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As the elderly population continues to grow, the number of elderly with chronic illnesses will expand as well. Studies show that up to 60% of hospitalized elderly have clinically significant PEM [37]. The best indicator of mortality in community-based, hospitalized, and institutionalized elderly is weight loss. Kagansky and colleagues reported PEM in 15% of the elderly community, over 60% of the hospitalized, and up to 85% of nursing home residents [27]. Sullivan and colleagues investigated nursing home residents for 6 months and concluded that weight loss can have an ominous implication for mortality. However, when weight loss is reversed, survival is improved [38].

Although PEM among the elderly has been well established, it remains largely ignored [39-42]. One study found that more than 50% of severe nutritional deficiency cases in the elderly are undiagnosed or undetected [41]. Even when geriatric nutritional problems were properly addressed, adequate nutritional support was rarely provided. Sullivan and colleagues concluded that insufficient nutrient intakes in elderly patients may contribute to increased risk of mortality [43]. The authors reported that the poor nutritional status in elderly populations likely occurs before hospitalization and continues to have a strong association with mortality after discharge [9]. Some literature states that because of strong correlations of serum albumin and low BMI with mortality even years after discharge, emphasis needs to be placed on nutritional support after discharge [44]. Prospective studies have shown strong associations between nutritional parameters, e.g., low serum albumin levels, and both short- and long-term mortality (see Table 2.5). So strong were the associations for more than 9 years that Phillips et al. compared it with that for cigarette smoking [45].

Table 2.5

Variables that Correlate with 1- and 6-year Mortality

Variable Significant at 1 year Significant at 1 and 6 years

Diagnosis +

Serum albumin +

over prior 6 months

Number of chronic +


^ Number of diagnoses (0-7) of the following diseases: congestive heart failure, type 2 diabetes mellitus, cerebral vascular accident, dementia (Alzheimer's or MID), Parkinson's, COPD, and ESRD. Adapted from Sullivan and Walls [44]

Despite stabilization of the acute illness, the elderly have less recuperative powers after discharge [46] and have more frequent hospital readmissions, placing them at increased risk of death within 1 to 4 years after discharge [26, 47, 48]. In a comparison study with younger men with equal health status, elderly men were found to have poorer eating habits and took longer to recover. After 1 year, they had greater weight loss and more health problems [49], suggesting the aging process might play a role in recovery.

PEM has a variety of deleterious effects in the elderly, including infections [50, 51], pressure ulcers (though its causality is yet to be determined) [52], hip fractures [53-55], and cognitive abnormalities. Malnutrition impairs immune function, especially cell-mediated immunity [56, 57]. Most if not all of these effects can be reversed with adequate nutrition. Though a recent meta-analysis of mostly randomized clinical trials of oral supplementation confirmed short-term outcome benefits and improvement of nutritional status [58], other studies did not result in significant improvement in patients' caloric intakes [59], BMI or body weight [60]. Lauque et al. showed improvement in weight after 60 days' supplementation with 400kcal/day [61]. Appetite stimulants (orexigenics) can also contribute to weight gain. Megesterol acetate was found to produce weight gain in elderly nursing home patients [62], and dronabinol has shown weight gain in the elderly, but has mostly been used for palliative care [63].

Nutritional support is used in elderly persons who are unable to sustain their weight and increase their oral food intake. Enteral nutrition is the recommended route and can reverse weight loss and produce weight gain. Tucker and Miguel suggested that hospital length of stay is shortened by nutritional support reducing complications [64]. However, reduced survival has been documented in elderly persons with cognitive impairments [65, 66]. Some authors suggest that aging must influence the refeeding process as nutritional intervention cannot maintain weight despite adequate caloric intake [67, 68]. Although malnutrition is not an inevitable process in aging, many changes occur in the elderly that promote malnutrition outside of the hospital. Most important is anorexia, which causes decreased energy intake through several different disturbances, e.g., deterioration of taste and smell sensations and changes in gastrointestinal function, leading to early satiety. In addition, poor appetite, poor dentition, impaired physical activity, poor cognition, depression, and poor social functioning can further potentiate declines in energy intake.

The causal connections between malnutrition and poor prognosis are complex. It cannot automatically be inferred that nutritional support will improve the clinical course of elderly patients. Little evidence exists that confirms that long-term outcomes will be improved with parenteral nutrition (PN) in the elderly population; therefore, exclusive parenteral nutrition is generally not recommended. There are obvious indications for PN, especially in patients with intestinal failure, high output enterocutaneous fistulas, short bowel syndrome and some perioperative situations in patients with cancer.

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Keep Your Weight In Check During The Holidays

Keep Your Weight In Check During The Holidays

A time for giving and receiving, getting closer with the ones we love and marking the end of another year and all the eating also. We eat because the food is yummy and plentiful but we don't usually count calories at this time of year. This book will help you do just this.

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