UNDIAGNOSED MALNUTRITION AND NUTRITION-RELATED PROBLEMS IN GERIATRIC PATIENTS

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1 12 VOLKERT/C/ppp:04 LORD_c 5/10/10 9:12 Page 387 JNHA: GERIATRIC SCIENCE UNDIAGNOSED MALNUTRITION AND NUTRITION-RELATED PROBLEMS IN GERIATRIC PATIENTS D. VOLKERT 1, C. SAEGLITZ 2, H. GUELDENZOPH 3, C.C. SIEBER 1, P. STEHLE 2 1. Institute for Biomedicine of Aging, University of Erlangen-Nürnberg, Germany (DV, CCS); 2. Department of Nutrition and Food Sciences (IEL) Nutrition Physiology, University of Bonn, Germany (CS, PS); 3. Department of Geriatric Medicine, Malteser-Hospital, Bonn, Germany (HG). Address for correspondence: Prof. Dr. Dorothee Volkert, PhD, Institute for Biomedicine of Aging, University of Erlangen-Nürnberg, Heimerichstraße 58, Nürnberg, Germany, Phone , Fax dorothee.volkert@aging.med.uni-erlangen.de Abstract: Background & aims: Malnutrition is common in geriatric patients and associated with poor outcome. If recognised, effective treatment is possible. In recent years, low nutritional awareness among health care professionals (HCPs) has been deplored with respect to the general hospital population. The aim of the present cross-sectional study was to assess to which extent malnutrition and nutrition-related problems are documented by physicians and nursing staff in geriatric patients and whether nutrition support is used in daily clinical routine. Methods: Patient s characteristics, nutritional status (BMI, Subjective Global Assessment, Mini Nutritional Assessment) and several nutrition-related problems (e.g. weight loss, poor appetite, chewing and swallowing problems) were assessed in 205 patients consecutively admitted to the geriatric ward of a community hospital on the first day after admission. After discharge, all documented information in the medical folders about nutritional status, nutrition-related problems and nutrition support was systematically collected. Results: According to BMI (< 22 kg/m²) and Subjective Global Assessment (C), malnutrition was observed in 25.4 %, according to Mini Nutritional Assessment (<17 points) in 30,2 % of the patients. In daily routine, clinical judgement of nutritional status by physicians was performed in 187 patients (91.2 %) of whom 6.4 % (5.9 % of all) were classified as malnourished. Weight was documented in 54.1 %, height in 25.9 %. BMI was not calculated. Nutrition-related problems were present in up to half of the patients and only partly documented by HCPs. Seventeen patients (8.3 %) received nutrition support, mostly in the form of oral supplements (3.9 %), followed by enteral (2.9 %) and parenteral nutrition (1.5 %). Conclusion: Despite high prevalence rates among geriatric patients, malnutrition and nutrition-related problems are rarely recognised and treated. In order to improve nutritional care, routine screening and standard protocols for nutritional therapy should be implemented in geriatric hospital wards. Key words: Malnutrition, awareness of malnutrition, nutriton-related problems, geriatric patients, routine documentation, management. Non-standard abbreviations: ADL: activities of daily living; CJ: clinical judgement of nutritional status; GDS: Geriatric Depression Scale; HCPs: health care professionals; MMSE: Mini Mental Status Examination; MNA: Mini Nutritional Assessment; SGA: Subjective Global Assessment. Introduction Malnutrition is a well-known attendant syndrome in geriatric patients. Within observational studies, malnutrition has frequently been diagnosed in the elderly admitted to hospital and is associated with serious health problems and poor outcome (1, 2). Several age-related problems like poor appetite, chewing and swallowing problems or difficulties cutting food adversely affect dietary intake in the elderly and contribute to the worsening of nutritional status. If recognized, effective treatment of malnutrition as well as elimination of the underlying causes are possible, resulting in improved nutritional status and outcome (3, 4). For a long time, the low nutritional awareness by health care professionals (HCPs) has been deplored by several authors (5-13). Malnutrition and nutrition-related problems are often overlooked and not realized in the general hospital population. Consequently, evidence-based concepts of nutritional therapy are not integrated in clinical routine. Nutrition support is underutilised and malnutrition therefore often remains untreated. Based on the fact that geriatric patients are known to be at especially high risk of malnutrition, it could be argued that nutritional awareness is better in HCPs caring for geriatric patients than for the general hospital population. Up to now the extent to which malnutrition and nutrition-related problems are realized, diagnosed and treated in geriatric patients is not known. Thus, the aim of the present cross-sectional study was, to assess to which extent malnutrition and nutrition-related problems in geriatric patients are detected and documented by physicians and nursing staff, and whether nutrition support is Received April 29, 2009 Accepted for publication August 18,

2 12 VOLKERT/C/ppp:04 LORD_c 5/10/10 9:12 Page 388 used in daily clinical routine. Patients and methods Study design All geriatric patients consecutively admitted to the geriatric ward of a community hospital (Malteser-Hospital, Bonn, Germany) from August 2003 to April 2004 were candidates for enrollment in this cross-sectional study. Inclusion criteria were: age 75 y, not in a terminal disease state, expected length of stay longer than 48 h (judged by physician on duty), first admittance and no participation in another study. Due to capacity reasons, not all patients fulfilling the criteria could be enrolled. Study recruitments were limited to 2 patients per day (random selection). The study was approved by the local ethics committee and all participating subjects gave a signed consent. If the patient was unable to sign, relatives ore another proxy were consulted. Patient s characteristics, nutritional status and several nutrition-related problems were assessed on the first day after admission by research staff outside of clinical routine. Results were not transferred to the clinical staff. Information about routine assessment and documentation of nutritional status, nutrition-related problems and nutrition support by physicians and nursing staff in the same patient group was collected from the medical folders after discharge of the patients. Patients characteristics Patients characteristics included date of birth, gender, living situation before admission, route of admission (via general practitioner or another hospital) and the severity of the underlying disease (subjectively judged by the physician on duty as slight, moderate or severe). The ability to perform basic activities of daily living (ADL) was recorded according to Mahoney and Barthel (14), and patients were classified as severely functionally impaired ( 30 points), in need of help (35-65 points) or independent ( 70 points). Mental status was assessed using the Mini Mental Status Examination (MMSE) (15) and depressive symptoms were detected with the Geriatric Depression Scale (GDS) (16). Main and secondary diagnoses were collected from the clinical folders at discharge. Nutritional status Body-Mass-Index (BMI). Patients were weighed with a digital chair scale (Seca, Hamburg, Germany) to the nearest 0.1 kg. Height was measured with a measuring rod to the nearest 0.1 cm with the patient standing. When patients were bedridden height was measured with the patient lying in bed in a straight position. When measurements of height or weight were not possible self-reported values were used. Body mass index (BMI) was calculated as weight/(height) 2. A patient was considered as malnourished if his or her BMI was less than 22 kg/m 2. This value corresponds to the 10th percentile of data recently assessed in a population of healthy non-hispanic white elderly (17). UNDIAGNOSED MALNUTRITION IN GERIATRIC PATIENTS 388 Subjective Global Assessment (SGA). According to Detsky et al. (18) patients were categorised as well nourished (A), moderately malnourished (B) or severely malnourished (C) on the basis of medical history (weight loss during the last six months, dietary change) and physical examination of subcutaneous fat, muscle mass and edema. Mini Nutritional Assessment (MNA). This questionnaire, specifically designed for the elderly, consists of 18 questions with given weighted answers that sum up to a maximum score of 30 points. Patients are classified as well nourished ( 24 points), at risk of malnutrition ( points) or malnourished (<17 points) (19). All measurements and assessments were performed by the same trained person (CS). Nutrition-related problems Using a standardized questionnaire, the following nutritionrelated problems were assessed in a personal interview: recent weight loss (noticeable in the last 6 months), poor appetite, chewing problems (always or with hard food), swallowing problems, difficulties in cutting food, need of help with eating, problems with food supply at home. Answers were rated yes or no. If the patient was unable to answer the questions due to mental impairment or somnolence, relatives were asked. Nutritional assessment and documentation in clinical routine In clinical routine, assessment and documentation of nutritional status and nutrition-related problems was partly performed by physicians and by nurses. Physicians on duty are supposed to document their subjective clinical judgement (CJ) of nutritional status (malnourished, normal, obese), body height and weight, weight changes and appetite changes as part of the initial examination of each patient. Nursing staff is responsible for weighing the patients at admission and discharge with a digital chair scale and for the documentation of nutrition-related problems. These are only documented if observed. No specific guidelines for nutritional assessment were established. All nutritional information in the medical folders was collected systematically after discharge of the patients. Nutrition support Information about nutrition support included whether a patient received oral supplements, enteral and parenteral nutrition or not, and was also collected from the medical folders after discharge of the patients. Evaluation and Statistics Data were analyzed in a descriptive manner using SPSS version 12.0 (SPSS Software, Munich, Germany). Prevalence rates of malnutrition and nutrition-related problems assessed by research staff and prevalence rates of malnutrition, nutritionrelated problems and nutrition support documented by HCPs are reported. Categorical variables are shown as absolute numbers and percentages. For continuous variables mean and

3 12 VOLKERT/C/ppp:04 LORD_c 5/10/10 9:12 Page 389 JNHA: GERIATRIC SCIENCE standard deviation (SD), median and range are presented. Chisquare testing was used to detect significant differences in the prevalence of nutrition support between malnourished and well-nourished patients. P-values below 0.05 were considered statistically significant. Results Patients characteristics 205 patients (142 females, 69.3 %) were enrolled in the study. The mean age was 83.0 ± 4.7 (median 82.0; range 75-95) years. All patients had multiple diseases with fractures being the most prevalent primary diagnosis (27.3 %), followed by cardiac and circulatory disorders (19.0 %), neuropathies (13.7 %), and muscle and skeleton disorders (13.7 %). Seventy percent of the patients had five or more secondary diagnoses with a median of 7 (range: 0-19). Three quarters (74.1 %) were admitted from other hospitals. About one quarter, respectively, had a severe disease, were severely functionally impaired, had mental disorders or showed depressive symptoms. Main characteristics are shown in Table 1. Table 1 Main characteristics of patients at admission (n = 205) (MMSE = Mini Mental State Examination (14)) n % Living situation Alone With family members Assisted living Nursing home Severity of disease Severe Moderate Slight Activities of daily living (ADL (13)) Severely impaired (< 35 p.) In need of help (35 65 p.) Independent (> 65 p.) Mental status Reduced (MMSE 22 p. or clinical diagnosis of dementia) Test not feasible Geriatric Depression Scale (GDS (15)) Depressive symptoms (GDS 7 p.) Test not feasible Nutritional status In 25 patients (12.2 %), height was measured recumbent. In 24 patients (11.7 %), measurement of height and in 17 patients (8.3 %) measurements of weight was not possible and, thus, self-reported values were used. In 2 patients no information about body weight could be obtained. Mean BMI was 25.1 ± 4.4 kg/m² (median 24.7; range kg/m²). In about a quarter of the patients (25.4 %) BMI was below 22 kg/m². According to SGA, 25.4 % of the patients were severely and 34.6 % moderately malnourished. As classified by the MNA, 30.2 % were malnourished and 60.0 % at risk of malnutrition. Nutrition-related problems Most of the patients were able to answer the questions by themselves, in 12.2 % relatives had to be asked. The prevalence of nutrition-related problems is shown in Table 2 (left column). Recent weight loss was the most frequently occurring problem (47.8 %), followed by difficulties in cutting food (45.9 %). Problems with food supply (9.3 %) were most uncommon. Table 2 Prevalence of nutrition-related problems as assessed in a standardised interview by research staff and documentation by health care professionals (HCPs) (n=205) Interview by research staff Documentation by HCPs Recent weight loss 47.8 % 24.4 % Poor Appetite 20.5 % 13.7 % Chewing problems 32.2 % 3.9 % Swallowing problems 23.9 % 9.8 % Difficulty in cutting food 45.9 % 33.7 % Need of help while eating 22.4 % 9.8 % Problems with food supply 9.3 % 0.0 % Nutritional assessment and documentation in clinical routine Body weight at admission was documented in 111 patients (54.1 %). In about three quarters (73.9 %) of the documented cases, weight was measured and in one quarter (26.1 %) it was asked for. Body height was documented in 25.9 % of the patients and was based in all cases on self-reported values. Data for both weight and height were recorded for 24.4 % of the patients. BMI was calculated in no single case. Clinical judgement of nutritional status by physicians was performed in 187 patients (91.2 %). Of these, 6.4 % (12 patients; 5.9 % of all) were classified as malnourished. Figure 1 shows the prevalence of malnutrition by clinical judgement of the physicians compared to the prevalence rates detected by the other methods performed by research staff. The mean BMI of those 12 patients recognized as malnourished was 19.0 ± 2.5 kg/m² - compared to 25.5 ± 4.3 kg/m² in the remaining (p<0.001). Ten of these patients had a BMI below 22 kg/m², 10 were also malnourished according to the MNA, 7 were judged to be severely and 5 to be moderately malnourished according to the SGA. 5 were judged to be severely and 7 moderately ill. Weight change was documented by the physicians in 120 patients (58.5 %), and 41.7 % of these (24.4 % of all) reported a recent weight loss. Appetite was asked for in 139 patients (67.8 %) of whom 20.1 % (13.7 % of all) reported a poor appetite. The prevalence of nutrition-related problems documented by nursing staff ranged from 0 % (problems with food supply) to 33.7 % (difficulties in cutting food) (Table 2). 389

4 12 VOLKERT/C/ppp:04 LORD_c 5/10/10 9:12 Page 390 UNDIAGNOSED MALNUTRITION IN GERIATRIC PATIENTS Figure 1 Prevalence of malnutrition in geriatric patients (n=205) as assessed by clinical judgement by the physician on duty (CJ) and by research staff using different methods of those receiving nutrition support was 21.7 ± 3.7 kg/m² vs ± 4.3 kg/m² in the others (p<0.001). Only 3 of the patients receiving nutrition support were judged to be malnourished by their physician. Nine had a BMI below 22 kg/m², 10 were malnourished according to the MNA, and 11 severely malnourished according to the SGA. Thirteen were severely and 3 moderately ill. Discussion (BMI = Body-Mass-Index; SGA = Subjective Global Assessment; MNA = Mini Nutritional Assessment) Figure 2 Prevalence of nutrition support in geriatric patients with and without malnutrition assessed by different methods (number of subjects in brackets) (BMI = Body-Mass-Index; SGA = Subjective Global Assessment; MNA = Mini Nutritional Assessment; CJ = clinical judgement of physician on duty); * p<0.05; *** p< Nutrition support Seventeen patients (8.3 %) received nutrition support, mostly in the form of oral supplements (3.9 %), followed by enteral (2.9 %) and parenteral nutrition (1.5 %). Irrespective of the method used for nutritional assessment, malnourished patients received significantly more often nutrition support than non-malnourished patients (p<0.05; Figure 2). The mean BMI The present study clearly documents a wide discrepancy between the actual presence of malnutrition and nutritionrelated problems and the identification by physicians and nurses, and a low percentage of patients receiving nutrition support in the geriatric department of a German community hospital. Thus, we could show that the diagnosis of malnutrition is often missing and nutritional problems ignored in daily clinical routine also in geriatric patients, as described earlier for the general hospital population (5-13). Obviously, doctors and nurses fail to recognise malnutrition and nutritionrelated problems also in great proportions of geriatric patients and only rarely use nutrition support despite the fact that this particular patient group is well known to be at especially high risk of malnutrition and better nutritional awareness might have been expected. The patients under study are typical for the geriatric population with a mean age over 80 years, multiple diseases and widespread physical and mental impairments (Table 1), and thus clearly differ from the general hospital population. As expected, malnutrition, risk of malnutrition and nutritionrelated problems were highly prevalent. About 25 to 30 % of the patients were malnourished according to BMI, SGA and MNA, as reported earlier in other geriatric patient groups (1, 2, 20-22). Different methods were used for the assessment of malnutrition because they focus on different aspects of nutritional status, and still no gold standard is available. Broad agreement between these methods was observed. In contrast only several patients were identified as malnourished by the physicians (Figure 1). Those recognized as malnourished by the physicians, however, mostly were correctly identified, as indicated by great agreement with the other methods. Physicians in this hospital department routinely assess malnutrition by a subjective clinical judgement. This method has the advantage of being quick and feasible and can be performed without any measurement or equipment. Accordingly, a clinical judgement of nutritional status was performed by the physicians in nearly all patients (91 %). Weight change and poor appetite were assessed by the doctors to a much lower extent with missing information in 42 and 32 %, respectively. In the patients asked, interestingly, the prevalence of these problems was comparable to that reported by the researcher. However, due to not asking, these problems were not realised in about one half and one third of the patients affected (Table 2). Similarly, weight and height were only 390

5 12 VOLKERT/C/ppp:04 LORD_c 5/10/10 9:12 Page 391 JNHA: GERIATRIC SCIENCE partly available and in no single case BMI was calculated. All nutrition-related problems which were recorded by the nurses revealed markedly higher prevalence rates in the research interview (Table 2). It is well known that these problems are widespread among geriatric patients (23, 24), and the prevalences found in the research interview do not seem to be overestimated. In contrast, it is more likely that nurses did not ask for the problems, resulting in lower prevalence rates with the consequence of missing treatment, since problems can only be addressed if noticed. Among the nutrition-related problems considered here, difficulties in cutting food were observed most often both in absolute figures and also compared to the prevalence found in the research interview. Chewing and swallowing problems were realised in considerable low proportions of documented cases: 4 % and 10 %, respectively, compared to 32 % and 24 % detected in the research interview (Table 2). Since both of these problems may severely impair adequate nutrition and reduce food intake and both are amenable to effective interventions, it would be desirable to assess these problems on a regular basis. Interestingly, none of the patients was asked for problems with food supply at home. Comprehensive nutritional care, however, includes not only adequate interventions in the hospital setting but also has to ensure adequate nutrition after discharge at home, e.g. by meals on wheels or social services. In the light of poor assessment and documentation of malnutrition, it is not surprising that only a small number of patients received nutrition support. Although nutrition support is more often given to malnourished patients than to not malnourished ones (Figure 2), it has to be pointed out that only one quarter of the patients identified as malnourished by the attending physician received nutrition support conversely meaning that 75 % of those judged to be malnourished by the physicians did not get nutrition support. Despite the fact that those patients receiving nutrition support were mostly malnourished and moderately or severely ill, it is difficult to judge from the present information, if nutrition support was used adequately. Beside the use of nutrition support, future studies should assess its appropriateness and benefits for the patients. It was beyond the scope of the present study to clarify these questions. Thus, nutrition support might have been used correctly in the present study, but is clearly underutilised, and the full potential to treat malnutrition is not tapped, as already described in surgical patients (5). Why do physicians fail to recognise and treat malnutrition and nutritional problems and what can be done to improve this situation? In the present study, unfortunately, the reasons for that have not been asked because such a big discrepancy between the actual presence of malnutrition and nutritionrelated problems and the identification by physicians and nurses, and the low percentage of patients receiving nutrition support were not expected at the beginning of the study. In several studies regarding the general hospital population, the following reasons have been identified: lack of time, lack of interest, low priority given to nutritional information, lack of knowledge, of routine procedures and of defined responsibilities (7, 25-27). We have no reason to believe that for HCPs caring for elderly patients other reasons are relevant. Obviously, also in the elderly nutritional information is considered unimportant. Based on the fact that malnutrition in the elderly can effectively be treated and nutrition-related problems potentially be eliminated by appropriate interventions (3,4), there is a high potential as well as an urgent need for quality improvement of nutritional care in geriatric institutions. This will not only go along with improved nutritional status and outcome, and thus potential individual benefit for the affected patient, but also with economic benefits both for the institution and the health care system (28). In order to reach this goal and improve the quality of nutritional care, malnutrition screening tools and nutritional guidelines have been developed (29, 30). A discrepancy, however, between these standards and clinical practice has been reported (9, 31). On the other hand, it has been shown that interventions like education of health care professionals, simple screening sheets and the elaboration and implementation of an action plan can indeed improve nutritional care and effectively correct the problem (25, 26). Routine screening, assessment and documentation of malnutrition and nutrition-related problems in patients newly admitted to hospitals is the first step to draw the attention to the potentially, malnourished patient and a prerequisite for any nutritional intervention. In addition practical guidelines and standard protocols for nutrition support should be implemented in geriatric hospital wards in order to facilitate adequate treatment. As a prerequisite, nutrition should be included in basic education and further training of health care professionals. In conclusion, this study suggests, that as reported earlier for the general hospital population also in geriatric patients the awareness of malnutrition and nutrition-related problems is generally low. Despite high prevalence rates among geriatric patients, malnutrition and nutrition-related problems are rarely recognised and treated. Thus, there is a clear need and high potential for improvement of nutritional care. Physicians and nursing staff should be made more sensible towards these problems as a basis for effective treatment and even better prevention of malnutrition. Routine screening and practical guidelines for adequate interventions and nutrition support should urgently be implemented in geriatric hospital wards in order to improve nutritional care. Acknowledgements: The study was partly supported by a grant of Fresenius Kabi (Bad Homburg, Germany). The sponsor was neither involved in study design, collection, analysis and interpretation of data, nor in writing of the manuscript or in the decision to submit the manuscript for publication. DV, CCS and PS were responsible for designing of the study and drafted the manuscript. CS carried out all measurements and assessments, performed the data analysis and helped to draft the manuscript. HG participated in formulating the study design and coordination. All authors read and approved the final mauscript. Disclosure of interest: There is no conflict of interest. 391

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