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MALNUTRITION
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OBJECTIVES
Know and understand:
• Age-related changes in nutritional health
• Nutritional syndromes common in older
people
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TO P I C S C O V E R E D
• Age-related Nutritional Changes and Needs
• Screening and Assessment
• Nutrition Syndromes
• Nutritional Interventions
A G E - R E L AT E D
NUTRITIONAL CHANGES
• Body composition
• Energy requirements
• Macronutrient needs
• Micronutrient requirements
• Fluid needs
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CHANGES IN BODY
COMPOSITION WITH AGE
•  Bone mass, lean mass, water content
•  Total body fat, commonly with  intraabdominal fat stores
• Cannot generalize well-standardized nutrient
requirements of young or middle-aged adults
to older adults
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ENERGY REQUIREMENTS
O F O L D E R A D U LT S
• Reduced basal metabolic rate (BMR) in older
adults reflects loss of muscle mass
• BMR is the principal determinant of total energy
expenditure
• Estimation of energy needs based on body
weight: 25 to 30 kcal/kg/day
• Avoid overfeeding, while still meeting basal
requirements
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MACRONUTRIENT NEEDS (2 of 2)
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MACRONUTRIENT NEEDS (2 of 2)
• Protein: 0.8 g/kg/day (1.5 g/kg/day under stress)
• Fat: 20%–35% of total energy intake per day, with
reduced cholesterol, saturated fat, and trans fatty
acids
• Carbohydrate: 45%–65% of total energy intake per
day, with complex carbohydrate as the preferred
fiber source
• Fiber: 30 g/day (men), 21 g/day (women)
M A C R O N U T R I E N T S A S P E R C E N TA G E
O F TO TA L E N E R G Y I N TA K E
• 20%–35% of calories as fat
 Reduced intakes of cholesterol, saturated fat, and
trans-fatty acids
• 45%–65% of calories as carbohydrates
 Daily fiber intake for those 60: 30 g for men, 21 g
for women
• 10%–30% of calories as protein
 0.8 g/kg/day
 With injury, 1.5 g/kg/day, but renal or hepatic
insufficiency may warrant protein restriction
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MICRONUTRIENT NEEDS
OF OLDER ADULTS
Nutrient
Men
Women
Calcium (mg)*
Magnesium (mg)
Vitamin D (IU)*
Vitamin C (mg)
Folate (µg)
B12 (µg)
Thiamin (mg)
1200
420
1600
90
400
2.4
1.2
1200
320
1600
75
400
2.4
1.1
*Adequate intakes, not recommended dietary allowances.
Source: Institute of Medicine, Dietary Reference Intakes.
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F L U I D N E E D S O F O L D E R A D U LT S
• Decreased perception of thirst is associated with normal
aging
• Also associated with normal aging:
 Decreased response to serum osmolarity
 Reduced ability to concentrate urine following fluid
deprivation
• 30 ml/kg/day or 1 ml/kcal ingested
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D E H Y D R AT I O N
• Dehydration is the most common fluid or
electrolyte disturbance in older adults
• Common signs of dehydration:
 Decreased urine output
 Constipation
 Mucosal dryness
 Confusion
NUTRITION SCREENING
AND ASSESSMENT
• Anthropometrics
• Nutritional intake
• Laboratory tests
• Drug-nutrient interactions
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ANTHROPOMETRICS
• Includes measures of weight and height
 Body mass index (BMI) = weight in kg/height in m2
 Risk threshold for low BMI = 18.5 kg/m2
• Weight loss of 5% in 1 month or 10% in 6 months
indicates nutritional risk and morbidity and predicts:
 Functional limitations
 Health care charges
 Need for hospitalization
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N U T R I T I O N A L I N TA K E
• Inadequate nutritional intake has been defined as
average intake of food groups, nutrients, or energy
25% to 50% below a threshold level of the RDA
• Minimum Data Set uses different measure: intake of
<75% of food provided triggers nutritional assessment
in nursing homes
• 5% to 18% of nursing home residents do not meet
standards for adequate nutritional intake
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L A B O R ATO RY T E S T S : A L B U M I N
• A risk indicator for morbidity and mortality
• Lacks sensitivity and specificity as a nutritional
indicator
• The prognostic value of low albumin (<3.5 g/dL) is
probably as a marker for injury, disease, or
inflammation
• Prealbumin may better reflect short-term changes in
protein status (because of shorter half-life) but has
largely the same limitations as albumin
L A B O R ATO RY T E S T S :
SERUM CHOLESTEROL
• Acquired hypocholesterolemia (<160 mg/dL) is a
nonspecific feature of poor health status that is
independent of nutrient or energy intake
• May reflect a pro-inflammatory condition
• Community-dwelling older adults with both low albumin
and low cholesterol have higher rates of morbidity and
mortality than those with either low albumin or low
cholesterol alone
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DRUG-NUTRIENT INTERACTIONS
(1 of 2)
Drug
Reduced nutrient availability
Alcohol
Zinc, vitamins A, B1, B2, B6, folate,
vitamin B12
Vitamin B12, folate, iron, total kcal
Vitamin K
Vitamin B12
Zinc, total kcal
Zinc, magnesium, vitamin B6,
potassium, copper
Vitamin B6, niacin
Calcium, vitamins A, B2, B12, D, E, K
Vitamin B6
Antacids
Antibiotics, broad-spectrum
Colchicine
Digoxin
Diuretics
Isoniazid
Laxatives
Levodopa
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DRUG-NUTRIENT INTERACTIONS
(2 of 2)
Drug
Reduced nutrient availability
Lipid-binding resins
Metformin
Mineral oil
Phenytoin
Salicylates
SSRIs
Theophylline
Trimethoprim
Vitamins A, D, E, K
Vitamin B12, total kcal
Vitamins A, D, E, K
Vitamin D, folate
Vitamin C, folate
Total kcal (via anorexia)
Total kcal (via anorexia)
Folate
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R I S K FA C TO R S F O R P O O R
N U T R I T I O N A L S TAT U S ( 1 o f 2 )
• Alcohol or substance abuse
• Cognitive dysfunction
• Decreased exercise
• Depression, poor mental health
• Functional limitations, limited mobility, transportation
• Inadequate funds
• Limited education
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R I S K FA C TO R S F O R P O O R
N U T R I T I O N A L S TAT U S ( 2 o f 2 )
• Medical problems, chronic diseases
• Medications
• Poor dentition
• Restricted diet, poor eating habits
• Social isolation
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NUTRITION SYNDROMES:
OBESITY
• BMI  30 kg/m2
• Associated with hypertension, diabetes mellitus,
cardiovascular disease, and osteoarthritis
• Adverse outcomes include impaired functional status,
increased health care resource use, increased mortality
• Prevalence has increased in all age groups
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T R E AT M E N T O F O B E S I T Y
• Diet
• Behavior modification
• Exercise
• For frail, obese older adults, emphasize preservation
of strength and flexibility rather than weight reduction
NUTRITION SYNDROMES:
UNDERNUTRITION
• Loss of weight, compromised protein status, or both
• The nomenclature implies that these syndromes are
distinct, but in practice they are difficult to distinguish,
partly because they commonly overlap
 Inflammation permeates the syndromes of
cachexia, protein energy undernutrition,
sarcopenia, failure to thrive, and obesity
 An inflammatory continuum may be a more
appropriate model
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PREVENTING UNDERNUTRITION
• Cater to patient’s food preferences
• Avoid restrictive “therapeutic diets” unless clinical value
is certain
• Enhance patient’s preparedness for meal; provide
assistance if needed
• Enhance comfort, taste, appearance of food
• Enhance social aspect; provide adequate time
• Address dental/oral complaints of chewing
discomfort/dysfunction
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D I E TA RY S U P P L E M E N T S
• Often decrease food intake, but overall nutritional
intake increases due to nutrient quality and
supplement density
• Contain macro- and micronutrients
• Available in liquid and bar forms
• Most formulas provide 1–1.5 calories/mL, and many
are lactose- and gluten-free
D R U G T R E AT M E N T F O R
UNDERNUTRITION SYNDROMES
• Appetite stimulants
 Antidepressant mirtazapine 7.5–30 mg qhs
 Cyproheptadine 2–4 mg with meals
 Megestrol 320–800 mg/day in 2 divided doses
• Anabolic agents (do not increase strength)
 Human growth hormone 0.125 mg/kg/day IM, divided
in 3 doses
 Testosterone 100–600 mg IM every 3 weeks, or 5-mg
topical patch or gel daily
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S U M M A RY
• Nutritional concerns affect many aspects of health and
disease in older adults
• Acceptable parameters of nutritional status such as
body weight and protein levels should be maintained,
unless the patient’s clinical condition demonstrates
that this is not possible
• A patient should receive a therapeutic diet when there
is a problem
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CASE 1 (1 of 3)
• The daughter of an 86-year-old woman wants to
discuss her mother’s weight loss.
• The mother had always been moderately obese, but
she has steadily lost >10% of her weight over the last
6 months.
• The patient lives in a dementia-care unit and has
slowly progressive, mild to moderate dementia.
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CASE 1 (2 of 3)
Which of the following is the best response regarding
weight loss in an older adult living in an institutional
setting?
A. Unintended weight loss in an obese adult often
improves outcomes.
B. Unintended weight loss requires evaluation.
C. The patient should be given protein supplements.
D. Weight loss in older adults is normal.
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CASE 1 (3 of 3)
Which of the following is the best response regarding
weight loss in an older adult living in an institutional
setting?
A. Unintended weight loss in an obese adult often
improves outcomes.
B. Unintended weight loss requires evaluation.
C. The patient should be given protein supplements.
D. Weight loss in older adults is normal.
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CASE 2 (1 of 4)
• A 90-year-old man comes to the office for follow-up.
• History includes atrial fibrillation, heart failure (ejection
fraction of 35%), type 2 diabetes mellitus controlled by
diet, and hypertension. Medications include atenolol,
digoxin, lisinopril, and warfarin.
• He was the primary caregiver for his wife, who had
dementia and died recently. The patient states that he
is somewhat fatigued and has a poor appetite but does
not feel depressed or sad.
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CASE 2 (2 of 4)
• He has had some dizziness and occasional nausea
and diarrhea with incontinence but no melena or
hematochezia. He has had no falls. There are no
symptoms of polyuria or polydipsia. He has a distant
smoking history and worked in the printing industry. He
lives in a senior retirement community.
• On examination, blood pressure is 110/60 mmHg and
heart rate is 58 beats per minute. He has lost 8.2 kg
(18 lb) (9% of his body weight) since his last visit 6
months ago. His affect seems fatigued and flat.
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CASE 2 (3 of 4)
Which of the following is the best next step?
A. Colonoscopy
B. Administration of Geriatric Depression Scale
C. High-resolution CT of the chest
D. Home visit
E. Measurement of serum digoxin level
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CASE 2 (4 of 4)
Which of the following is the best next step?
A. Colonoscopy
B. Administration of Geriatric Depression Scale
C. High-resolution CT of the chest
D. Home visit
E. Measurement of serum digoxin level
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CASE 3 (1 of 3)
• A 70-year-old woman comes to the clinic for a routine
examination.
• History includes mild HTN, which is well-controlled with
hydrochlorothiazide. She takes no other medication, has
never smoked, and rarely consumes alcohol. She walks
>10 miles each week and works as a school volunteer.
• A recent dual-energy x-ray absorptiometry scan revealed
normal bone density readings at all sites.
• The patient asks whether she needs vitamin D
supplements.
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CASE 3 (2 of 3)
Which of the following recommendations applies?
A.
Adults >65 years old should have serum 25(OH)D levels
measured as part of routine screening for vitamin D
deficiency.
B.
Adults >65 years old should take supplemental vitamin D
≤4,000 IU/day to avoid hypercalcemia.
C.
For adults >70 years old, the recommended dietary
allowance (RDA) for vitamin D is 800 IU/day.
D.
Older adults with low serum 25(OH)D levels should receive
treatment to achieve a serum level of 40–50 ng/mL (100–
125 nmol/L).
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CASE 3 (3 of 3)
Which of the following recommendations applies?
A.
Adults >65 years old should have serum 25(OH)D levels
measured as part of routine screening for vitamin D
deficiency.
B.
Adults >65 years old should take supplemental vitamin D
≤4,000 IU/day to avoid hypercalcemia.
C.
For adults >70 years old, the recommended dietary
allowance (RDA) for vitamin D is 800 IU/day.
D.
Older adults with low serum 25(OH)D levels should receive
treatment to achieve a serum level of 40–50 ng/mL (100–
125 nmol/L).
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GRS Slides Editor:
Annette Medina-Walpole, MD, AGSF
GRS8 Chapter Author:
James S. Powers, MD
GRS8 Question Writer:
Dennis Sullivan, MD
Medical Writers:
Beverly A. Caley
Faith Reidenbach
Managing Editor:
Andrea N. Sherman, MS
Copyright © 2013 American Geriatrics Society
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