We continue our series of discussions exploring malnutrition – specifically, undernutrition – in hospitalized patients in more depth. Our topic is malnutrition in the elderly hospitalized patient, including the documentation and coding of it, its impact on outcomes, its treatment, and its prevalence and the physical, social and psychological factors contributing to it. Recall that a variety of diseases and conditions should alert us to look for documentation of malnutrition.
Malnutrition or undernutrition, as we have learned, results from inadequate intake (inability to get food to the hand into the mouth and down the intestine), inability to digest and absorb nutrients from food successfully taken in, inability to utilize nutrition that is absorbed, and excessive loss of nutrients. The elderly may be at more risk than other age groups for the various etiologies of malnutrition, which include trauma, infection, inflammatory and metabolic disease, cancer, disability, infirmity, depression, and poverty. In simple terms, the longer we are on Earth, the greater the chance of experiencing the vagaries of fate.
We all surely have a caricatured mental image of an elderly person: shrunken, wrinkled, bent over, diminished eyesight, hard of hearing, frail, gnarled fingers on a tremoring hand, short of breath, unstable on foot without a walker, slipping dentures or edentulous, worn clothing, at times incoherent, feeble, etc. Bewildered by gadgets of the modern world. Often living in a nursing home, dependent on others, living alone if still independent. It doesn’t take much imagination to begin to enumerate the reasons why the elderly are at high risk for malnutrition, and how it can be the straw that breaks their backs.
The longer we live, the more we are likely to have or have been treated for cancer. Breast and colon cancer screening begins at 50, for example. The cancer itself may affect one’s appetite, as with pancreatic or gastric cancer, leading to decreased caloric intake. It often saps one of energy, making a patient averse or unable to shop for and prepare food. Treatments such as surgery, chemotherapy, and radiation therapy may worsen appetite and fatigue further, and add factors such as mucositis or nausea as from pain medication. In an elderly patient, think cancer, fatigue, infirmity and malnutrition, whether mild, moderate, or severe.
With age brings experience and trauma, as falls from ladders and car accidents, the wear and tear of manual labor, injury and repair, pain and contracture, bone density loss and osteoporosis, wasting from the sedentary life of non-manual laborers and commuting, and immobility from diseases such as osteoarthritis and rheumatoid arthritis all can play factors in personal health. One’s strength, flexibility, and sturdiness declines, both due to natural changes of aging in an otherwise healthy individual and the damaging effects of life. We have all seen ads for emergency call button devices., and another icon of the aged: dentures. A good pair of dentures is key to functional chewing of an appetizing variety of nourishing foods. Poorly fitting dentures (or worse, no dentures) affect not only one’s ability to eat but also what one wishes to eat, as well as one’s self-image and overall desire to eat. In an elderly patient, think physical limitations due to age and life’s traumas, inability to go shopping or even to open cans and jars, and a general inability to care for oneself – and inevitably there can be malnutrition, whether mild, moderate, or severe.
Along with age, cancer, and the trauma of life comes the most advanced stages of organ and chronic disease. End-stage renal disease results in nausea, bone disease, and an unpalatable diet. Heart disease leads to swelling, shortness of breath, and fatigue. Diabetes mellitus causes heart and kidney disease, as well as vascular disease, leading to amputations, eye disease, and dietary limitations. Pulmonary disease limits exercise tolerance and mobility. Cataracts may limit one’s ability to drive, read, navigate, and access and prepare food safely. In an elderly patient, think chronic disease, dietary limitation, difficulty acquiring and preparing food, metabolic derangement, and nutrient loss – again, with malnutrition, whether it be mild, moderate, or severe.
With age also can come psychological disorder from simple disorientation, as the world can tend to evolve faster than the elderly can adapt to and absorb, playing a factor in the presentation of depression and/or dementia. How many elderly people use smart phones? How many use online banking? How often do patients become confused in the hospital? Elderly individuals also can be less organized as they age, despite often being more preoccupied by it. Meals and portions become smaller and less routine. The elderly can see their days as numbered, their productivity falling, their value and importance diminished, and this can lead to decreased appetite. They may also be widowed and feel alone or fearful. Many people living alone, no matter what age, don’t like to “cook for one,” and so meals become snacks, then small snacks. And dementia can lead to losses of all of this, in particular due to dependence on others for acquiring and preparing food, as well as feeding. In an elderly patient, think changes in outlook, mental capacity, solitude, ability and desire to care for oneself, desire to eat, ability to eat, ability to absorb and utilize – and of course, with all of this can come malnutrition, whether it be mild, moderate, or severe.
Finally, poverty can affect stability in all the above domains, at all ages. It can include factors such as there being not enough to eat, not enough nutritious foods to eat, no place to prepare meals, no place to eat, no utensils, etc. For persons age 60 and older, 8 percent of households with seniors and 9 percent of seniors living alone have food insecurity.
The elderly, by virtue of their age, are at high risk for developing just about any disease or condition, in addition to being subject to normal functional decline, and therefore they are at risk for developing malnutrition (mild, moderate, or severe) from all pathways: intake; digestion and absorption; nutrient utilization; and excess nutrient loss.
So look for documentation, encourage documentation, and for providers, treat malnutrition as indicated with appetite stimulant, dietary supplement, enteral tube feedings, and parenteral nutrition, as necessitated by severity and cause.