ReviewOlder adults and patients in need of nutritional support: Review of current treatment options and factors influencing nutritional intake
Introduction
Much attention is given to the obesity problem i.e. people who consume more energy than they need, and less attention is given to the many, often older people who do not consume enough nutrients and/or energy to support their minimum requirements. Malnutrition is very common in this group, even in Western society.1 Up to 12.5% of patients residing in the community with chronic disease are underweight. The prevalence of undernutrition and risk of undernutrition in community dwelling older adults (>65 years) have been reported to be 4.3% and 25.4%, respectively.2 Two recent studies showed that 49.5% of residents (average age 84.2 years) in residential care facilities were moderately to severely malnourished,3 and that 6% of frail older adults (78–86 years) undergoing rehabilitation were malnourished and 13% mildly malnourished.4 The prevalence of malnutrition in long-term care home residents has been estimated to be as high as 85%.5 It has been estimated that the mean prevalence of being underweight in patients admitted to hospital is approximately 18% (range 5%-37.5%).6 On average nutritionally at risk patients incurred 19% higher hospital costs than the average of those not at risk with a similar diagnosis.7 Other studies have reported figures of up to 75% and even 300% greater treatment costs associated with the presence of malnutrition.8, 9, 10
Malnutrition has been defined as “…a state of nutrition in which a deficiency or excess (or imbalance) of energy, protein and other nutrients causes measurable adverse effects on tissue/body form (body shape, size and composition) and function, and clinical outcome”.11
Malnutrition is one of the greatest threats to the health, well-being and autonomy of older adults.12 The National Health and Nutrition Survey (NHANES) II in the USA, has shown that involuntary weight loss is disproportionately high in older adults and is associated with increased mortality.12 In older patients unintentional weight loss is associated with higher risk of infection, depression and death. Unintentional weight loss can lead to muscle wasting, decreased immunocompetence and increased rate of complications.7
A BMI below 20 kg/m2 and/or recent unintentional weight loss can be used to detect protein-energy malnutrition, which has been defined as undernutrition due to an inadequate intake of protein, fat, and carbohydrate.6 A loss of approximately 5–10% of body weight in the previous 12 months may indicate a problem in the older patient. The leading causes of involuntary weight loss are depression, cancer, cardiac disorders, lower socioeconomic status, functional disabilities and benign gastrointestinal diseases. Overall, psychiatric disorders, including depression, account for 58% of the cases of involuntary weight loss in nursing home patients.13
The aim of this review is to give an overview of malnutrition factors that influence nutritional intake in older adults and current ways to treat protein-energy malnutrition status.
Section snippets
Methods
Medline, Science Citation Index, ScienceDirect and Google databases were searched (until December 2008) with the keywords malnutrition, elderly, older adults, food intake, energy density, variety, taste, satiety, and appetite. The first author prepared the initial list of publications based on the search results. Based on this initial list, all authors (WFN, HW, PR and MMH) made the selection of the papers together and analyzed the scientific studies used in this review. Publications were
Results
Based on our search and subsequent selection of papers, 123 papers have been reviewed. These were reviewed for their topic content and then sub-divided into the topics of factors influencing nutritional intake i.e. personal, food and environmental factors. Current practices to improve nutritional intake in malnourished older adults i.e. dietary advice, meal fortification, variety, between-meal snacks and frequent small meals, and Oral Nutritional Supplements were also reviewed.
Conclusion
From the evidence reviewed here, it is clear that improving nutritional intake in older adults in need of nutritional support is a multifactorial problem. We have identified 37 factors affecting nutritional intake that can be divided in three categories:
- (1)
Personal factors
Older adults undergo a series of social, physiological and psychological changes that affect their eating process and ultimately their energy intake (Fig. 2). Older adults are more quickly satiated, often suffer from olfactory
Conflict of interest statement
Willem F. Nieuwenhuizen, Hugo Weenen, Paul Rigby are employees of Danone, a supplier of ONS. This work was funded by Danone Research, Center for Specialised Nutrition, Wageningen The Netherlands.
Statement of authorship and author agreement
WFN, HW, PR and MMH analyzed scientific studies used in this review and wrote the manuscript together. All authors read and approved the final manuscript.
Acknowledgements
We gratefully acknowledge Willemijn van Schuppen and Jennifer Hall for literature searches used in this review.
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