Section II
The Role of Nutrition in the Management of Disease



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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population Section II The Role of Nutrition in the Management of Disease

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population 4 Undernutrition As new markers of poor nutritional status have been identified, the definition of undernutrition has been considerably refined. Most notably, better methods of measuring body composition and biochemical measures of inflammation and nutritional health have led to refined classification systems of undernutrition. Concurrently, there has been increasing recognition of clinical syndromes that appear to have a major nutritional component (e.g., failure to thrive). This report considers several aspects of undernutrition including the following: Markers of Undernutrition Weight loss and morphometric measures of undernutrition Poor nutritional intake Biochemical markers of malnutrition (albumin, transferrin, retinol binding protein) Syndromes of Undernutrition Body composition changes with aging or sarcopenia Cachexia Wasting Protein–energy undernutrition Failure to thrive None of these markers or syndromes (except poor nutritional intake) are specific for malnutrition, and it must be recognized that the interfaces

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population between nutrition, energy requirements, and disease are complex. Moreover, approaches to diagnosis and management usually have not followed these definitions. Finally, despite global research efforts, there are still many gaps in the understanding of undernutrition in older persons. For each of these markers and syndromes, the following topics are addressed where information is available: commonly used definitions, clinical importance in different settings (e.g., frequency, increased risk for adverse events), potentially treatable contributing factors and assessment methods (including current practice and a more optimal approach), and approaches to treatment and treatment outcomes. There is considerable overlap across conditions with respect to assessment, contributing factors, and treatments. Although this chapter focuses on markers and syndromes of undernutrition, it must be recognized that undernutrition may affect the course of specific acute (e.g., pneumonia [Riquelme et al., 1996]) and chronic diseases (e.g., congestive heart failure, chronic obstructive pulmonary disease, pressure sores). In some instances, the treatment of these diseases (e.g., congestive heart failure) may lead to dietary restrictions that compromise nutritional status (Reuben et al., 1997). In others, the burden of the disorder may lead to increased energy requirements. Finally, some disorders (e.g., stroke with dysphagia, malabsorption) may precipitate undernutrition because of the inability to ingest or absorb nutrients. Although the recognition of these potential influences is important and may guide management, undernutrition accompanying specific diseases will eventually be expressed through the markers and syndromes described below. MARKERS OF UNDERNUTRITION Weight Loss Several definitions of clinically important weight loss have been described. These vary according to the amount of weight lost and the duration of the weight loss. In outpatient settings, commonly employed definitions include more than 10 pounds in 6 months, 4 to 5 percent of body weight in 1 year, or 7.5 percent in 6 months. In the nursing home, the definition of weight loss has usually followed that included in the Omnibus Budget Reconciliation Act (OBRA) regulations of 1987. This legislation mandated implementation of the

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population Minimum Data Set (MDS) and Resident Assessment Protocols (RAPs) in Medicare-certified nursing homes to ensure prompt identification and response to problems in nursing home residents. (The MDS is a functionally based assessment tool; RAPs utilize MDS assessment information to flag potential problem and risk areas in nursing home residents.) The OBRA MDS considers weight loss as greater than or equal to 5 percent of body weight in the past month or greater than or equal to 10 percent in the last 6 months. Clinical Importance A 4-year cohort study determined that the annual incidence of involuntary weight loss (defined as loss of more than 4 percent of body weight) among veterans followed in an outpatient setting was 13.1 percent. Over a 2-year follow-up period, those with involuntary weight loss had an increased risk of mortality (relative risk [RR] = 2.4, 95 percent confidence interval [CI] = 1.3–4.4), which was 28 percent among those who lost weight and 11 percent among those who did not. Individuals with voluntary weight loss had a 36 percent mortality rate during this time (Wallace et al., 1995). In a study of Alzheimer’s patients followed for up to 6 years, greater than or equal to 5 percent weight loss in any year before death predicted mortality (RR 1.5, 95 percent CI = 1.09–2.07); 22 percent of Alzheimer’s patients experienced such weight loss (White et al., 1998). Two longitudinal studies also suggest that weight loss in later life predicts mortality. In the Established Populations for Epidemiologic Studies of the Elderly (EPESE) cohort, older persons who lost 10 percent of their body weight or more between ages 50 and 70 years had higher adjusted risks of mortality (men: RR = 1.69, 95 percent CI = 1.19–1.65; women: RR = 1.62, 95 percent CI = 1.45–1.97) (Losonczy et al., 1995). The Iowa Women’s Health Study demonstrated that women greater than or equal to 55 years of age who had an episode of unintentional weight loss (19 percent of the study participants) had an adjusted OR of 1.45 (95 percent CI = 1.24–1.70) for all-cause 5-year mortality (French et al., 1999). Although the time spans utilized in these latter definitions are impractical for clinical purposes, they do provide evidence of an association between weight loss and subsequent mortality. For the nursing home population, there are fewer prevalence data. One study found that 5 percent of residents at one nursing home met these criteria (Blaum et al., 1997). Weight loss may be an insensitive measure of malnutrition because nursing home residents may stop eating for several weeks between weight measurements.

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population Potentially Treatable Contributing Factors and Assessment Methods Many of the causes of weight loss (e.g., depression, type 2 diabetes, hyperthyroidism, gastrointestinal diseases, cancer) are treatable with effective therapies supported by randomized clinical trials (Blaum et al., 1995; Morley and Kraenzle, 1994; Wilson et al., 1998). Among nursing home residents, reversible factors such as poor oral intake, feeding dependency, chewing problems, depressive symptoms or behavior, medications, and swallowing disorders were related to observed weight loss in two cross-sectional studies (Blaum et al., 1995; Morley and Kraenzle, 1994). In hospital settings (defined here as short-stay, acute care hospitals), the current approach to assessment of causes of weight loss and undernutrition is generally haphazard. Although many nursing intake forms include questions on weight loss, functional status related to nutrition, and special dietary needs, staff complete these forms in an inconsistent manner. At many institutions, dietary technicians spend significant amounts of time collecting data, which may have little clinical value, in order to meet the Joint Commission for Accreditation of Healthcare Organizations (JCAHO) mandate of nutritional assessment data collection of all hospitalized persons. Usually nursing home residents are weighed once a month. When the RAP for malnutrition is triggered by any of the MDS nutrition criteria, there must be documentation of responses by the health care team, including an assessment of feeding as well as investigation, when appropriate, for medical disorders that can cause weight loss. The assessment of weight loss is guided by other associated symptoms (e.g., gastrointestinal, cancer-related, depression, diabetes) if they are present. In addition, other potential contributors to weight loss or any of the other undernutrition disorders are evaluated for potentially remediable conditions. This assessment may include some or all of the following: assessment of food security, if the older person is community dwelling (e.g., specific questions about financial status, referral to social worker); assessment of food-related functional status (e.g., specific questions about shopping, meal preparation, and feeding); assessment of appetite and documentation of dietary intake (e.g., dietitian referral, 72-hour calorie count); assessment of depressive symptoms (e.g., dietitian referral, 72-hour calorie count);

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population assessment of dental and chewing status (e.g., documented oral examination or referral to a dentist); assessment of swallowing ability (e.g., bedside swallowing study, referral for swallowing study, or videofluoroscopy); assessment of medications that might be associated with decreased appetite (e.g., digoxin, fluoxetine, anticholinergics); assessment of cognitive impairment (e.g., screening for dementia with the Mini-Mental State Examination); and assessment of disease-related dietary restrictions (e.g., low salt, low protein). Approaches to Treatment and Treatment Outcomes Treatment of specific identified causes of weight loss such as cancer or thyroid disease is supported by clinical trials. However, to date, no randomized clinical trial data have evaluated the ability of consultation by a dietitian or the use of nutritional supplements to provide clinical or health utilization benefits for older persons other than in situations following recovery from pneumonia or hip fracture (Schürch et al., 1998; Woo et al., 1994). Among homebound elderly with involuntary weight loss or baseline low body mass index (BMI), a case series of 12 weeks of dietary supplements (500 kcal per day) demonstrated increases in weight, total lymphocyte count, and general well-being score (Gray-Donald et al., 1994). A subsequent randomized clinical trial using the same intervention demonstrated increases in weight (2.1 kg in the supplemented group compared to 0.6 kg in the control group, p < 0.01) but no changes in functional status (Gray-Donald et al., 1995). A case-series of persons who had lost at least 20 percent of their body weight or at least 10 percent in 3 months demonstrated improvement in nutritional parameters, including serum albumin, after being hospitalized in a nutritional support unit and receiving enteral nutrition via a nasogastric tube which provided approximately three times the measured energy expenditure for 4 weeks (Hébuterne et al., 1995). In nursing home settings, many residents who sustain weight loss do so because they are not adequately fed, in part due to limitations of nursing resources (see discussion of “poor nutritional intake” below) (Kayser-Jones and Schell, 1997). Although no studies are available to suggest that nursing home staffing or behavioral changes can improve dietary intake, these problems are potentially correctable. A case-control study of nursing home residents who were receiving oral supplements at least twice daily for weight loss or poor appetite demonstrated that most of these

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population residents regained weight back to their admission weight over a period of 9 to 10 months (Johnson et al., 1993). In a nonrandomized study that provided increased nutritional support to nursing home residents, undernourished residents (defined by BMI, weight loss, and anthropometric measurements) who gained weight over 10 months had fewer recurring infections and were less likely to die. They had a 17 percent mortality rate, compared to a 45 percent mortality rate among those who were undernourished but lost weight during the follow-up period, and a 35 percent mortality rate among those who were undernourished and maintained their weight (Keller, 1995). Anthropometric Measurements Anthropometric measures are used in research and in some clinical settings to identify older persons with malnutrition. Some of the more common measurements include: triceps skinfold thickness (TSF), which is measured on the upper arm, halfway between the inferior border of the acromion process and the tip of the olecranon process, and mid-arm muscle circumference (MAMC) (Bienia et al., 1982; Shenkin et al., 1996). The MAMC is calculated using the mid upper-arm circumference (AC) and the standard formula: MAMC = AC – 3.14 (TSF) (Bienia et al., 1982). Clinical Importance Because TSF thickness spans a wide range among normal individuals, sequential changes in the same individual may be more valuable than one-time measurements (Shenkin et al., 1996). However, measurement error increases with size of skinfold, and inter- and intraobserver variation may be large (Fuller et al., 1991). Moreover, these anthropometric measurements suffer from poorer reliability in elderly compared to younger subjects, in part because of difficulties in accurately locating anatomic landmarks (Sullivan et al., 1989) and because of age-related changes in skin elasticity. For example, a TSF measurement taken at the level of the midarm may vary by as much as 150 percent from a measurement taken only 1 to 2 centimeters above or below this point (Sullivan et al., 1989). With aging, a smaller proportion of total body fat is subcutaneous; therefore, skinfold thickness is less likely to indicate total body fat in older compared to younger persons. Nevertheless, in community-dwelling older persons, low corrected arm muscle area and low TSF predict subsequent 40- to 46-month ageadjusted mortality. For example, in a prospective cohort study, having a corrected arm muscle area below the 5th percentile was associated with a RR of 3.5 (95 percent CI = 1.6–8.2), and having a corrected arm muscle

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population area between the 5th and 10th percentiles was associated with a RR of 2.2 (95 percent CI = 1.0–4.9). In the same study, having a TSF below the 5th percentile was associated with a RR of 4.9 (95 percent CI = 2.1–11.1). BMI did not remain in the logistic model and the authors noted that BMI determinations can be inaccurate in the elderly due to difficulties in obtaining accurate heights and the effects of edema or dehydration on weight (Campbell et al., 1990). Potentially Treatable Contributing Factors and Assessment Methods The contributors to anthropometric abnormalities have not been formally studied but are not likely to differ substantially from those contributing to weight loss or low BMI. Assessment methods for abnormal anthropometric measures are similar to those used for weight loss. Approaches to Treatment and Treatment Outcomes Anthropometric measures have been used as entry criteria in some clinical trials of nutritional supplementation in hospitalized older persons (Bastow et al., 1983; Gariballa et al., 1998). A randomized clinical trial studied the administration of a 600 kcal and 20 g protein supplementation twice daily to patients who had sustained a stroke and who had anthropometric evidence of undernutrition by TSF and MAMC. Subjects in the supplemented group demonstrated a smaller decrease in serum albumin than those in the control group (mean decrease 1.5 g/L compared to 4.4 g/L, p = 0.025) and a nonsignificant reduction in 3-month mortality (10 percent in the supplemented group versus 35 percent in the control group, p = 0.12) (Gariballa et al., 1998). Another clinical trial of women hospitalized for hip fracture who were classified as thin or very thin based on arm circumference and TSF studied the effect of overnight supplementary nasogastric tube feedings of 1,000 calories, which were continued until discharge or death. Rehabilitation time to independent mobility (median 16 days in the treated group compared to 23 days in the control group, p = 0.02) and hospital stay were shortened (median 29 days in the treated group compared to 38 days in the control group, p = 0.04), particularly among the very thin (Bastow et al., 1983). Low Body Mass Index Low BMI (weight [kg] versus height [m2]) is considered definitive for chronic protein–energy undernutrition (PEU) if less than 17 and for being consistent with but not diagnostic of PEU if between 17 to 20 (Shenkin et al., 1996).

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population Clinical Importance Among community-dwelling older persons, BMI has been shown to demonstrate a U-shaped relationship to functional impairment, with increased risk among those at the lowest and highest BMIs (Galanos et al., 1994). However, change in BMI may be more important than actual value. In the EPESE study, persons who were in the lowest quintile of BMI at age 50 were not at increased risk of mortality during old age (Losonczy et al., 1995). Potentially Treatable Contributing Factors and Assessment Methods There are two population groups of older persons who have low BMI: those who have always been thin and those whose BMI has declined. Among the latter group, the causes of low BMI are not likely to differ substantially from the causes of weight loss. Assessment methods for low BMI are similar to those used for weight loss. Approaches to Treatment and Treatment Outcomes A randomized clinical trial of nutritional supplements for demented patients with low BMI (15.1–19.9) who were admitted to a psychiatric hospital and who received a 600 kcal oral supplement demonstrated significant increases in weight (3.7 versus 0.6 kg), MAMC (0.5 cm versus no change), and TSF (1.5 versus 0.5 mm) at 12 weeks compared to the placebo group (Carver and Dobson, 1995). Other studies have included low BMI, in addition to weight loss or abnormal anthropometric measurements, as an entry criterion (see discussion of weight loss above). Poor Nutritional Intake Generally, poor nutritional intake has been defined as average or usual intake of servings of food groups, nutrients, or energy below recommended amounts. Estimates for energy needs may be obtained from published references (WHO/FAO/UNU, 1985) or calculated using regression equations (e.g., Harris-Benedict). Many of the regression equations in use take into account age, height, and/or body weight. The energy needs are then adjusted for the estimates of activity level and the effects of disease and treatment. A threshold percentage used to define poor nutritional intake has been 66 or 75 percent of the Recommended Dietary Allowance (RDA) (IOM, 1994). This is not an appropriate use of the RDA as the numbers are derived in multiple ways from available data (IOM, 1997; NRC, 1986).

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population While some of these recommended intakes are based on the minimum average amount most individuals are thought to need to prevent deficiency, plus additional amounts to account for decreased absorption or bioavailability of the nutrient and for individual variation in requirements, others are based on what appear to be average intakes of healthy groups of people (IOM, 1994). Newer methodology indicates that a more appropriate reference intake for use in assessing adequacy for a specific nutrient in a group of people is the Estimated Average Requirement (IOM, 1994, 1997). However, these reference intakes are not yet available for all nutrients of interest (IOM, 1997, 1998). Some recent studies conducted in hospital settings have used less than or equal to 30 and 50 percent of estimated energy requirements as a threshold (Incalzi et al., 1998; Sullivan et al., 1999). The MDS uses less than 75 percent of food provided as the threshold to trigger the malnutrition resident assessment protocol. These are subjective assessments frequently conducted by nursing staff. Prior to implementation of the MDS, the RDA was used as a goal for monitoring nutritional intake and is still used as a standard by many dietitians working in nursing home settings. Subsequent to OBRA implementation in 1987, the specific MDS items for poor nutritional intake are the following: The resident complains about the taste of many foods. The resident regularly or repeatedly complains of hunger. The resident leaves 25 percent or more of his or her food uneaten at most meals. The unreliability and subjective nature of accurately assessing these measures have been raised. Two studies have documented that nursing home staff significantly overestimate nutritional intake of nursing home residents (Kayser-Jones et al., 1997; Pokrywka et al., 1997). In summary, efforts to develop assessment tools for use with elderly have not yet been able to identify aspects of health and status that can be monitored and evaluated objectively in older individuals with varying stages of functional capability that will accurately discriminate between those at risk and those not. Clinical Importance Although older persons under-report energy intake (Goran and Poehlman, 1992; Sawaya et al., 1996; Tomoyasu et al., 1999), community surveys estimate that between 37 to 40 percent of elderly men and women (those age 65 and over) report energy intakes less than two-thirds of the

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population Approaches to Treatment and Treatment Outcomes Interventions for wasting syndromes have generally focused on increasing nutrient intake through nutritional supplementation and appetite stimulation via drug therapy. However, outcome and ability to accrue lean body mass appear largely to be determined by the underlying disease process. Protein–Energy Undernutrition PEU is defined by the presence of both clinical (physical signs such as wasting, low BMI) and biochemical (albumin or other protein) evidence of insufficient intake. The most commonly used threshold to define PEU, albumin less than 3.5 g/dL, was derived in hospitalized patients (Bistrian et al., 1974). More recently, this threshold has been questioned as increased risk of adverse outcomes has been identified among hospitalized patients with higher levels of serum albumin (Del Savio et al., 1996). Clinical Importance The prevalence of PEU varies widely across settings. Using a threshold of less than or equal to 3.5 g/dL, 25 to 53 percent of elderly patients meet this criteria among hospitalized older persons (Bienia et al., 1982; Constans et al., 1992), as do 35 percent of geriatric rehabilitation unit patients (Sullivan et al., 1995). Among community-dwelling older persons sampled in the first National Health and Nutrition Examination Survey (NHANES), 1 percent of persons 55 to 74 years of age had albumin levels less than 3.5 g/dL, but 8 percent had values of less than or equal to 3.8 g/dL (Reuben et al., 1997). The prevalence of hypoalbuminemia rises with age as a result of the increased burden of diseases and probably a slight physiological decrease in albumin level with aging. Among those 90 years of age or older in the EPESE cohort, 10 percent had values less than 3.5 g/dL (Salive et al., 1992). Community-dwelling older persons who are homebound appear to be at particular risk for hypoalbuminemia; 19 percent had serum albumin levels less than 3.5 g/dL in one survey (Ritchie et al., 1997). In the nursing home setting, approximately 28 percent of residents have albumin levels less than 3.5 g/dL (Abbasi and Rudman, 1993). Numerous studies have associated low serum albumin in hospitalized older persons (measured at various times during hospitalization) with in-hospital complications, longer hospital stays, more frequent readmissions, in-hospital mortality, and increased mortality at 90 days and at 1 year (Agarwal et al., 1988; Anderson et al., 1984; Burness et al., 1996; Cederholm et al., 1995; D’Erasmo et al., 1997; Ferguson et al., 1993;

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population Friedmann et al., 1997; Harvey et al., 1981; Herrmann et al., 1992; Incalzi et al., 1998; Marinella and Markert, 1998; McClave et al., 1992; Patterson et al., 1992; Sullivan and Walls 1995; Sullivan et al., 1995; Volkert et al., 1992). When considering mortality, the lower the albumin level, the higher the risk of death. Among nursing home residents who were hospitalized, one prospective cohort study found that severe hypoalbuminemia predicted mortality (Ferguson et al., 1993). Low serum albumin has been predictive of 1-year mortality in male nursing home residents (Rudman et al., 1987). Similarly, a prospective cohort study found that hypoalbuminemia predicted 3-month mortality among long-term care residents receiving tube feedings (Henderson et al., 1992). In community-dwelling populations, hypoalbuminemia predicts higher mortality rates at 3, 5, and 9 to 10 years (Agarwal et al., 1988; Corti et al., 1994; Klonoff-Cohen et al., 1992; Sahyoun et al., 1996) and in healthier older persons (Reuben et al., 1999). The magnitude of this risk is most pronounced in those who meet the classic hypoalbuminemic criterion of less than 3.5 g/dL. In the EPESE cohort, the adjusted RR of mortality over 5 years for those who met this criterion was 1.9 for men and 3.7 for women. That study also noted significantly increased RR (1.9 for men and 2.5 for women) among persons with more modest hypoalbuminemia (≤3.8 g/dL). In the MacArthur Studies of Successful Aging, which enrolled older persons who had little or no functional impairment at the study’s onset, those with albumin levels less than 3.8 g/dL had an adjusted RR of 3-year mortality of 1.8 (Reuben et al., 1999). Prealbumin has also been shown to provide long-term prognostic value of mortality for patients admitted to a geriatric assessment unit (Mühlethaler et al., 1995). Low prealbumin and transferrin levels predicted short-term (3 month) mortality among nursing home residents (Woo et al., 1989). Potentially Treatable Contributing Factors and Assessment Methods Using data from the first NHANES, 14 risk factors for hypoalbuminemia were identified (Reuben et al., 1997). These included age greater than or equal to 65 years; receipt of welfare; having a condition that interferes with eating; vomiting greater than or equal to 3 days per month; prior surgery for gastrointestinal tumor; having heart failure; having recurring cough attacks; feeling tired, worn out, or exhausted; loss of teeth or having poor dentition; getting little or no exercise; being prescribed a low salt diet; currently smoking cigarettes; trouble chewing firm meats; and having albuminuria, glycosuria, or hematuria. Those who had between three and five of these conditions had an odds ratio of 2.73 for

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population having an albumin level less than or equal to 3.8 g/dL, and those with six or more risk factors had an odds ratio of 6.44. Many of these risk factors are modifiable; however, the link between modifying risk factors and reduction of hypoalbuminemia and subsequent consequences has not yet been established. The assessment of hypoalbuminemia includes tests of liver and renal function to exclude cirrhosis and nephrotic syndrome. Other assessment methods are similar to those used to evaluate weight loss and are described above. Approaches to Treatment and Treatment Outcomes Among hospitalized older persons, the most relevant research has been that aimed at poor nutritional intake (summarized above and in chapter 2). There have been no randomized clinical trials of specific treatments for PEU or hypoalbuminemia in community-dwelling older persons, but a small case-series indicated that a nurse-administered, in-home assessment may uncover remediable problems that contribute to hypoalbuminemia (Reuben et al., 1999). Failure to Thrive This term was originally coined to describe infants who failed to achieve height, weight, or behavioral milestones consistent with population-based normative data. It was later adapted to describe older persons who lose weight, decline in physical and/or cognitive function, and demonstrate signs of hopelessness and helplessness (Braun et al., 1988). In 1991, the National Institute on Aging described failure to thrive as “a syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol” (Lonergan, 1991). Some people have advocated abandoning this term as a disease construct in favor of four treatable contributing domains: (1) impaired physical functioning, (2) malnutrition, (3) depression, and (4) cognitive impairment (Sarkisian and Lachs, 1996). Because failure to thrive has not been approached systematically, prevalence data are not available. Specific treatments have not been developed or tested. Accordingly, the approach to failure to thrive is not considered separately. LIMITATIONS OF CURRENT EVIDENCE The detection of undernutrition in older persons in all settings is limited by the lack of valid and reliable detection methods. Other than in

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population specific situations (e.g., after hip fracture), the treatment of undernutrition is more empirical than evidence based. SUMMARY Undernutrition is exceedingly common among hospitalized older persons. Some are undernourished at the time of admission; others become undernourished during the hospitalization as a result of poor nutritional intake and high energy requirements. The treatment for undernutrition depends on the underlying cause. Although there are limited data supporting nutritional intervention in this setting, efforts to assess dietary intake and intervene should be encouraged. The JCAHO has designated the geriatric population as being at high risk and has required screening within 24 hours. Although the details of this screening are not specified, in practice, substantial amounts of dietitian and dietary technician time are spent in attempting to meet JCAHO requirements with little evidence that this actually benefits the care of patients. Undernutrition among nursing home residents is also common. Inadequate numbers of qualified staff and resulting feeding problems are major contributors. Treatable acute and chronic medical problems may also be important contributing factors. Most markers (i.e., weight loss, body composition, and biochemical) that are used to indicate undernutrition are not specific for this disorder and may be affected by both acute and chronic illness. Nevertheless, all convey valuable prognostic information. Newly defined syndromes, such as sarcopenia, cachexia, and wasting, may occur singly or in combination. The contributions of nutritional components as well as age-related changes and disease must be considered. The role(s) for nutritional therapy in the treatment of these syndromes awaits clarification. There is a pressing need for research on undernutrition in older persons. In many instances, key issues have not been formally studied. In other instances, the research previously conducted does not provide definitive answers. RECOMMENDATIONS Although the optimal method for identifying undernutrition in hospitalized older persons has not been determined, the currently employed methods are time consuming and insufficient. The current standards for screening for risk of malnutrition in hospitalized Medicare beneficiaries must be revised and standardized. While additional research is being conducted, it is rational to focus on assessments that

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population have prognostic value (e.g., weight loss, serum proteins) or which indicate that patients are not receiving adequate intake in the hospital, particularly patients whose hospitalization exceeds 72 hours. If potential undernutrition is identified, it is imperative that this information be communicated formally to the physician responsible for the patient’s care. Community-dwelling older persons and nursing home residents who have experienced weight loss should be evaluated by a dietitian for potentially reversible causes as part of their Medicare benefits. This evaluation should include some or all of the following: food security food-related functional status appetite and dietary intake depressive symptoms swallowing ability medications that might be associated with decreased appetite cognitive impairment disease-related dietary restrictions. Adequacy of feeding assistance in nursing home and hospital settings should be a performance standard for licensing. The federal government, through agencies such as the National Institute on Aging, the Agency for Healthcare Research and Quality, and the Health Care Financing Administration, should support clinical research on nutrition in older persons. Some of the most important research questions include the following: Which body composition and biochemical measures are most specific for undernutrition? What are the best methods for identifying older persons with undernutrition in hospital settings? What are the benefits of provision of nutritional supplements among older persons who have experienced decreased appetite during hospitalization? What are the benefits of provision of nutritional supplements among older persons who have lost weight for which an identifiable cause has not been found? What are the most appropriate methods for providing nutritional intake for older persons who will not or cannot safely ingest sufficient nutritional intake?

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population What are the best methods to ensure that nursing home residents are adequately fed? What are the most effective combinations of nutrition therapy, exercise, trophic factors, and appetite stimulants that lead to optimal outcomes among those with undernutrition? What is the role of nutrition therapy among older persons who have evidence of sarcopenia, cachexia, or wasting syndromes? REFERENCES Abbasi AA, Rudman D. 1993. Observations on the prevalence of protein–calorie undernutrition in VA nursing homes. J Am Geriatr Soc 41:117–121. Agarwal N, Acevedo F, Leighton LS, Cayten CG, Pitchumoni CS. 1988. Predictive ability of various nutritional variables for mortality in elderly people. Am J Clin Nutr 48:1173–1178. Anderson CF, Moxness K, Meister J, Burritt MF. 1984. The sensitivity and specificity of nutrition-related variables in relationship to the duration of hospital stay and the rate of complications. Mayo Clin Proc 59:477–483. Anker SD, Clark AL, Kemp M, Salsbury C, Teixeira MM, Hellewell PG, Coats AJS. 1997. Tumor necrosis factor and steroid metabolism in chronic heart failure: Possible relation to muscle wasting. J Am Coll Cardiol 30:997–1001. Bastow MD, Rawlings J, Allison SP. 1983. Benefits of supplementary tube feeding after fractured neck of femur: A randomised controlled trial. Br Med J 287:1589–1592. Baumgartner RN, Stauber PM, McHugh D, Koehler KM, Garry PJ. 1995. Cross-sectional age differences in body composition in persons 60+ years of age. J Gerontol 50A:M307– M316. Baumgartner RN, Koehler KM, Gallagher D, Romero L, Heymsfield SB, Ross RR, Garry PJ, Lindeman RD. 1998. Epidemiology of sarcopenia among the elderly in New Mexico. Am J Epidemiol 147:755–763. Beutler B, Mahoney J, Le Trang N, Pekala P, Cerami A. 1985. Purification of cachectin, a lipoprotein lipase-suppressing hormone secreted by endotoxin-induced RAW 264.7 cells. J Exp Med 161:984–995. Bienia R, Ratcliff S, Barbour GL, Kummer M. 1982. Malnutrition in the hospitalized geriatric patient. J Am Geriatr Soc 30:433–436. Bistrian BR, Blackburn GL, Hallowell E, Heddle R. 1974. Protein status of general surgical patients. J Am Med Assoc 230:858–860. Blaum CS, Fries BE, Fiatarone MA. 1995. Factors associated with low body mass index and weight loss in nursing home residents. J Gerontol 50A:M162–M168. Blaum CS, O’Neill EF, Clements KM, Fries BE, Fiatarone MA. 1997. Validity of the Minimum Data Set for assessing nutritional status in nursing home residents. Am J Clin Nutr 66:787–794. Bortz WM II. 1982. Disuse and aging. J Am Med Assoc 248:1203–1208. Braun JV, Wykle MH, Cowling WR III. 1988. Failure to thrive in older persons: A concept derived. Gerontologist 28:809–812. Breslow RA, Sorkin JD. 1993. Comparison of one-day and three-day calorie counts in hospitalized patients: A pilot study. J Am Geriatr Soc 41:923–927. Burness R, Horne G, Purdie G. 1996. Albumin levels and mortality in patients with hip fractures. N Z Med J 109:56–57.

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