Despite a general understanding among hospitalists that malnutrition has severe negative effects on hospitalized patients, preventive or corrective measures often aren’t taken.
The ill effects of nutritional deficiency are particularly profound in elderly inpatients. Estimates of protein-energy malnutrition vary between 20%-78% of elderly medical patients, who are uniquely disposed to the cognitive, metabolic, and immune-mediating consequences of malnutrition.1
Most hospitalists know when to request a nutritionist consultation or order extra mealtime cans of Ensure. But many do not realize these efforts often do little to alter patients’ descent into nutritional deficiency.
Define the Problem
Four patterns of problematic eating have been described in elderly inpatients.
The first and most common is the patient who is permitted nothing by mouth and is not provided an alternate route of nutrition. Data show 44% of elderly malnourished inpatients fall into this category.2
Other abnormal feeding subgroups include patients who need to be fed but have no other eating problem, patients who refuse food but can swallow with difficulty, and those who aspirate liquid or solid food. In a study of 73 institutionalized patients with Alzheimer’s dementia, the latter subgroup accounted for 34% of the patients assessed.
Poor diet is the main source of protein-energy deficiency in elderly inpatients. Occult malabsorption secondary to bacterial overgrowth in the small intestine may also be an important factor, as is the increased catabolic state associated with acute illness.
Though the most at-risk patients have severe mental and physical incapacities, other problems including respiratory disease, gastrointestinal disease, and stroke are associated with a malnourished state.3
Though hospitalists generally acknowledge the potential seriousness of a patient developing nutritional deficits, the attending healthcare team may be slow to diagnose or manage this problem because:
- Elderly patients can be malnourished on admission, but classic signs of protein-energy deficiency are mistaken for normal signs of aging;
- Nutritional problems are observed by the medical staff, but aggressive treatment is deferred in light of seemingly more pressing medical issues;
- Many physicians take action to prevent nutritional deficiencies, but these interventions are often insufficient or ineffective in preventing the spiral into malnutrition; and
- Physicians may assume a nutritionist is working to prevent and treat nutritional deficiencies, while the nutritionist is waiting for the medical staff to address the problem with a feeding tube.
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Clinical Outcomes
Most physicians have observed the declining physical and cognitive capabilities of a nutritionally deprived elderly inpatient.
Although a causal relationship between malnutrition and adverse events has not been established, this is most likely because an older person’s clinical course affects and is affected by his nutritional status. Further, frequently compromised homeostatic mechanisms make the risk of complications related to malnutrition potentially more severe.
Though researchers are studying how inadequate nutritional intake contributes to the risk of adverse outcomes in elderly inpatients, numerous studies have identified strong correlations between the severity of the nutritional deficit and the risk of subsequent morbid events.
Sullivan, et al., found in their 1999 study of protein-energy undernutrition among elderly hospitalized patients that those maintained on nutrient intakes far less than their estimated energy requirements were at more risk of in-hospital mortality.
Other studies have shown that the risk of in-hospital starvation correlates strongly with polypharmacy and long stay. The severity of the nutritional deficiency correlates not only with weight loss and secretory protein loss, but also the risk of in-hospital and long-term complications.
Who Needs Help
Basic nutritional requirements vary much less than might be expected among younger and older patients. However, while a malnourished 20-year-old can be easily identified, the classic signs of malnutrition (wasting, brittle hair, dry skin, fissured mucus membranes) are less easily detected in elderly patients. They are often mistaken for signs of normal aging. Questions that can elicit evidence of a protein-energy deficiency include: