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Malnutrition is a physiological state of the body characterised by a decrease in the intake or absorption of nutrients over time relative to one’s needs. In addition to poverty, mental illness, infections and neoplasms,various metabolic diseases are among the causes of malnutrition:
Protein-calorie malnutrition is, together with mineral and vitamin deficiency, particularly common in the elderly.
The category at greatest risk of malnutrition is the frail elderly. The frail elderly person is old or very old, suffering from multiple chronic diseases, clinically unstable, frequently disabled, often with socio-economic problems such as loneliness and poverty. In the frail elderly, nutritional status and the ability to feed oneself adequately are often compromised. Severe protein-calorie malnutrition was observed in 10-38% of the non-hospitalised elderly, 5-12% of those living at home, 26-65% of those hospitalised and 5-85% of institutionalised individuals.
The main causes of malnutrition are as follows.
Ageing leads to certain physiological changes including atrophy of the mucous membrane of the oral cavity and tongue with taste sensitivity deficit, digestion and nutrient absorption deficit. Chewing defects due to tooth loss are widespread and are often associated with incorrect dietary and hygiene habits and poor socio-economic conditions. Chewing defects due to tooth loss are widespread and are often associated with incorrect dietary and hygiene habits and poor socio-economic conditions.
Swallowing disorders are a widespread problem in the frail elderly population: dysphagia is found in 20-50% of institutionalised patients. Secondly, organ failure (heart failure, advanced chronic renal failure, respiratory failure, etc.) and neoplasms can cause increased nutritional requirements and consequent hypoanorexia. In addition, the many medications often taken by the elderly may interfere with the absorption (antacids, laxatives) or renal excretion (diuretics) of certain substances and may lead to taste alterations.
Economic hardship, isolation, loneliness and/or institutionalisation may be the cause of inadequate food intake. Malnutrition has a negative impact on a person’s nutritional and psycho-social status and correlates with a worsening of chronic diseases, increased incidence of infections, bedsores, falls. A particular consequence of malnutrition in the elderly is the loss of autonomy with a deteriorating quality of life.
The first phase of the nutritional intervention is aimed at verifying the possibility of oral feeding.
The aim of this phase is to correct and enhance the protein-calorie intake with natural foods, and nutritional advice, food fortification and the use of supplements. In case of failure to reach the oral nutritional target enteral artificial nutrition (NE), via nasogastric tube (SNC), percutaneous endoscopic gastrostomy (PEG) or percutaneous endoscopic jejunostomy (PEJ), and/or parenteral nutrition (NP) must be used.
If lack of appetite, early gastric fullness and fatigue in food intake prevail, an initial nutritional intervention is to direct the patient to take a fractionated diet, in Small-volume meals, at least 4 or 5 in the day, with high caloric densityfor the purpose of providing more energy and protein in a smaller volume.
It may be useful to suggest to your patients to enrich their food with condiments (oil, butter), sauces (cooking cream, mayonnaise, béchamel), whipped cream, ice cream, sugar, honey, jams, syrups, fruit juices as a source of calories; milk, including condensed powdered milk, cheese, eggs as a source of protein.
The purpose of taking oral supplements is to provide people who are still able to feed themselves naturally with enough additional nutrients to cover their nutritional needs. This avoids the need for more invasive nutritional support techniques such as enteral or parenteral nutrition. Oral supplements may be useful in malnourished individuals or those at risk of malnutrition where food fortification has been ineffective but they still manage to get at least half of their requirements from natural foods. Over the last few years the range of oral supplements has broadened considerably, both in terms of bromatological composition and in terms of taste variants with improved palatability of the different products. This allowed more nutritionally targeted use and improved patient compliance with long-term intake. The use of supplements is clearly recommended (Level of evidence A) by the guidelines for artificial nutrition in the elderly patient: “oral supplementation is clearly recommended to ensure energy, protein and micronutrient intake, maintain or improve nutritional status, improve survival in patients who are malnourished or at risk of malnutrition”. A recent meta-analysis demonstrated a statistically significant increase in body weight with reduced mortality in malnourished elderly treated with oral protein-calorie supplements. In addition, oral supplements, particularly those rich in protein, can reduce the risk of pressure ulcers and are therefore clearly recommended in guidelines. Enteral and/or parenteral artificial nutrition (NE) and/or parenteral artificial nutrition (NP) must be used if the oral nutritional target is not met.
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