure of normal energy-setting mechanism that operate in younger persons. In another study by the same group, it was found that, in contrast to the young, older persons fail to develop sensory-specific satiety.[ 54 ]
Several investigators have demonstrated that older persons develop dysregulation of food intake based on internal cues.[ 55 , 56 , 57 ] Cook et al[ 58 ] found that following an overnight fast, older persons were less hungry and had less desire to eat than younger individuals. Clarkston et al[ 55 ] found that fasting older individuals were less hungry, and after a standardized meal they demonstrated a higher level of satiation than did younger persons. Utilizing two-day food diaries, de Castro[ 56 ] compared 3,007 healthy adults aged 20-80 years and reported that older subjects ate less but drank similar amounts of fluids compared to younger controls. They were likely to eat smaller meals and they tended to eat their meals at a slower pace. Hunger was an equal driving force for food intake in younger and older subjects. Roberts et al[ 57 ] examined the effect of overfeeding or underfeeding in young and older subjects for 21 days. Following overfeeding, younger males decreased their food intake while older males failed to demonstrate this spontaneous hypophagia. This resulted in the younger men returning to their pre-experimental weight, while older men failed to lose weight. Following underfeeding, young men developed hyperphagia and regained the lost weight, while older persons failed to increase food intake and failed to regain the body mass lost during underfeeding.
Etiology of the Physiological Anorexia of Aging
The physiological decrease in food intake with aging, referred to as anorexia of aging, may be attributed to several factors. Older persons show multiple changes in taste sensation. Gustatory papillae atrophy has been demonstrated to occur in humans from middle age onward.[ 59 ] Taste threshold tends to increase with advancing age, with sweet taste being less affected than other modalities.[ 60 ] Average taste-detection threshold for older persons varies across the different taste modalities, with salt showing the greatest increase. There is no connection, however, between taste detection threshold and food consumption.[ 61 , 62 ] Schiffman et al[ 63 ] found that while in some instances the decline in enjoyment of food seen in older persons was reversed by the use of flavor enhancers, there was no net increase in caloric intake.
There is a marked decline in the ability to smell with aging.[ 64 ] Older subjects, when blindfolded, have approximately half the ability of younger subjects to recognize blended foods.[ 65 ] This olfactory dysfunction is more marked in patients with Alzheimer’s disease[ 66 ] as well as those with Parkinson’s disease.[ 67 ] The changes in smell sensation with aging were related to less interest in food-related activities and to a greater intake of sweets.[ 68 ]
In addition to changes in taste and smell, aging is associated with several changes in both the central feeding system and the peripheral satiety system. Animal studies have demonstrated a decrease in the endogenous opioid feeding drive with aging,[ 69 , 70 ] which is attributed to the reduction in opioid receptors that occurs with aging.[ 71 ] As endogenous opioid predominantly drives fat intake,[ 71 ] this finding is in keeping with the fact that the decrease in food intake with aging is predominantly due to a decrease in fat intake.[ 49 ] In addition, animal studies have shown an increased satiating effect of cholecystokinin in older animals compared to younger ones.[ 73 ] In humans, cholecystokinin levels were found to be elevated in older malnourished persons, suggesting that this compound may play a role in the maintenance of anorexia in older persons.[ 74 ] Neuropeptide Y has been demonstrated to stimulate food intake less in older rats compared to younger rats[ 75 ] but not mice.[ 76 ] The effectiveness of other neurotransmitters on modulating food intake does not appear to change with age.[ 77 ]
Leptin concentrations do not appear to be dramatically altered with aging and are more closely related to body fat levels.[ 78 ] In humans, increases in body fat were generally accompanied by an increase in leptin levels.[ 79 ] Perry et al[ 79 ] found an increase in leptin levels at middle age in women, followed by a decline in older women. A fifteen year longitudinal study in aging individuals found that in males, but not in females, leptin concentrations declined at a slower rate compared to the rate of body fat decline.[ 80 ] Testosterone administration in older males decreases leptin concentrations,[ 81 ] and testosterone concentrations decline longitudinally with aging.[ 82 ] These findings suggest a possible role for leptin in producing the psychological anorexia of aging in males, but not females.
With aging, a decline in gastric emptying of large meals has been associated with satiation.[ 83 ] It appears that there is a decreased adaptive relaxation of the fundus of the stomach, resulting in more rapid antral filling. Nitric oxide release causes adaptive relaxation. There is a decrease in gastric nitric oxide synthase in older animals with aging.[ 55 ] In humans, infusion of glyceryl trinitrate resulted in dilation of the fundus of the stomach and thus longer retention of the food in the fundus.[ 84 ] These findings support the concept that decreased adaptive relaxation of the gastric fundus may significantly contribute to early satiation in older persons.
Causes of Pathological Anorexia and Weight Loss
The causes of anorexia and weight loss in the elderly are numerous. These causes can generally be classified into three major groups: social, psychological, and physical.
Social causes--Poverty is by far the major social cause of anorexia and weight loss in the elderly.[ 85 ]A common, but often unrecognized, cause of poverty is iatrogenic. When physicians prescribe expensive medications, older persons with limited resources often reduce their food budget to afford their medications. Social isolation due to death of family and friends is another important cause of anorexia and weight loss in the elderly.[ 86 ]de Castro et al[ 87 ] found that socialization results in increased food intake over a meal. Elder abuse, occurring in up to 5% of older persons, can result in anorexia secondary to distress or by deliberate food deprivation by the caregiver.[ 88 ]
Other social causes include inability to shop, cook, or feed oneself. Two percent of persons aged 65-84 years require assistance with feeding. This figure rises to 7% for persons aged 85 years or older. In the 75 to 84 years age group, 12% need help managing their finances, 16% need help with food preparation, and 29% need assistance with shopping.[ 89 ] In nursing homes, failure to pay attention to ethnic food preferences may result in food refusal and anorexia.[ 90 ]
Psychological causes--Depression is one of the most important treatable causes of weight loss in older persons. In the outpatient setting, depression has been shown to be one of the most common causes of weight loss in older adults.[ 91 ] In nursing home settings, depression was consistently recognized as a major cause of weight loss and failure to thrive among residents.[ 92 , 93 , 94 ] Depression is associated with increased corticotropin releasing factor, a potent anorectic agent, in the cerebrospinal fluid.[ 95 , 96 ] In addition, depressed patients have many symptoms that can lead to weight loss, including weakness (61%), stomach pains (37%), nausea (27%), anorexia (22%), and diarrhea. (20%)[ 97 ] Successful treatment of depression has been shown to reverse weight loss in nursing home residents.[ 98 ]
Dementia is commonly associated with weight loss.[ 99 , 100 ] Older persons with dementia often forget or refuse to eat, and feeding can become a time-consuming process. Excessive wandering, psychotropic medications, paranoid ideations, and associated depression are other implicated factors. Some patients with dementia develop apraxia of swallowing and must be reminded to swallow after each mouthful of food.[ 85 ] Late-life paranoia, later-life mania, and anorexia nervosa are other psychological conditions that may contribute to malnutrition in older persons.[ 101 ]
Physical causes--Numerous medical conditions can result in anorexia and weight loss in older persons. Most of these conditions cause weight loss by one or more of the following mechanisms: hypermetabolism, anorexia, swallowing difficulty, or malabsorption. Oral disease can lead to a decrease in energy intake of about 100 kcal/day.[ 102 ] Swallowing disorders are associated with increased risk of aspiration and food aversion, which may be conscious or subconscious. Diseases that interfere with the ability of the person to eat or to prepare food, such as stroke, tremors, or arthritis, can all lead to decreased food intake.
Infections are an important cause of weight loss in older persons, especially those residing in a nursing home. It is estimated that the average nursing home resident acquires a new acute infection every three months.[ 103 ] Infection may result in confusion, anorexia, and negative nitrogen balance, all of which may contribute to anorexia and weight loss.[ 104 ] Persons with chronic obstructive pulmonary disease experience a decrease in arterial oxygen tension when eating due to the thermic energy of eating and the brief interruption of respiration with swallowing. They frequently are unable to complete their meals due to dyspnea.[ 105 ] Their weight loss is further aggravated by hyperventilation and use of accessory muscles, leading to increased metabolism.[ 106 ] Acquired immunodeficiency syndrome (AIDS) and rheumatoid arthritis result in increased levels of circulating cytokines which in turn lead to increased resting energy expenditure and decreased serum albumin levels.[ 107 ] Hyperthyroidism,[ 108 ] Parkinson’s disease,[ 109 ] and pheochromocytoma[ 110 ] cause hypermetabolism and may result in weight loss. Pancreatic insufficiency and gluten enteropathy may cause weight loss through malabsorbtion.
Numerous medications are associated with weight loss. Those most frequently implicated include digoxin, theophylline, nonsteroidal anti-inflammatory drugs, and psychotropic drugs such as fluoxetine, lithium and phenothiazines. Therapeutic diets are often unpalatable and poorly tolerated by older persons, leading to weight loss. In nursing homes, diabetic diets appear to have no effect on diabetic control.[ 111 ] Therapeutic diets, including low salt, low fat, and sugar-restricted diets should be avoided in the elderly.( Ramzi et al., 2004 )
Elderly persons often develop malnutrition, common causes of which include decreased appetite, dependency on help for eating, impaired cognition and/or communication, poor positioning, frequent acute illnesses with gastrointestinal losses, medications that decrease appetite or increase nutrient losses, polypharmacy, decreased thirst response, decreased ability to concentrate urine, intentional fluid restriction due to fear of incontinence or choking if dysphagic, psychosocial factors such as isolation and depression, monotony of diet, higher nutrient density requirements, and other demands of age, illness, and disease on the body. Elderly patients are often at risk for protein energy malnutrition ( PEM )because of inadequate nutrition, which has been determined to be a common comorbid factor for increased morbidity and mortality in elderly burn victims.6 Patients with liver cirrhosis are also at risk for PEM, which is a risk factor that portends a poor prognosis for survival. This risk correlates with the degree of liver injury and the etiology of liver injury, with the risk of PEM being more severe in persons with alcoholic cirrhosis than in those with nonalcoholic cirrhosis. Patients on long-term hemodialysis also may develop PEM; this is associated with increased morbidity and mortality. Patients with squamous cell carcinoma of the esophagus are at risk for PEM.( Noah ,2008)
Effects of elderly malnutrition
Based on animal studies and human investigations, it is known that malnutrition can adversely affect virtually every organ system.[ 31 ] The extent of the clinical manifestation of malnutrition is related to the duration and the degree of nutritional compromise. The most striking clinical manifestations include delayed wound healing, development of pressure ulcers,[ 32 , 33 , 34 ] susceptibility to focal and systemic infections,[ 35 , 36 , 37 ] functional decline,[ 38 , 39 ] cognitive decline,[ 40 ] and delayed recovery from acute illness.[ 41 , 42 ] Hospitalized and malnourished elderly patients have nearly four times the risk of developing delirium as do those who are not malnourished.[ 43 ] Most manifestations are reversible with appropriate nutritional support, but with prolonged and profound malnutrition, clinical deterioration supervenes, culminating in irreversible organ damage and ultimately death. Profound malnutrition and serious illnesses often present concurrently, and each can accelerate the progression of the other. The importance of early detection and aggressive intervention is of utmost importance to arrest the downward spiral. Prompt diagnosis relies on a high index of suspicion and available screening tools. (Ramzi et al., 2004 )
Complications of elderly malnutrition
• Slower wound healing.
• Increased risk of infection.
• Decreased muscle strength.
• Poor cognition.
• Increased dependency.
• Increased mortality. (Liu et al.,2003 )
Malnutrition can prevent people recovering from illness, and make them more prone to developing more health problems. It can have a range of consequences, from adverse physical effects such as fatigue, to psychological problems including depression and anxiety.( Health ,2001)
an inadequate food intake in the elderly increases immunological system vulnerability, the risk for infections, and it also leads to muscle atrophy, high sugar and fat plasma levels, fatigue, apathy, greater risk for bone fractures, and lower response to medication. (Morillas et al.,2006)
The nutritional state is one of the major determinants of the quality of life in the elderly. (Maaravi et al.,2000)
Bone loss and muscle wasting are associated with increased morbidity and mortality in the elderly, most frequently as a result of fractures associated with poor neuromuscular conditioning leading to accidental falls. (Lytras and Tolis , 2007)
There is a complex interrelationship between nutritional status, illness severity, and clinical outcomes among the hospitalized elderly. (Sullivan et al.,2002)
recent data suggest that malnutrition has to be considered as an independent risk factor for morbidity, complications and re-hospitalizations in the elderly. (Pandolfo et al.,2004)
Malnutrition has deleterious consequences on the body’s ability to prevent and heal pressure ulcers. (Connie et al.)
Most mental functions - memory, emotionality, and mental performance - are not greatly affected by age-related physiological changes, although the speed of thought is liable to decrease with age. In spite of the resilience of mental capacity, it remains dependent on brain cell function, which is contingent on adequate energy and oxygen intake, and a supply of important micronutrients.( Staehelin, 1999)
Elderly hospitalized patients frequently do not mount a vigorous febrile response. This diminished response could be due to the combined effects of age and protein malnutrition .(Bradley et al.,1987)
Nutritional disorders can affect any system in the body and the senses of sight, taste, and smell. Malnutrition begins with changes in nutrient levels in blood and tissues. Alterations in enzyme levels, tissue abnormalities, and organ malfunction may be followed by illness and death.(Free Health Encyclopedia )
It may affect up to 30% of otherwise ”healthy elderly.”[6] Undernourished elders are more likely than their well-nourished counterparts to die from infectious diseases[7] or to develop pressure sores and poor wound healing during acute hospital stays or in long-term institutional facilities.[8-10] Even modest systemic nutritional deficiency results in a decline of delayed-type hypersensitivity (DTH) responses and a decreased number of total and mature T lymphocytes. Neutrophil function is reduced, and while phagocytosis is generally not affected, the ability to destroy ingested bacteria appears to decline. (Ronny et al.,1998)
Advancing age, malnutrition, alcoholism, malignancy, and a chronic, terminal illness were each individual risk factors for reduced testicular size,( D. J. Handelsman and S. Staraj ,1985)
Malnutrition is likely to have considerable impact on the mental and physical state of the elderly. ( Bhat et al.,2005)
Diagnosing malnutrition
*Assessment of nutritional status and weight loss should start with questioning the patient about any history of weight loss during the past three months and past year and about the patient’s perceived nutritional problems. Including a family member or caregiver is helpful for obtaining an accurate history. A thorough general assessment should consider the following:
• Severity of nutritional compromise and rate of weight decline;
• Patient’s living situation (living independently, alone, in an assisted living facility, or in a skilled nursing facility);
• Functional status, specifically including mobility, ability to shop and prepare meals, ability to feed self;
• Mental and psychologic status, including depression and any decline in memory or cognition;
• Dietary assessment: intake of food and fluids in the past day; availability of food and types of food consumed; methods used for meal preparation; and identity of person or persons preparing the patient’s meals;
• Medical and surgical history, including gastrointestinal, cardiac, respiratory, and renal disease, recurrent infection, and psychiatric illness;
• Current use of medication.6,9
The physical examination should be narrowly focused on information obtained in the medical history and must assess the patient’s current weight and body mass index (BMI); oral cavity, especially the dentition and ability to swallow; and gastrointestinal as well as respiratory systems.
Diagnosis of a specific problem focuses intervention on treatment of the underlying cause. Often, however, a team approach is needed to address problems of nutrition and weight loss. Nurses, dieticians, a speech therapist, an occupational therapist, and social services staff can contribute important components to the treatment of malnutrition .( Carol Evans ,2005)
Presentation of malnutrition In adults
Adults tend to lose weight - often insidiously. Oedema may mask weight loss.
BMI is a key measure (weight in kg divided by height in metres squared)
17-18.5 - mild malnutrition
16-17 - moderate malnutrition
<16 - severe malnutrition
Other features may include listlessness, increasing fatigue, cold sensitivity, nonhealing wounds, severe decubitus ulcers. (Warrell et al.,2004)
Nutritional assessment in an older person should involve taking a thorough history and physical examination in addition to anthropometric and biochemical measures. A carefully obtained history is the most valuable tool for identifying persons at risk for malnutrition. Weight change over time is one of the most important aspects of the history. Unintentional weight loss of 10 pounds or more over a period of 6 months is a strong indicator of nutritional risk and morbidity.[ 112 ] A dietary history includes providing the patient with a simple questionnaire (food diary) that inquires into quantity as well as quality of food intake. The history should also ascertain the presence of risk factors for deficient nutrition intake such as poverty, social isolation, and inability to shop, prepare food, or feed.[ 3 ] Additionally, any chronic medical condition that may potentially affect nutritional status must be documented, such as diabetes, cardiopulmonary disease, cerebrovascular disease, gastrointestinal conditions, depression, dementia, and rheumatological disease. Acute illnesses may demand increased nutritional requirements, and the frequency and severity of such events must be noted. Review of both prescription and over-the-counter medications is essential to avoid polypharmacy. Many commonly used drugs are anorexigenic, notably digoxin, theophylline, non-steroidal anti-inflammatory drugs (NSAIDs), and psychotropic drugs such as fluoxetine, lithium and phenothiazines.[ 113 ] A comprehensive list of potential drug offenders can be found at [ltcnutrition.org] .
The physical examination should determine general body habitus, present body weight and height, and the presence of any sign of nutritional deficiency in the skin, hair, nail, eyes, mouth, or muscles. The body mass index (BMI) is a useful measurement for assessing nutritional status and can be calculated using the formula (BMI= Weight (kg)/ [height (m)] 2 ). The association between BMI and mortality in older adults follows a J-shaped curve, unlike the U-shaped curve relationship in younger adults.[ 114 , 115 ] Data from several studies of elderly aged 60-90 years indicate the lowest mortality occurred at progressively increasing body weight,[ 116 ] and higher mortality occurred with lower body weight.[ 117 ] The desired BMI for older people is 24 to 29, compared with 20 to 24 in younger persons, and a measure below 24 is an indicator of malnutrition in older persons.[ 118 ] BMI, however, may not be as informative in the elderly as it is at younger ages. There is little documentation relating BMI to direct measurements of body composition in the elderly, especially at very old ages or in non-caucasian ethnic groups. In addition, stature often cannot be measured accurately in the elderly individuals because of increased prevalence of spinal curvatures, which is reported to be as high as 30%.[ 119 ] For such individuals, the estimation of stature from knee height is probably the best method for providing this information.[ 120 ] Knee height has been measured in the Third National Health and Nutrition Examination Survey, or NHANES III, for persons 60 years of age or older.
Other anthropometric methods include measurements of arm circumference, mid-arm muscle area, calf circumference, triceps skin-fold, and sub scapular skin-fold thickness. Calf circumference has been recommended as a more sensitive measure of the loss of muscle mass in the elderly than arm circumference and mid arm muscle area.[ 119 ] Skin-fold thickness is frequently used to assess body fat stores. The accuracy of this technique in nutritional evaluation is hampered by the unpredictable response of subcutaneous fat to undernutrition and the absence of a definite correlation between skin-fold thickness and total body fat. In older men, skin-fold thickness over the scapula and iliac crest have been found to correlate most closely with total body fat, while the triceps and the thigh are the preferred measurement sites in older women.[ 121 ]
Laboratory Evaluation
Serum albumin level is the most frequently utilized biochemical marker for malnutrition. With a half-life of approximately three weeks, albumin is a good indicator of baseline nutritional status but is less useful in assessing effectiveness of acute nutritional intervention. Furthermore, cytokines and postural changes, commonly present in acute illness, may result in lower albumin levels. Cytokines such as tumor necrosis factor, interleukin-2 and interleukin-6 inhibit synthesis of albumin at the gene level[ 122 , 123 ] and may facilitate extravasation of albumin from the intravascular to the interstitial space.[ 124 , 125 ] The dilution effect of chronic recumbency is associated with increased intravascular volume and may diminish measured albumin by as much as 0.5 mg/dL.[ 126 ] These factors, in part, explain the rapid decline in serum albumin levels (beyond what is expected from diminished nutritional intake) shortly after an elderly person is hospitalized.[ 127 ] Nonetheless, albumin levels less than 3.5 mg/dL are strongly suggestive of PEM,[ 128 ] and levels less than 3.2 mg/dL are excellent predictors of mortality and morbidity in the elderly. There is a 24% to 56% increase in the likelihood of dying for every decline of .35mg/dL in serum albumin.[ 129 ]
Serum cholesterol level is another biochemical marker of malnutrition. Serum levels less than 160 mg/dL suggest low lipoprotein levels, and thus low visceral protein. Rudman et al1[ 130 ] showed cholesterol levels below 160 mg/dL to be highly predictive of subsequent mortality in a cohort of nursing home residents, and even lower levels were correlated with a ten-fold increase in mortality. A decrease in cholesterol levels from above 160 mg/dL to less than 120 mg/dL during acute hospitalization has been associated with increased length of stay, complications, and mortality.[ 131 ] Hypocholesterolemia, however, develops later in the progression of malnutrition, so its value as a screening tool is limited.
Total lymphocyte count (TLC) is another useful screening test. Selzer et al[ 132 ] reported a four-fold increase in mortality with a TLC of less than 1500 cells/mm. Levels less than 800 cells/mm indicate severe malnutrition.[ 133 ] Clinically, this is reflected in suppressed cellular immunity, as evidenced by delayed cutaneous hypersensitivity testing with common antigens such as Candida. Specifically, the CD4 cell count has been noted to DROP with progressive malnutrition,[ 134 ] and the CD4:CD8 ratio declines, as occurs with HIV patients. The relative immune compromise is reversed with nutritional support, but, left untreated, may progress to sepsis and death. As with hemoglobin, a low white blood cell count may be related to specific nutrient deficiencies such as folate, vitamin B12, and iron.
Proteins with a shorter half-life than albumin are occasionally used to assess acute response to nutritional intervention. Prealbumin, with a half-life of two days, and retinol binding proteins, with a half-life of two hours, fit this criterion. Leptin, a protein produced by fat cells, is a good marker of total body fat. It is being studied and validated as a nutritional marker but is affected by testosterone levels, age, and gender. It is important to note that all these tests are affected by non-nutritional factors and none alone is adequately sensitive or specific to diagnose malnutrition.
Screening Tools
Since no single physical finding, historical fact, or biochemical test in itself is a sufficient predictor or determinant of malnutrition, several screening tools have been developed to better document and monitor PEM. The most common and best-evaluated are discussed below.
The Instant Nutritional Assessment (INA)-- The INA is one of the simplest and most practical nutrition screening tools. It was introduced by Seltzer and coworkers[ 135 ] in 1997, and is widely used. It combines three easily obtainable elements – lymphocyte count, albumin, and weight change. This test is often referred to as “LAW”, the first letter of each item. While each item alone may have low predictive value, used together the three identify individuals at risk for malnutrition with a high degree of accuracy.
The Subjective Global Assessment (SGA)-- The SGA differs from the INA in that it does not use laboratory criteria but relies heavily on functional capacity and physical signs of malnutrition. Specifically, it combines information from the patient’s history (such as weight loss, dietary intake, functional status), physical examination (such as muscle and fat distribution, edema), and the clinician’s judgment. As such, it is highly dependent on the screening clinician for accuracy. On initial validation, its ability to predict infection as a complication of malnutrition was compared to six other independent methods (including albumin and anthropometric measures). The SGA was found to be 82% sensitive and 72% specific,[ 136 ] and outperformed all six methods. However, when this study was repeated with less experienced clinicians, the results were much less promising.[ 137 ] Other studies have also led to the conclusion that the SGA is only reliable in the hands of well-trained clinicians.
The nutritional screening initiative and the DETERMINE checklist-- The DETERMINE checklist was developed by the Nutritional Screening Initiative (NSI), an interdisciplinary multi organizational effort aimed at introducing nutritional screening into the American health care system.[ 138 ] The DETERMINE Your Nutritional Health Checklist is a self-administered list of ten questions covering different risk factors for malnutrition. Four questions cover dietary concerns, four questions cover general health assessment, and two questions cover social and economic issues. Each question is scored according to its importance as determined by the developer of the checklist. Patients with a total score of six or higher (highest score is 21, with higher being worse), are directed to various follow up and assessment.
The DETERMINE Checklist was developed as a screening, education, and public awareness tool. It is not a reliable diagnostic tool, as a high score was shown by Sahyoun et al[ 139 ] to be a weak predictor of mortality. It has shown somewhat better predictability as a screening tool in retrospective and prospective validation studies. This tool has found widespread use; one of its best attributes is in promoting public awareness of malnutrition.
The malnutrition risk scale (SCALES)--The malnutrition risk scale was developed by Morley et al[ 140 ] as an outpatient screening tool. The acronym SCALES represents the six elements in this screening tool (Sadness, Cholesterol, Albumin, Loss of weight, Eating problems, and Shopping) that cover common known risk factors for malnutrition, including depression, which has emerged as a major risk factor for malnutrition and death,[ 141 ] but is often overlooked. The SCALES screening does not include functional or physical assessments, and therefore the user does not need to be a trained or experienced professional. A score of three or higher suggests high risk for malnutrition.
The Mini-Nutritional Assessment (MNA)-- The MNA[ 142 ] is a simple, rapid, and reliable tool for assessing nutrition in the elderly and has rapidly become the screening tool of choice for many geriatric clinicians. It is frequently used in the nursing home setting and is composed of 18 items that require a professional to administer. It requires 10-15 minutes to complete and does not require laboratory tests. It consists of four sections: anthropometric, general, dietary, and self-assessment. The MNA was shown to be 98% accurate when compared with a comprehensive nutritional assessment which included food records and laboratory tests.[ 143 ] In another study, there was no added benefit in adding biochemical measurements, as the test was highly accurate with or without these tests.[ 143 ] . (Ramzi et al.,2004)
. The available screening and assessment instruments is Mini Nutritional Assessment (MNA) aims at the standardization of the diagnosis and early recognition of malnutrition. the MNA seems to be more appropriate for the community-dwelling elderly. (Bauer et al.,2007).
Why MNA ? The Mini Nutritional Assessment (MNA) is an assessment tool that can be used to identify older adults (>65 years) who
are at risk of malnutrition. It is a clinician-completed instrument with two components: screening and assessment. A score of 11 or less on the screen indicates a problem and the need for a completion of the assessment portion. The assessment score is then added to the screen score; if the total score on both parts totals 17 – 23.5, there is a risk of malnutrition, while a score of < 17 indicates existing malnutrition. The MNA should be supplemented with information regarding the patient’s cultural factors, preferences, social needs/desires surrounding meals. A review of symptoms and objective clinical findings, including pertinent physiological measures used to assess nutritional status should be assessed (including serum pre-albumin, serum albumin, transferrin, and total lymphocyte count, as well as hemoglobin and hematocrit). A 72-hour food dairy, recording the patent’s consumption, is another important
supplement to the MNA.
TARGET POPUTLATION: The MNA provides a simple and quick method of identifying older adults who are at risk of malnutrition.
The MNA should be completed at regular intervals, no matter the setting.
VALIDITY AND RELIABILITY: The MNA is both a screening and assessment tool for the identification of malnutrition in the older adult. This tool eliminates the need for more invasive tests such as blood sampling. The MNA has been validated in many research studies in older adults throughout the world in hospital, nursing home and ambulatory care patients and in community screening. Internal consistency, inter-observer reliability and validity were shown to be acceptable (Beck, Oversen, & Schroll, 2001; Bleda, et al, 2002).
STRENGTHS AND LIMITATIONS: Unlike many other nutritional instruments, the MNA was developed to be user-friendly, quick, non-invasive, and inexpensive. The MNA has been tested predominantly on Caucasians with involvement of Mexican-Americans in studies conducted in New Mexico (Sheirlinkx, K., et al., 1998). A limiting factor may be clinician lack of familiarity with the requirement, in the assessment portion, of measuring both the mid-arm and calf circumference. One criterion to determine risk is based on a BMI less than 19 and actually gives maximum points for a BMI over 23 (item F in Screen). At this time, with the percent of Medicare enrollees who are classified as obese (BMI ³ 30) at 22.5% (up from 11.7% in 1997), overweight (BMI ³ 25 – 29.9) at 34.3% (up from 32.1% in 1997), and those underweight (BMI < 18.5) actually decreasing to 9.0% in 2002 from 16.9% in 1997, ( Elaine et al.,2007)
The MNA is an 18-item tool used to assess nutritional risk; it includes anthropometric measurements (body mass index, midarm and calf circumferences, and weight loss), a dietary questionnaire (number of meals consumed, food and fluid intakes, and feeding autonomy), global assessment (lifestyle, medication, and mobility), and self-assessment (self-perception of health and nutrition). The MNA was designed and validated to rapidly assess the nutritional status of frail older persons so that nutritional intervention may be facilitated. The estimated time required to administer the MNA is 10 min. A scoring algorithm assigns subjects to well-nourished, at-risk, and malnourished categories. (Melissa McGee and Gordon L Jensen ,2000)
The MNA was useful to screen the elderly for nutritional status because it reflected the activities of daily living (ADL )and the prognosis, as well as conventional nutritional indexes such as anthropometric values and serum albumin. (Inoue et al.,2007)
Management of malnutrition
Prevention
(NICE guidelines) (NICE guidelines ,2006)
Screening for malnutrition and for those at risk of developing it should take place:
• All hospital inpatients on admission and repeated on a weekly basis during admission.
• All outpatient attendees at first clinic appointment.
• On entering a care home.
• At initial registration with a general practice (GP) and opportunistically at, for example, influenza vaccination.
• where clinical concern exists.
Screening should assess BMI, percentage unintentional weight loss and consider time scale of reduced nutritional intake and likelihood of this continuing in the future.
Nutritional support should be considered for those:
• With a BMI<18.5.
• Unintentional weight loss >10% over last 3-6 months.
• BMI <20 and unintentional weight loss of >5% over last 3-6 months.
• Who have eaten little or nothing for >5 days and who are unlikely not to for next 5 days or longer.
• Who have poor absorption, high nutrient losses or increased nutritional needs.
Options for nutritional support include the use of oral, enteral or parenteral nutrition alone or in combination.
GPs widely prescribe oral nutritional supplements, most often to those with cancer or cardiovascular disease, but rarely record height, weight or other markers of nutritional status prior to prescribing.
Using oral nutritional support:
• Use appropriate fortified standard foods as first-line treatment of malnourished patients prior to use of supplements.
• Always use in conjunction with appropriate dietary advice.
• Do not prescribe on a long-term basis without regular monitoring and reassessment.
• Nutritional needs and food intake determine the number of supplements needed - usually not more than 500-600 Kcal daily (approximately 2 cartons of sip feed) unless under care of a dietician.
• Supplements should be given between meals and not with or instead of a meal.
• Try different flavours and types of feeds to avoid boredom.
• Only prescribable on the NHS for ACBS (Advisory Committee on Borderline Substances) approved conditions (short bowel syndrome, malabsorption syndromes, pre-operative preparation of malnourished patients, inflammatory bowel disease, total gastrectomy , dysphagia, bowel fistulae, disease-related malnutrition).
Consider carefully consent issues and whether or not the provision/withdrawal of nutritional support is appropriate .( MeReC Bulletin,1998)
General measures for elderly population in UK:
• General nutritional advice.
• Use of supplements - more effective than nutritional advice alone.
• Inability to shop/prepare meals - refer to social services, meals on wheels, community dietician, local day centers.
• Factors such as increasing number of people present at meals, improving the palatability of meals and finding optimal time of day and location of meals may also improve intake.
• Difficulty with feeding utensils - refer to occupational therapy to consider aids/equipment.
• Nausea - consider anti-emetics.
• Oral pathology - treat if present.
• Dysphasia - investigate and refer to speech and language therapy. If not amenable to treatment, consider pureed food or thickened fluids.
Acute management of severely malnourished
• Clinical assessment - check for co-existing dehydration, infection, anemia, hypoglycemia
• Correct shock and dehydration and restore electrolyte balance. Reverse malnutrition without overloading cardiac, renal, GI, or hepatic function.
• Often need to treat coexisting infection (high prevalence - such that WHO recommends use of empirical antibiotics for first 7 days).
• Many need vitamin replacement and treatment of hypoglycemia with IV glucose and/or oral sucrose.
• Cases showing hypothermia require warming.
• Rehabilitation phase of treatment: starts as patient’s appetite returns, usually a week after treatment is started. Many essential nutrients are still deficient. Children should receive at least 130kcal/kg/day. Frequent feeds, with gradual increases in energy and protein intake to avoid cardiac failure. (Milne et al.,2006)
extending a healthy lifespan in an ultra-aged society requires less intake of animal fats and more intake of vitamin B1 and calcium and a close assessment of the nutritional state of zinc, iron, and selenium. In order to prevent lifestyle-related diseases and to extend healthy life expectancy, the nutrition management of the elderly living alone is particularly important .(Ohno et al.,2006)
Supplementation produces a small but consistent weight gain in older people. There may also be a beneficial effect on mortality. However, there was no evidence of improvement in clinical outcome, functional benefit or reduction in length of hospital stay with supplements. Additional data from large – scale multi – centre trials are still required.
( Cochrane Rev Abstract. 2007).
The treatment of unintentional weight loss is directed at the underlying causes. While the work-up is proceeding or if a cause is not well defined, the goal is to prevent further weight loss. Initiating nutritional support early may help to avoid some of the complications related to weight loss The contributions of dietitians, speech therapists (for oropharyngeal and swallowing evaluations) and social services personnel cannot be overestimated because the efforts of these staff can improve many strategies to increase food intake. In the long-term care facility, the food service manager and caregivers can often offer individualized suggestions for facilitating food intake. Because restricted diets are often unpalatable, one early intervention is to remove dietary limitations (e.g., restrictions on intake of salt or high-cholesterol foods). Patients with diabetes mellitus may also be given a less restrictive diet. In some instances, weight loss in these patients with diabetes mellitus may reflect overzealous blood glucose control. However, blood sugar and glycosylated hemoglobin levels should continue to be monitored in patients with diabetes mellitus. Adding flavor enhancers that amplify the intensity of food odor may be useful in patients with hyposmia.13 Pureed foods and thickened liquids may be needed in patients with dysphagia. Patients may benefit simply from being offered frequent small servings of foods that they like. Large portions may be overwhelming and may actually discourage intake. When possible, physical exercise and even physical therapy should be encouraged because increased activity has been shown to promote appetite and food intake. One study found that caloric intake was greater in patients who received both nutritional supplements and exercise than in patients who received only supplements.
When liquid calorie supplements are used, they should not be given with meals. Total caloric intake does not improve with this method of administration. Liquid supplements are preferable to solids. With liquids, gastric emptying time is quicker, and total caloric intake is more likely to be maximized. (Huffman ,2006)
Prevention and Treatment
• Treatment usually with oral feeding
• Supportive care (eg, environmental changes, assistance with feeding, orexigenic drugs)
Worldwide, the most important preventive strategy is:
• To reduce poverty
• Improve nutritional education
• Public health measures.
Mild or moderate PEU, including brief starvation, can be treated by providing a balanced diet, preferably orally. Liquid oral food supplements can be used when solid food cannot be adequately ingested. Diarrhea often complicates oral feeding because starvation makes the GI tract more likely to move bacteria into Peyer’s patches, facilitating infectious diarrhea .Patients should also be given a multivitamin supplement. Severe PEU or prolonged starvation requires treatment in a hospital with a controlled diet. The first priority is to correct fluid and electrolyte abnormalities and treat infections. Next is to supply macronutrients orally or, if necessary (eg, when swallowing is difficult), through a feeding tube, a nasogastric tube (usually), or a gastrostomy (G) tube. Parenteral nutrition is indicated if malabsorption is severe . Other treatments may be needed to correct specific deficiencies, which may become evident as weight increases. To avoid deficiencies, patients should take micronutrients at about twice the recommended daily allowance (RDA) until recovery is complete. Underlying disorders should be treated. For example, if AIDS or cancer results in excess cytokine production . (John E and Morley, 2007)
Nutritional Needs of The Older
Russell and his associates created a modified pyramid that takes into account the specific dietary habits and needs of people over 70 years of age (Figure 1). The new pyramid was published in 1999 in The Journal of Nutrition.
The Russell pyramid uses the official pyramid as its reference point, but it adds a bottom layer of eight or more servings of water. ”Elderly people have a dampened thirst sensation,” Russell noted, and they incur a severe risk of dehydration unless they are reminded to consume water.
At the next levels, the Russell pyramid follows the standard pyramid closely, with some variation in the recommended quantities. But at the top, Russell has added a flag that represents supplements for calcium, vitamin D and vitamin B12.
”There are a few nutrients that, even if you follow the guidelines-even ours-are problematic,” Russell said. ”For example, the recommendation for vitamin D is 15 micrograms, three times as much as for a young adult. That would mean you would have to drink a quart and a half of milk. An older person is not going to do that and probably can’t do that. So, we recommended using supplements.
”For B12, a fairly substantial number of older people have atrophic gastritis, which means they’re not putting out the same amount of acid and pepsin in the stomach. As much as 15% to 20% of people over 65 have this condition, which means they are unable to split vitamin B12 from food proteins. They can’t absorb it because they can’t split it off from the food complex. So we recommend a vitamin pill, which they can absorb normally. Everyone over age 60 should consider taking B12 as a supplement or as a fortified cereal product where it is sprayed on, not bound up with the food.
Russell sees the pyramid as an educational tool, designed to help seniors understand what they need to include in their diets. In his Journal of Nutrition article, he noted, ”Guidance is essential regarding the selection of foods that are high in nutrient density.”
Because older adults have reduced energy requirements resulting from their sedentary lives, they have to get all their nutrients in with a lesser amount of food. They need to choose foods that are more dense-that have more nutrients per calorie than [are] recommended in the classic food pyramid for adults. We’re trying to stress ’nutrient dense food,’ such as whole wheat grains, darkly colored fruits and vegetables, and legumes.”
Russell recommended dark green, orange or yellow fresh, frozen or canned vegetables for vitamin C, folic acid, vitamin A and dietary fiber. He also noted that vegetables such as beets, kale, cabbage and broccoli contribute antioxidant phytochemicals such as indoles, flavones and isothiocyanates. For fruits, he stressed the need for whole foods rather than juices to ensure proper fiber intake.
from the dairy group, Russell recommended low-fat products and suggested lactose-free foods to overcome lactose intolerance in the elderly. For meats, he stressed the need for lean cuts and suggested that fish is a good substitute because it provides high-quality protein and fatty acids. He added, ”Suggestive epidemiologic data show that fish in the diet may lower the risk of developing cardiovascular disease when eaten on at least a weekly basis.” He pointed out that bean, grain and vegetable main dishes ”provide high-quality protein, add fiber to the diet and...when substituted for meat, help to minimize saturated fat and cholesterol intake.” Russell cautioned against refined carbohydrates because they are ”generally lower in nutrient density than the naturally occurring counterpart.” .Fiber is important for the elderly as a means of preventing constipation, diverticulosis and diverticulitis, Russell said. He recommended using whole-grain breads rather than breads made with refined flour, brown rice rather than white rice, whole fruits, legumes instead of meat at least twice a week, cooked vegetables, fresh salads and ”most importantly, the choice of a high-fiber cereal for breakfast.”
Russell made it clear that his recommendations are intended for relatively healthy individuals, and he emphasized the need for continuous monitoring to ensure that there are no negative effects. Russell also believes that his work is just the beginning of the process needed to refine the recommendations for elderly individuals. ”Our studies are all based on the literature,” he said. ”They’re not pretested for understanding by the older community, and we haven’t done any kind of population testing on older [peoples’] abilities to follow our recommendations. (Richard and Sherer ,2005 )
figure (1) recommended food guide pyramid for elderly people
Role of family physicians in managing malnutrition
Nutritional advice
Given the large number of illnesses and diseases encountered in family practice for which diet and nutrition are relevant interventions, food-related advice is an important part of daily practice. family physicians should approach their patients with advice and counseling in ”ready bits” that fit into the time constraints of regular consultations and make sure these bits are consistent over time and address specific individual patients’ values and barriers with regard to modification of food habits. Orientation of patients’ expressed readiness to change can present a template of patient-centeredness. Primary care nutritional guidelines should in particular acknowledge the strengths of family medicine.
Many practitioners find advising patients about food habits is difficult. The relationship between disease and nutrients, and between nutrients and foods, is complicated and sometimes hard to explain to patients. Moreover, it is not always known what effect advice and counseling will have on patients’ behavior. However, the challenge for family physicians (FPs) with regard to diet can be related to the basic concepts of family medicine when grouped under the following 4 headings:
Promoting health by promotion of healthy food. For most common health problems (obesity, diabetes mellitus, or cardiovascular disease), dietary advice should focus on ”healthy foods”—both what they are and how much of them to eat. Information about healthy foods and nutrition instructions for patients are easily available in a user-friendly form that can be used in the practice.
Cooperation with dietitians. The FP is a member of a larger health care team. For diseases that require more specific nutritional instructions, practice guidelines can summarize concrete actions and instruction by dietitians is possible. In this way, sufficient expertise is made available for patients who need it and doctors worry less about diet and nutrition advice.
Continuity of care: long-term perspective and focus on greatest needs. Continuity of care enables the FP to break down advice and counseling over successive consultations. This allows the doctor to coach the patient over time to find his or her own way of putting the advice into effect, rather than present the patient with a ready solution. This allows for tailoring of advice to patients’ personal circumstances and for spending due time on the assessment of the likelihood that patients will actually change their nutritional behavior. Simple interventions linked to the ”stages of change” model produce promising results in nutritional advice
Family medicine: involvement of the family. A specific aspect of food—and consequently of nutritional advice—is that eating is a social and cultural activity as well as a necessary act. Effective changes in diet are often feasible only when the entire family makes the changes. In this way, the family orientation of family medicine allows for a systems approach rather than individual intervention. (Chris van Weel,2003).
The holistic approach of family medicine and the multidisciplinary approach of geriatric medicine are complimentary to each other. Both disciplines together provide a solid foundation for the practice of good community geriatric medicine. In time, family physicians with formal geriatric medicine training can help to improve the hospital bed situation, save hospital costs, minimize inappropriate use of the facilities and hence better use of the resources of the community as a whole.(S L T Tsoi ,2004)
Screening of malnutrition
The number of persons 65 years of age and older continues to increase dramatically in the United States. Comprehensive health maintenance screening of this population is becoming an important task for primary care physicians. As outlined by the U.S. Preventive Services Task Force, assessment categories unique to elderly patients (Karl et al., 2000).
The Mini Nutritional Assessment (MNA) has recently been designed and validated to provide a single, rapid assessment of nutritional status in the elderly. The MNA provides primary care physicians with a tool for rapid screening of patients who may subsequently need a more extensive nutritional assessment.(B. Vellas et al,1999) .
(NICE guidelines) (NICE guidelines ,2006)
Screening for malnutrition and for those at risk of developing it should take place:
• All hospital inpatients on admission and repeated on a weekly basis during admission.
• All outpatient attendees at first clinic appointment.
• On entering a care home.
• At initial registration with a GP and opportunistically at, for example, influenza vaccination.
• where clinical concern exists.
Screening should assess BMI, percentage unintentional weight loss and consider time scale of reduced nutritional intake and likelihood of this continuing in the future.
Nutritional support should be considered for those:
• With a BMI<18.5.
• Unintentional weight loss >10% over last 3-6 months.
• BMI <20 and unintentional weight loss of >5% over last 3-6 months.
• Who have eaten little or nothing for >5 days and who are unlikely not to for next 5 days or longer.
Who have poor absorption, high nutrient losses or increased nutritional needs. .( MeReC Bulletin,1998)
Study population :
Elderly group above age of 65years old .in a rural area ,Abou khalifa village Ismailia governorate .which is a rural area ,lies about 20 kilometer from Ismailia .
The total population in Abou Khalifa are (36000 )
The target population in Abou Khalifa are =36000x3.4/100= 1224
3.4%= the percent of elderly aging 65 and above in Egypt (www.emro.who.int)
The sample size :
The sample size is determined by the following equation
N = (Z/SE)2 x P x(1- P)
N = sample size .
P = the prevalence of malnutrition in elderly in a previous study which is (26 %) .(kabir et al,2006)
Z = percentile of standard normal distribution determined by 95% confidence interval = 1.96 % .
SE = 0.05
The sample size (N) =(1.96/0.05)2 x 0.26 x0.74 = 295
Sampling :
A systematic random sample was taken .To reach the sample size by dividing the number of the target population on the sample size
=1224/295=4.
we took one house from every 4 houses according to the coding of the village and the first house was chosen randomly .
Inclusion criteria :
-Old persons above the age of 65years .
-Males and females are involved in our study .
exclusion criteria :
- Patients with extreme illnesses (end stage diseases such as end stage liver disease and end stage renal disease ) was excluded .
- Patient with intentional regimen to lose weight .
Study design :
A cross sectional household study.
Data collection :
- Socio demographic data was collected in the form of : name, age ,gender , telephone number and detailed address .
- Socio-economic status was measured using the Amenities and Possessions Index (API) developed by the Demographic and Health Surveys (Kishor and Neitzel 1996). (appendix 1)
- Assessment of the nutritional status through the Mini Nutritional Assessment tool (Grace Brooke Huffman ,2002) (appendix 2) which consisted of :
1- Anthropometric assessment points :body mass index ,mid arm circumference and calf circumference .
2- General assessment including : drugs , presence of well diagnosed diseases , type of mobility and neuropsychological problems .
3- Dietary assessment : number of meals, type of food ,mode of feeding and amount of fluid intake .
4- Self perception of nutritional status .
Each point in the questionnaire has a score and the sum of the scores indicates the nutritional status .
This questionnaire was completed by the researcher through interviewing the subjects involved in the study in their homes .
Statistics and data presentation :
Data was collected by the researcher and was processed using SSPS V 11 .
- Chi square test was used for categorical variables and the level of significance was considered statistically significant if (p value is below 0.05 )and was statistically high significant if (p value is below 0.01 )
- T test was done for continuous variables .
- The results were presented in order of percentages and tabulated in tables and graphs .
Ethical considerations :
- Written consent was taken and involved in our study .
- Respect privacy and confidentiality of the collected data .
- Any patient with positive finding were referred for further work up either to the primary health care center or to the secondary care according to the level of the problem .
- Explanation of the aim in a simple manner to the involved persons was done .
- Right of the patient to withdraw from the study at any time without giving any reason .
- All persons involved in the study were announced by the results .
Time Table:-
Year 2007 2008
months 6-8 9-11 12 1-5 6-8 9-11
Protocol preparation
Literature review
Data collection
Data analysis
Report writing
Complete presentation
الملخص العربي
ان عدد الأفراد الذين يصل عمرهم إلى65 عام و يزيد فى زيادة مستمرة و من المهم للأطباء العاملين فى الرعاية الصحية الأولية أن يهتموا بعمل المسوح المستمرة للحفاظ على صحة هذه الفئة .
إن سوء التغذية عند كبار السن ليس فقط شائعا و لكنه أيضا يمر دون الالتفات اليه و من الممكن أن يحدث عنه الكثير من المضاعفات منها تكرار الحجز بالمستشفى ,نقص المناعة ,تأخر التئام الجروح و ممكن أن يصل الأمر إلى الموت .
و فى دراسات متعددة و منها دراسة وقعت فى منطقة ريفية من بنجلاديش وجد الباحث أنه بناءا على قياس معدل الكتلة فإن نسبة الأفراد الذين يعانون من سوء التغذية يصل إلى 50% من كبار السن بالمجتمع و باستخدام استمارة قياس الحالة الغذائية فقد وجد نسبة 26% يعانون من سوء التغذية و نسبة 62% في خطر من حدوث هذا المرض .
أهداف و خطوات البحث :
تهدف هذه الرسالة الى قياس معدل انتشار سوء التغذية لدى كبار السن و معرفة أهم العوامل المؤدية إليه فى قرية أبو خليفة بالاسماعيلية وهى قرية ريفية .و ذلك عن طريق دراسة وصفية .
تم استخدام استمارة قياس الحالة الغذائية مع مؤشر الحالة الاجتماعية و الاقتصادية على الأشخاص المبحوث عليهم و كان عددهم 300 مسن فيما يساوى او يزيد العمر عن 65 عام و تم عمل البحث على المسنين الذين يعيشون فى منازلهم و تم اختيارهم عشوائيا , و تم ملء الاستمارة بواسطة الباحث من خلال مقابلة المسنين فى منازلهم و عمل القياسات المطلوبة .
النتائج :
بناءا على نتائج هذه الدراسة فقد وجد أن معدل انتشار سوء التغذية عند كبار السن حوالي 19% و45% فى خطر من حدوث هذا المرض .
وجد أيضا أن هناك عدد من العوامل التي تبين تأثيرها الملحوظ على حدوث سوء التغذية و منها ان يكون المسن أنثى ,التقدم فى العمر, نقص عدد الوجبات يوميا ,قصور محتوى الوجبات يوميا من حيث الخضروات و الفاكهة و المواد البروتينية ,نقص السوائل ,وجود مرض نفسي أو عقلي,تاريخ مرضى بحدوث قلق أو إكتئاب فى خلال الثلاث شهور الماضية , عدم القدرة على الحركة ,تعاطى المسن لأكثر من ثلاث أدوية يوميا ,نقص فى كمية الطعام المأخوذ يوميا فى خلال الثلاث شهور الماضية و لكن وجد عدم تأثير الحالة الاجتماعية و الاقتصادية في حدوث سوء التغذية .
التوصيات :
بناءا على النتائج السابقة فإن من الموصى به ما يلى
- اهتمام الاطباء بقياس الحالة الغذائية للمسنين و تشجيعهم و زيادة وعيهم بالوجبات الصحية التى تساعدهم فى تجنب هذا المرض .
- التفات وزارة الصحة الى الدورات التدريبية للأطباء لزيادة وعيهم و عمل برامج تثقيفية للمسنين عن هذا المرض و كيفية تفاديه.
- دور جهات البحث فى تكثيف الجهود عن طرق قياس و اكتشاف هذه المشكلة و الاختيار لأمثل هذه الطرق لاستخدامها فى العمل فى الرعاية الصحية .