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Nutritional status assessment in geriatrics: Consensus declaration by the Spanish society of geriatrics and gerontology nutrition work group M. Alicia Camina-Martín a , Beatriz de Mateo-Silleras a , Vincenzo Malafarina b,∗ , d ˜ Rosa Lopez-Mongil c , Virtudes Nino-Martín , J. Antonio López-Trigo e , a M. Paz Redondo-del-Río a
Nutrition and Bromatology Area, Faculty of Medicine, Valladolid University, Avenida de Ramón y Cajal 7, 47005, Valladolid, Spain Geriatrics Department, Clinica Los Manzanos, Grupo Viamed, Calle Hermanos Maristas, 26140, Lardero, Spain c Dr Villacián Care Centre, C/Orión 2, 47014, Valladolid, Spain d Universidad de Valladolid, Spain e Área de Accesibilidad Universal, Ayuntamiento de Málaga, Avenida de Cervantes 4, 29016, Málaga, Spain b
a r t i c l e
i n f o
Article history: Received 21 April 2015 Accepted 29 April 2015 Available online xxx Keywords: Elderly Undernutrition Nutritional assessment Free-fatty mass Functional status
a b s t r a c t Ongoing population ageing is one of the factors influencing the increase in the prevalence of undernutrition, because elderly people are a vulnerable group due to their biological, psychological and social characteristics. Despite its high prevalence, undernutrition is underdiagnosed in the geriatric sphere. For this reason, the aim of this consensus document is to devise a protocol for geriatric nutritional assessment. A multidisciplinary team has been set up within the Spanish Society of Geriatrics and Gerontology (in Spanish Sociedad Espa˜ nola de Geriatría y Gerontología, SEGG) in order to address undernutrition and risk of undernutrition so that they can be diagnosed and treated in an effective manner. The MNA-SF is a practical tool amongst the many validated methods for nutritional screening. Following suspicion of undernutrition or after establishing the presence of undernutrition, a full assessment will include a detailed nutritional history of the patient. The compilation of clinical-nutritional and dietetic histories seeks to aid in identifying the possible risk factors at the root of a patient’s undernutrition. Following this, an anthropometric assessment associated to laboratory data, will describe the patient’s physical and metabolic changes associated to undernutrition. Currently, the tendency is to further nutritional assessment through the use of non-invasive techniques to study body composition in association with functional status. The latter is an indirect index for nutritional status which is very interesting from a geriatrician’s point of view. To conclude, correct nutritional screening is the fundamental basis for an early undernutrition diagnosis and to assess the need for nutritional treatment. In order to achieve this, it is fundamental to foster research in the field of nutritional geriatrics, in order to expand our knowledge base and to increasingly practice evidence-based geriatrics. © 2015 Elsevier Ireland Ltd. All rights reserved.
Contents 1. 2. 3.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 Nutritional screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 Full nutritional assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 3.1. Clinical-nutritional history . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 3.2. Dietetic history . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Abbreviations: BIA, Bioimpedance analysis; FFM, fat-free mass; FM, fat mass; MN, malnutrition; RMN, risk of malnutrition; SMM, Skeletal Muscle Mass; UWL, Unintentional weight loss. ∗ Corresponding author. Tel.: +34 941 499 490; fax: +34 941 499 491. E-mail address: [email protected] (V. Malafarina). http://dx.doi.org/10.1016/j.maturitas.2015.04.018 0378-5122/© 2015 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: Camina-Martín MA, et al. Nutritional status assessment in geriatrics: Consensus declaration by the Spanish society of geriatrics and gerontology nutrition work group. Maturitas (2015), http://dx.doi.org/10.1016/j.maturitas.2015.04.018
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3.3. Anthropometric assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 3.4. Biochemical assessment and laboratory data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 3.5. Body composition assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 4. Functional assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 5. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 6. Final recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 Competing interests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 Provenance and peer review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
1. Introduction An ongoing demographic change has been taking place in developed societies over recent decades; the population is getting older. Forecasts for Spain suggest that by 2025 the population above 50 years of age will grow from almost 16 million to over 21 million [1]. Important bio-psycho-social changes take place in this phase of life, making the elderly population a group at risk of suffering nutritional alterations which, in turn, negatively affect the course of illness, in terms of both their progress and recovery. Malnutrition has been described as an imbalance between intake and requirements that causes an alteration in a person’s metabolism, compromises function and brings on a loss of body mass [2]. Malnutrition can also be defined as deficiency or excess (or imbalance) of energy, protein, and other nutrients causes measurable adverse effects on tissue/body form, function, and clinical outcome [3]. Malnutrition due to inadequate intake is one of the most prevalent problems among the elderly. Therefore, in this document we shall refer to it as undernutrition. It is a risk factor for the onset of dependency, which could explain the strong association between undernutrition and comorbidity, frailty and increased mortality [4–7]. There is increasing awareness of the importance of maintaining an appropriate nutritional status in elderly people in the scientific community and among health professionals. Correct nutrition can help to optimize the overall health of people, improve the effectiveness of treatment of chronic illnesses and geriatric syndromes and reduce the costs of complications. This is especially important if we bear in mind that, in developed countries, health expenditure is growing twice as fast as overall economic growth [8], and most of these resources are devoted to dealing with chronic illnesses [9]. A correct assessment of nutritional status is fundamental in order to detect undernutrition early, to be able to identify risk situations and the causes of possible nutritional deficits, to design action plans to improve patients’ nutritional status and to assess the effectiveness on nutritional interventions. The fact that undernutrition is underdiagnosed in this segment of the population is well documented [10,11] and there are states of undernutrition that can go unnoticed [12]. The prevalence of undernutrition increases with age and varies according to the reference setting, whereby it is lower among the elderly living in the community (7.8%), and increases progressively in functional recovery units (14%), care homes (28.4%), hospitals (40%), reaching up to 56% in long-stay institutions [13–15]. There is currently no reference geriatric nutritional assessment tool, nor are there nutritional parameters which, considered in isolation, are valid to diagnose undernutrition. Geriatric nutritional assessment is a complex process because it must take the multifactor aetiology of undernutrition and the wide-ranging variability of assessed subjects into account. A multidisciplinary team of health professionals (dieticiansnutritionists, nurses, biologists, doctors) and academic staff has
been assembled within the Spanish Society of Geriatrics and Geronnola de Geriatría and Gerontología, SEGG), tology (Sociedad Espa˜ setting up a Nutrition Group in Geriatrics. In order to agree this document, a literature review was carried out and the group met a number of times so as to achieve consensus on the criteria for diagnosis of undernutrition in the field of geriatrics. The aim of this consensus document is to produce a geriatric nutritional assessment protocol that can be applied in differing settings (the community, care homes, hospital).
2. Nutritional screening Nutritional screening responds to the need to detect situations of risk of malnutrition (RMN) or of malnutrition (MN) without resorting to complex techniques or specific equipment. Nutritional screening must allow access to the greatest number of patients in the shortest period of time with the resources available. It is always the first step of geriatric nutritional assessment, seeking to achieve early identification of subjects that require in-depth nutritional assessment and who may benefit from early nutritional intervention. Due to its characteristics and aim, nutritional status is included in comprehensive geriatric assessments and is systematically and periodically repeated as part of the follow up of geriatric patients, whether they are outpatients, institutionalized or hospitalized [16,17]. Currently, there is a lack of consensus on the appropriate frequency of nutritional status assessments. According to the most recent Clinical Practice Guides [11], nutritional status assessments should be carried out weekly on patients who are hospitalized or in functional recovery units, monthly in institutionalized elderly people, and at least yearly on elderly outpatients. Due to its preventive nature, screening tools must be quick, costeffective, valid (sensitive and specific) and precise (reproducible). Multiple screening instruments have been developed under these premises, but it is important to consider that the various methods used portray varying degrees of sensitivity [18–20] and often do not allow detection of potentially important nutritional alterations [21,22]. The Mini Nutritional Assessment (MNA) is a structured nutritional assessment method validated for populations above 65 in hospital, care home or community settings [23]. It is the most widely accepted questionnaire and it is used worldwide [16]. The MNA is a practical tool that does not require laboratory data and allows identification of subjects at risk of malnutrition before alterations of their biochemical and anthropometric parameters appear [24]. The MNA has also been praised for its high diagnostic and prognostic power [25,26]. Patients are defined as malnourished if they have MNA scores ≤17 points, at risk of malnutrition with scores between 17.5 and 23.5, and well nourished with MNA scores ≥24 points [25,27]. A reduced version known as Mini Nutritional Assessment-Short Form (MNA-SF) was developed in the year 2001 [28–31].
Please cite this article in press as: Camina-Martín MA, et al. Nutritional status assessment in geriatrics: Consensus declaration by the Spanish society of geriatrics and gerontology nutrition work group. Maturitas (2015), http://dx.doi.org/10.1016/j.maturitas.2015.04.018
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The SEGG Nutrition Work Group recommends the full questionnaire is used regardless of scores achieved by patients during screening as this allows early diagnosis of the possible causes of undernutrition. In addition, bearing in mind the high prevalence of dysphagia [32], and the serious complications that can be brought about by dysphagia in elderly people, the Group also recommends the use of the Eating Assessment Tool-10 (EAT-10) for dysphagia screening [33]. To conclude, the ideal screening tool should include three key elements of nutritional status assessment: (1) Body Mass Index (BMI). (2) Unintentional weight loss. (3) Changes in intake. 3. Full nutritional assessment
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quantitative assessment, at the very least the following parameters should be recorded: (1) (2) (3) (4) (5) (6)
Number of daily intakes. Recent changes in feelings of hunger and satiety. Food preferences and aversions. Presence of food allergies or intolerances. Following of special diets. Use of dietary supplements.
3.3. Anthropometric assessment Anthropometric assessment begins by measuring subjects’ weight and height. Given the characteristics of this population (skeletal alterations), it can be difficult to determine height, so various estimation models can be used. The most widespread model is measuring knee height [40], using Chumlea’s equations [41]: Men : Height(cm) = 78.31 + [1.94 × knee height(cm)]
A full nutritional assessment shall be carried out if RMN or MN is detected during nutritional status assessment [34–36]. It will include a patient’s: (1) (2) (3) (4) (5) (6)
Clinical-nutritional history. Dietetic history. Anthropometric assessment. A biochemical assessment and laboratory data. A body composition assessment. A functional assessment.
Its aim is to attempt to identify the specific causes of nutritional risk and to establish a correct nutritional diagnosis in order to implement an appropriate nutritional approach [16,17]. 3.1. Clinical-nutritional history Analysis of personal precedents will allow detection of syndromes and illnesses that can have an important impact on nutritional status due to their increase of energy expense (e.g., Chronic Obstructive Pulmonary Disease—COPD, dementia, pressure ulcers) and those that can be associated to a reduction in intake (e.g., stroke, Parkinson’s disease, dementia, depression or geriatric anorexia). We advise a review of the number of medications being taken. Polypharmacy, defined as the concomitant presence of five or more drugs, is associated to an increase in the risk of undernutrition. Within anamnesis (basal functional situation), special attention should be given to dental status and the existence of mouth problems (chewing, xerostomia, bad teeth and mouth hygiene). 3.2. Dietetic history A patient’s dietetic history allows the identification of possible gaps in his or her usual diet. For a full assessment it would be necessary to study a person’s eating habits and assess whether a given elderly person’s usual intake conforms to reference dietetic intakes [37–39]. However, available methods require a long time period, so the SEGG Nutrition Work Group proposes, for hospitalized and institutionalized patients, the compilation of 24-hour individual dietetic records using observation techniques, going to the dining room or to patients’ rooms during the main meal times and noting an estimation of the percentage of each food group consumed from every course (0, 25, 50, 75 and 100%) for each patient. In the case of outpatients, although the most appropriate tool would be a three-day record, if there is no time for qualitative and
− [0.14 × age(in years)]
Women : Height(cm) = 82.21 + [1.85 × knee height(cm)] − [0.21 × age(in years)] It must be taken into account that many of the nutritional indicators derived from anthropometric parameters have been extrapolated from reference values established for nutritional status assessment in adults. Therefore, anthropometric indices are often difficult to interpret in geriatric nutitional assessment. Several studies have shown that the prognostic value of BMI in elderly people is different to its value in adults, with a characteristic U–shaped pattern of BMI and the risk of morbi-mortality. A BMI between 25 and 28 kg/m2 is associated to a better health state [42,43]. These differences regarding adults could be related to changes in body composition associated to ageing: increase of fatty mass and decrease in fat-free mass (muscle and bone mass) [44]. Unintentional weight loss (UWL) is another very interesting nutritional parameter. It is calculated by estimating the percentage of usual weight lost: [current weight (kg)/usual weight (kg)] × 100. Unintentional weight loss is considered significant if weight loss is equal to 5%, 7.5% or 10% respectively in one, three or six months [45]. If usual weight is unknown, it is substituted by ideal weight, estimated with the Lorentz equation [46], as follows: Men : Ideal weight(kg) = Height(cm) − 100 − [(Height(cm) − 150)/4]
Women : Ideal weight(kg) = Height(cm) − 100 − [(Height(cm) − 150)/2.5] In order to diagnose undernutrition, the European Society of Parenteral and Enteral Nutrition (ESPEN) has recently proposed a BMI below 22 kg/m2 as an indicator of undernutrition for those above 70, especially if it is associated to an unintentional weight loss above 10% over an indefinite period of time or above 5% in the last three months [47]. Arm circumference reflects muscular and fatty body compartments (as bone is considered to be practically constant) and calf circumference is a very sensitive anthropometric parameter related to loss of muscle mass in the elderly [48,49].
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Table 1 Prediction equations to calculate fat-free mass and skeletal muscle mass. Source
Predictive models
Kyle et al. [61] Sun et al. [62]
FFM = −4.104 + [0.518 × (H2 /R)] + (0.231 × W) + (0.130 × Xc) + (4.229 × S1 ) Men: FFM = 10.68 + (0.26 × W) + [0.65 × (H2 /R)] + (0.02 × R) Women: FFM = 9.53 + (0.17 × W) + [0.69 × (H2 /R)] + (0.02 × R) SMM = 5.102 + [0.401 (H2 /R)] − (0.071 × A) + (3.825 × S1 ) SMM = −24.021 + (0.33 H) − (0.031 R) + (0.083 Xc) + (1.58 S2 ) + (0.046 W)
Janssen et al. [63] Tengvall et al. [64]
FFM: fat free mass (kg), SMM: skeletal muscle mass (kg), H: height (cm), R: resistence (), Xc: Reactance (), W: weight (kg), A: Age (in years), S1 : sex (women = 0; men = 1), S2 : sex (women = 1; men = 0).
3.4. Biochemical assessment and laboratory data Biochemical assessment completes the information obtained through clinical, dietetic and anthropometric assessment procedures, allowing detection of subclinical nutritional deficits. Nevertheless, these indicators can be very unspecific and can be altered by other pathological situations. The most referenced of these indicators are visceral proteins and red blood cell count. Visceral proteins are acute phase negative reactants, so their plasma levels are lower in acute processes or in surgery patients. Albumin serum concentration is very sensitive for diagnosing undernutrition in hospitalised elderly patients but has low specificity [50]. Nevertheless, albumin, together with weight loss, allows calculation of the Geriatric Nutritional Risk Index (GNRI), which is a good indicator of risk of morbidity and mortality in hospitalized [51,52] and institutionalized [53] elderly people. A red blood cell count is of interest due to its link to many specific nutrient deficits that are often associated to anaemia. Finally, since it is part of routine biochemical tests in all centres, cholesterol must also be considered as a predictor of morbimortality [54].
Nevertheless, the use of vectorial bioimpedance analysis (VBIA) can reduce estimation errors [67]. 4. Functional assessment Functional assessment is achieving increasing importance as an indirect indicator of undernutrition [68]. Our Group advises measuring maximum hand grip strength using a dynamometer and carrying out the walking speed test [69]. The hand dynamometer test is a straightforward and quick way to asses function in order to quantify deficit of isometric hand grip strength. It is a good indicator of muscular strength and of risk of morbi-mortality in elderly populations [70,71], and its prognostic value is a highly interesting subject in clinical practice [72]. This measure is closely related to muscle strength of the lower limbs [69]. There is increasing evidence that hand grip strength, and especially its change over time, is an early indirect indicator of risk of undernutrition [73]. Hand grip strength shall be measured with a hand dynamometer, following standard protocol [74]. 5. Conclusions
3.5. Body composition assessment The tools used for body composition assessment in care settings must be innocuous, non-invasive and cost-effective. Indirect estimation of fat mass (FM) and of fat-free mass (FFM) is based on anthropometric measurements or bioimpedance analysis [55]. Both methods are widely accepted in clinical and epidemiological work [55–57]. However, there are studies that advise against the use of anthropometric measurements to assess muscle mass in elderly people, because the premises on which it is based can be invalid in elderly populations [58]. Bioimpedance analysis (BIA) is a valid alternative to reference techniques in clinical practice (computerized tomography, magnetic resonance or DXA), which are mainly used in research [59]. BIA monofrequency (at 50 kHz) with a tetrapolar electrode configuration is a precise body analysis method of determining the volume of body fluids and fat-free mass (FFM) in stable patients and healthy subjects [60]. The interpretation of the BIA results would be done with predictive models that have been validated in populations similar to the one under study. Table 1 shows FFM and Skeletal Muscle Mass (SMM) prediction equations which have been validated and are widely used. Given these two variables (FFM and SMM) the corresponding indices can be calculated by dividing their value into height squared (FFMI and SMMI). These indices allow classification of subjects according to the reference population percentiles [65,66]. According to the ESPEN consensus document [47], a FFMI below 15 kg/m2 in women and below 17 kg/m2 in men, added to an UWL above 10% over an indefinite period, or above 5% in the last three months in a diagnostic criterion for undernutrition.The principal limitation of BIA is that it is very sensitive to abrupt hydric changes in the organism (liquid retention or dehydration) which can lead to important errors in the estimation of body compartments.
It is very useful to have an agreed protocol that systematizes geriatric nutritional assessment in the various care settings. This document was produced by a multi-disciplinary team, so it integrates the specific contributions of the various health professions involved in geriatric care. Upon drafting this document, the fact that nutritional assessment can be carried out in varying levels of depth was taken into account, so we chose to include tools that allow for all these levels, from the most basic techniques to the most complex and resource demanding ones. Risk of malnutrition and malnutrition are very prevalent in elderly people. Detection of risk would allow early intervention, which would prevent the onset of associated comorbidities, reducing the costs stemming from their treatment. However, only undernutrition is recognized in the latest edition of the International Classification of Diseases ICD-10 (codes E40–E46) [75]. The SEGG Nutrition Group believes the “risk of malnutrition” should be recognized as an independent nosological entity in the ICD. As stated above, a full nutritional assessment should follow detection of risk of malnutrition, as it is necessary for a correct diagnosis that in turn allows the most appropriate nutritional intervention for each patient. These aspects shall be tackled in future documents by this consensus group. 6. Final recommendations • Nutritional assessment can allow early identification of elderly people who are malnourished or at risk of malnutrition. • It is very important that the presence of the risks of malnutrition or of malnutrition itself are recorded in diagnoses. • Nutritional assessment can be carried out in various ways and with differing levels of depth.
Please cite this article in press as: Camina-Martín MA, et al. Nutritional status assessment in geriatrics: Consensus declaration by the Spanish society of geriatrics and gerontology nutrition work group. Maturitas (2015), http://dx.doi.org/10.1016/j.maturitas.2015.04.018
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• Certain biochemical parameters can change due to illness as well as to malnutrition, so it is advisable to use more than one marker, bearing the situation of each patient in mind. • In is necessary to re-assess patients systematically and routinely due to the high prevalence and incidence of undernutrition related to illness • Undernutrition can alter independence in the basic activities of daily living, affect quality of life, increase susceptibility to infection, foster the onset of pressure ulcers, prolong hospital stay, increase morbid-mortality and health costs. Contributors All authors were fully involved in writing the manuscript and take responsibility for this work. Each of the authors has read and concurs with the content in the final version. Rosa Lopez Mongil is the coordinator of the group and Virtudes ˜ Martín is the secretary. Nino Competing interests None Funding None. Provenance and peer review Provenance and peer review: not commissioned and externally peer reviewed. Acknowledgements The Group would like to thank the Spanish Society of Geriatric and Gerontology (Sociedad Espa˜ nola de Geriatría and Gerontología) for their support during the drafting and writing of this document. Special thanks to Belen Royo for her logistics and organizational support. References [1] Svedbom A, Hernlund E, Ivergard M, et al. Osteoporosis in the European Union: a compendium of country-specific reports. Arch Osteoporos 2013;8(1–2):137 [013-0137-0. Epub 2013 Oct 11]. [2] Kinosian B, Jeejeebhoy KN. What is malnutrition—does it matter. Nutrition 1995;11(2):196–7. [3] Lochs H, Allison SP, Meier R, et al. Introductory to the ESPEN guidelines on enteral nutrition: terminology, definitions and general topics. Clin Nutr 2006;25(2):180–6. [4] Abizanda Soler P, Paterna Mellinas G, Martinez Sanchez E, Lopez Jimenez E. Comorbidity in the elderly: utility and validity of assessment tools. Rev Esp Geriatr Gerontol 2010;45(4):219–28. [5] Kane RL, Shamliyan T, Talley K, Pacala J. The association between geriatric syndromes and survival. J Am Geriatr Soc 2012;60(5):896–904. [6] Schaible UE, Kaufmann SH. Malnutrition and infection. Complex mechanisms and global impacts. PLoS Med 2007;4(5):e115. [7] Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol Ser A: Biol Sci Med Sci 2001;56(3):M146–56. [8] Starr M, Dominiak L, Aizcorbe A. Decomposing growth in spending finds annual cost of treatment contributed most to spending growth, 1980–2006. Health Affairs (Project Hope) 2014;33(5):823–31. [9] Thorpe KE, Ogden LL, Galactionova K. Chronic conditions account for rise in medicare spending from 1987 to 2006. Health Affairs (Project Hope) 2010;29(4):718–24. [10] Mudge AM, Ross LJ, Young AM, Isenring EA, Banks MD. Helping understand nutritional gaps in the elderly (HUNGER): a prospective study of patient factors associated with inadequate nutritional intake in older medical inpatients. Clin Nutr (Edinb, Scotl) 2011;30(3):320–5. [11] Watterson C, Fraser A, Banks M, et al. Evidence based practice guidelines for the nutritional management of malnutrition in adult patients across the continuum of care. Nutr Diet 2009;66:S1–34.
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Contents lists available at ScienceDirect
Maturitas journal homepage: www.elsevier.com/locate/maturitas
Nutritional status assessment in geriatrics: Consensus declaration by the Spanish society of geriatrics and gerontology nutrition work group M. Alicia Camina-Martín a , Beatriz de Mateo-Silleras a , Vincenzo Malafarina b,∗ , d ˜ Rosa Lopez-Mongil c , Virtudes Nino-Martín , J. Antonio López-Trigo e , a M. Paz Redondo-del-Río a
Nutrition and Bromatology Area, Faculty of Medicine, Valladolid University, Avenida de Ramón y Cajal 7, 47005, Valladolid, Spain Geriatrics Department, Clinica Los Manzanos, Grupo Viamed, Calle Hermanos Maristas, 26140, Lardero, Spain c Dr Villacián Care Centre, C/Orión 2, 47014, Valladolid, Spain d Universidad de Valladolid, Spain e Área de Accesibilidad Universal, Ayuntamiento de Málaga, Avenida de Cervantes 4, 29016, Málaga, Spain b
a r t i c l e
i n f o
Article history: Received 21 April 2015 Accepted 29 April 2015 Available online xxx Keywords: Elderly Undernutrition Nutritional assessment Free-fatty mass Functional status
a b s t r a c t Ongoing population ageing is one of the factors influencing the increase in the prevalence of undernutrition, because elderly people are a vulnerable group due to their biological, psychological and social characteristics. Despite its high prevalence, undernutrition is underdiagnosed in the geriatric sphere. For this reason, the aim of this consensus document is to devise a protocol for geriatric nutritional assessment. A multidisciplinary team has been set up within the Spanish Society of Geriatrics and Gerontology (in Spanish Sociedad Espa˜ nola de Geriatría y Gerontología, SEGG) in order to address undernutrition and risk of undernutrition so that they can be diagnosed and treated in an effective manner. The MNA-SF is a practical tool amongst the many validated methods for nutritional screening. Following suspicion of undernutrition or after establishing the presence of undernutrition, a full assessment will include a detailed nutritional history of the patient. The compilation of clinical-nutritional and dietetic histories seeks to aid in identifying the possible risk factors at the root of a patient’s undernutrition. Following this, an anthropometric assessment associated to laboratory data, will describe the patient’s physical and metabolic changes associated to undernutrition. Currently, the tendency is to further nutritional assessment through the use of non-invasive techniques to study body composition in association with functional status. The latter is an indirect index for nutritional status which is very interesting from a geriatrician’s point of view. To conclude, correct nutritional screening is the fundamental basis for an early undernutrition diagnosis and to assess the need for nutritional treatment. In order to achieve this, it is fundamental to foster research in the field of nutritional geriatrics, in order to expand our knowledge base and to increasingly practice evidence-based geriatrics. © 2015 Elsevier Ireland Ltd. All rights reserved.
Contents 1. 2. 3.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 Nutritional screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 Full nutritional assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 3.1. Clinical-nutritional history . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 3.2. Dietetic history . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Abbreviations: BIA, Bioimpedance analysis; FFM, fat-free mass; FM, fat mass; MN, malnutrition; RMN, risk of malnutrition; SMM, Skeletal Muscle Mass; UWL, Unintentional weight loss. ∗ Corresponding author. Tel.: +34 941 499 490; fax: +34 941 499 491. E-mail address: [email protected] (V. Malafarina). http://dx.doi.org/10.1016/j.maturitas.2015.04.018 0378-5122/© 2015 Elsevier Ireland Ltd. All rights reserved.
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2
3.3. Anthropometric assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 3.4. Biochemical assessment and laboratory data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 3.5. Body composition assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 4. Functional assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 5. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 6. Final recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 Competing interests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 Provenance and peer review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
1. Introduction An ongoing demographic change has been taking place in developed societies over recent decades; the population is getting older. Forecasts for Spain suggest that by 2025 the population above 50 years of age will grow from almost 16 million to over 21 million [1]. Important bio-psycho-social changes take place in this phase of life, making the elderly population a group at risk of suffering nutritional alterations which, in turn, negatively affect the course of illness, in terms of both their progress and recovery. Malnutrition has been described as an imbalance between intake and requirements that causes an alteration in a person’s metabolism, compromises function and brings on a loss of body mass [2]. Malnutrition can also be defined as deficiency or excess (or imbalance) of energy, protein, and other nutrients causes measurable adverse effects on tissue/body form, function, and clinical outcome [3]. Malnutrition due to inadequate intake is one of the most prevalent problems among the elderly. Therefore, in this document we shall refer to it as undernutrition. It is a risk factor for the onset of dependency, which could explain the strong association between undernutrition and comorbidity, frailty and increased mortality [4–7]. There is increasing awareness of the importance of maintaining an appropriate nutritional status in elderly people in the scientific community and among health professionals. Correct nutrition can help to optimize the overall health of people, improve the effectiveness of treatment of chronic illnesses and geriatric syndromes and reduce the costs of complications. This is especially important if we bear in mind that, in developed countries, health expenditure is growing twice as fast as overall economic growth [8], and most of these resources are devoted to dealing with chronic illnesses [9]. A correct assessment of nutritional status is fundamental in order to detect undernutrition early, to be able to identify risk situations and the causes of possible nutritional deficits, to design action plans to improve patients’ nutritional status and to assess the effectiveness on nutritional interventions. The fact that undernutrition is underdiagnosed in this segment of the population is well documented [10,11] and there are states of undernutrition that can go unnoticed [12]. The prevalence of undernutrition increases with age and varies according to the reference setting, whereby it is lower among the elderly living in the community (7.8%), and increases progressively in functional recovery units (14%), care homes (28.4%), hospitals (40%), reaching up to 56% in long-stay institutions [13–15]. There is currently no reference geriatric nutritional assessment tool, nor are there nutritional parameters which, considered in isolation, are valid to diagnose undernutrition. Geriatric nutritional assessment is a complex process because it must take the multifactor aetiology of undernutrition and the wide-ranging variability of assessed subjects into account. A multidisciplinary team of health professionals (dieticiansnutritionists, nurses, biologists, doctors) and academic staff has
been assembled within the Spanish Society of Geriatrics and Geronnola de Geriatría and Gerontología, SEGG), tology (Sociedad Espa˜ setting up a Nutrition Group in Geriatrics. In order to agree this document, a literature review was carried out and the group met a number of times so as to achieve consensus on the criteria for diagnosis of undernutrition in the field of geriatrics. The aim of this consensus document is to produce a geriatric nutritional assessment protocol that can be applied in differing settings (the community, care homes, hospital).
2. Nutritional screening Nutritional screening responds to the need to detect situations of risk of malnutrition (RMN) or of malnutrition (MN) without resorting to complex techniques or specific equipment. Nutritional screening must allow access to the greatest number of patients in the shortest period of time with the resources available. It is always the first step of geriatric nutritional assessment, seeking to achieve early identification of subjects that require in-depth nutritional assessment and who may benefit from early nutritional intervention. Due to its characteristics and aim, nutritional status is included in comprehensive geriatric assessments and is systematically and periodically repeated as part of the follow up of geriatric patients, whether they are outpatients, institutionalized or hospitalized [16,17]. Currently, there is a lack of consensus on the appropriate frequency of nutritional status assessments. According to the most recent Clinical Practice Guides [11], nutritional status assessments should be carried out weekly on patients who are hospitalized or in functional recovery units, monthly in institutionalized elderly people, and at least yearly on elderly outpatients. Due to its preventive nature, screening tools must be quick, costeffective, valid (sensitive and specific) and precise (reproducible). Multiple screening instruments have been developed under these premises, but it is important to consider that the various methods used portray varying degrees of sensitivity [18–20] and often do not allow detection of potentially important nutritional alterations [21,22]. The Mini Nutritional Assessment (MNA) is a structured nutritional assessment method validated for populations above 65 in hospital, care home or community settings [23]. It is the most widely accepted questionnaire and it is used worldwide [16]. The MNA is a practical tool that does not require laboratory data and allows identification of subjects at risk of malnutrition before alterations of their biochemical and anthropometric parameters appear [24]. The MNA has also been praised for its high diagnostic and prognostic power [25,26]. Patients are defined as malnourished if they have MNA scores ≤17 points, at risk of malnutrition with scores between 17.5 and 23.5, and well nourished with MNA scores ≥24 points [25,27]. A reduced version known as Mini Nutritional Assessment-Short Form (MNA-SF) was developed in the year 2001 [28–31].
Please cite this article in press as: Camina-Martín MA, et al. Nutritional status assessment in geriatrics: Consensus declaration by the Spanish society of geriatrics and gerontology nutrition work group. Maturitas (2015), http://dx.doi.org/10.1016/j.maturitas.2015.04.018
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The SEGG Nutrition Work Group recommends the full questionnaire is used regardless of scores achieved by patients during screening as this allows early diagnosis of the possible causes of undernutrition. In addition, bearing in mind the high prevalence of dysphagia [32], and the serious complications that can be brought about by dysphagia in elderly people, the Group also recommends the use of the Eating Assessment Tool-10 (EAT-10) for dysphagia screening [33]. To conclude, the ideal screening tool should include three key elements of nutritional status assessment: (1) Body Mass Index (BMI). (2) Unintentional weight loss. (3) Changes in intake. 3. Full nutritional assessment
3
quantitative assessment, at the very least the following parameters should be recorded: (1) (2) (3) (4) (5) (6)
Number of daily intakes. Recent changes in feelings of hunger and satiety. Food preferences and aversions. Presence of food allergies or intolerances. Following of special diets. Use of dietary supplements.
3.3. Anthropometric assessment Anthropometric assessment begins by measuring subjects’ weight and height. Given the characteristics of this population (skeletal alterations), it can be difficult to determine height, so various estimation models can be used. The most widespread model is measuring knee height [40], using Chumlea’s equations [41]: Men : Height(cm) = 78.31 + [1.94 × knee height(cm)]
A full nutritional assessment shall be carried out if RMN or MN is detected during nutritional status assessment [34–36]. It will include a patient’s: (1) (2) (3) (4) (5) (6)
Clinical-nutritional history. Dietetic history. Anthropometric assessment. A biochemical assessment and laboratory data. A body composition assessment. A functional assessment.
Its aim is to attempt to identify the specific causes of nutritional risk and to establish a correct nutritional diagnosis in order to implement an appropriate nutritional approach [16,17]. 3.1. Clinical-nutritional history Analysis of personal precedents will allow detection of syndromes and illnesses that can have an important impact on nutritional status due to their increase of energy expense (e.g., Chronic Obstructive Pulmonary Disease—COPD, dementia, pressure ulcers) and those that can be associated to a reduction in intake (e.g., stroke, Parkinson’s disease, dementia, depression or geriatric anorexia). We advise a review of the number of medications being taken. Polypharmacy, defined as the concomitant presence of five or more drugs, is associated to an increase in the risk of undernutrition. Within anamnesis (basal functional situation), special attention should be given to dental status and the existence of mouth problems (chewing, xerostomia, bad teeth and mouth hygiene). 3.2. Dietetic history A patient’s dietetic history allows the identification of possible gaps in his or her usual diet. For a full assessment it would be necessary to study a person’s eating habits and assess whether a given elderly person’s usual intake conforms to reference dietetic intakes [37–39]. However, available methods require a long time period, so the SEGG Nutrition Work Group proposes, for hospitalized and institutionalized patients, the compilation of 24-hour individual dietetic records using observation techniques, going to the dining room or to patients’ rooms during the main meal times and noting an estimation of the percentage of each food group consumed from every course (0, 25, 50, 75 and 100%) for each patient. In the case of outpatients, although the most appropriate tool would be a three-day record, if there is no time for qualitative and
− [0.14 × age(in years)]
Women : Height(cm) = 82.21 + [1.85 × knee height(cm)] − [0.21 × age(in years)] It must be taken into account that many of the nutritional indicators derived from anthropometric parameters have been extrapolated from reference values established for nutritional status assessment in adults. Therefore, anthropometric indices are often difficult to interpret in geriatric nutitional assessment. Several studies have shown that the prognostic value of BMI in elderly people is different to its value in adults, with a characteristic U–shaped pattern of BMI and the risk of morbi-mortality. A BMI between 25 and 28 kg/m2 is associated to a better health state [42,43]. These differences regarding adults could be related to changes in body composition associated to ageing: increase of fatty mass and decrease in fat-free mass (muscle and bone mass) [44]. Unintentional weight loss (UWL) is another very interesting nutritional parameter. It is calculated by estimating the percentage of usual weight lost: [current weight (kg)/usual weight (kg)] × 100. Unintentional weight loss is considered significant if weight loss is equal to 5%, 7.5% or 10% respectively in one, three or six months [45]. If usual weight is unknown, it is substituted by ideal weight, estimated with the Lorentz equation [46], as follows: Men : Ideal weight(kg) = Height(cm) − 100 − [(Height(cm) − 150)/4]
Women : Ideal weight(kg) = Height(cm) − 100 − [(Height(cm) − 150)/2.5] In order to diagnose undernutrition, the European Society of Parenteral and Enteral Nutrition (ESPEN) has recently proposed a BMI below 22 kg/m2 as an indicator of undernutrition for those above 70, especially if it is associated to an unintentional weight loss above 10% over an indefinite period of time or above 5% in the last three months [47]. Arm circumference reflects muscular and fatty body compartments (as bone is considered to be practically constant) and calf circumference is a very sensitive anthropometric parameter related to loss of muscle mass in the elderly [48,49].
Please cite this article in press as: Camina-Martín MA, et al. Nutritional status assessment in geriatrics: Consensus declaration by the Spanish society of geriatrics and gerontology nutrition work group. Maturitas (2015), http://dx.doi.org/10.1016/j.maturitas.2015.04.018
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Table 1 Prediction equations to calculate fat-free mass and skeletal muscle mass. Source
Predictive models
Kyle et al. [61] Sun et al. [62]
FFM = −4.104 + [0.518 × (H2 /R)] + (0.231 × W) + (0.130 × Xc) + (4.229 × S1 ) Men: FFM = 10.68 + (0.26 × W) + [0.65 × (H2 /R)] + (0.02 × R) Women: FFM = 9.53 + (0.17 × W) + [0.69 × (H2 /R)] + (0.02 × R) SMM = 5.102 + [0.401 (H2 /R)] − (0.071 × A) + (3.825 × S1 ) SMM = −24.021 + (0.33 H) − (0.031 R) + (0.083 Xc) + (1.58 S2 ) + (0.046 W)
Janssen et al. [63] Tengvall et al. [64]
FFM: fat free mass (kg), SMM: skeletal muscle mass (kg), H: height (cm), R: resistence (), Xc: Reactance (), W: weight (kg), A: Age (in years), S1 : sex (women = 0; men = 1), S2 : sex (women = 1; men = 0).
3.4. Biochemical assessment and laboratory data Biochemical assessment completes the information obtained through clinical, dietetic and anthropometric assessment procedures, allowing detection of subclinical nutritional deficits. Nevertheless, these indicators can be very unspecific and can be altered by other pathological situations. The most referenced of these indicators are visceral proteins and red blood cell count. Visceral proteins are acute phase negative reactants, so their plasma levels are lower in acute processes or in surgery patients. Albumin serum concentration is very sensitive for diagnosing undernutrition in hospitalised elderly patients but has low specificity [50]. Nevertheless, albumin, together with weight loss, allows calculation of the Geriatric Nutritional Risk Index (GNRI), which is a good indicator of risk of morbidity and mortality in hospitalized [51,52] and institutionalized [53] elderly people. A red blood cell count is of interest due to its link to many specific nutrient deficits that are often associated to anaemia. Finally, since it is part of routine biochemical tests in all centres, cholesterol must also be considered as a predictor of morbimortality [54].
Nevertheless, the use of vectorial bioimpedance analysis (VBIA) can reduce estimation errors [67]. 4. Functional assessment Functional assessment is achieving increasing importance as an indirect indicator of undernutrition [68]. Our Group advises measuring maximum hand grip strength using a dynamometer and carrying out the walking speed test [69]. The hand dynamometer test is a straightforward and quick way to asses function in order to quantify deficit of isometric hand grip strength. It is a good indicator of muscular strength and of risk of morbi-mortality in elderly populations [70,71], and its prognostic value is a highly interesting subject in clinical practice [72]. This measure is closely related to muscle strength of the lower limbs [69]. There is increasing evidence that hand grip strength, and especially its change over time, is an early indirect indicator of risk of undernutrition [73]. Hand grip strength shall be measured with a hand dynamometer, following standard protocol [74]. 5. Conclusions
3.5. Body composition assessment The tools used for body composition assessment in care settings must be innocuous, non-invasive and cost-effective. Indirect estimation of fat mass (FM) and of fat-free mass (FFM) is based on anthropometric measurements or bioimpedance analysis [55]. Both methods are widely accepted in clinical and epidemiological work [55–57]. However, there are studies that advise against the use of anthropometric measurements to assess muscle mass in elderly people, because the premises on which it is based can be invalid in elderly populations [58]. Bioimpedance analysis (BIA) is a valid alternative to reference techniques in clinical practice (computerized tomography, magnetic resonance or DXA), which are mainly used in research [59]. BIA monofrequency (at 50 kHz) with a tetrapolar electrode configuration is a precise body analysis method of determining the volume of body fluids and fat-free mass (FFM) in stable patients and healthy subjects [60]. The interpretation of the BIA results would be done with predictive models that have been validated in populations similar to the one under study. Table 1 shows FFM and Skeletal Muscle Mass (SMM) prediction equations which have been validated and are widely used. Given these two variables (FFM and SMM) the corresponding indices can be calculated by dividing their value into height squared (FFMI and SMMI). These indices allow classification of subjects according to the reference population percentiles [65,66]. According to the ESPEN consensus document [47], a FFMI below 15 kg/m2 in women and below 17 kg/m2 in men, added to an UWL above 10% over an indefinite period, or above 5% in the last three months in a diagnostic criterion for undernutrition.The principal limitation of BIA is that it is very sensitive to abrupt hydric changes in the organism (liquid retention or dehydration) which can lead to important errors in the estimation of body compartments.
It is very useful to have an agreed protocol that systematizes geriatric nutritional assessment in the various care settings. This document was produced by a multi-disciplinary team, so it integrates the specific contributions of the various health professions involved in geriatric care. Upon drafting this document, the fact that nutritional assessment can be carried out in varying levels of depth was taken into account, so we chose to include tools that allow for all these levels, from the most basic techniques to the most complex and resource demanding ones. Risk of malnutrition and malnutrition are very prevalent in elderly people. Detection of risk would allow early intervention, which would prevent the onset of associated comorbidities, reducing the costs stemming from their treatment. However, only undernutrition is recognized in the latest edition of the International Classification of Diseases ICD-10 (codes E40–E46) [75]. The SEGG Nutrition Group believes the “risk of malnutrition” should be recognized as an independent nosological entity in the ICD. As stated above, a full nutritional assessment should follow detection of risk of malnutrition, as it is necessary for a correct diagnosis that in turn allows the most appropriate nutritional intervention for each patient. These aspects shall be tackled in future documents by this consensus group. 6. Final recommendations • Nutritional assessment can allow early identification of elderly people who are malnourished or at risk of malnutrition. • It is very important that the presence of the risks of malnutrition or of malnutrition itself are recorded in diagnoses. • Nutritional assessment can be carried out in various ways and with differing levels of depth.
Please cite this article in press as: Camina-Martín MA, et al. Nutritional status assessment in geriatrics: Consensus declaration by the Spanish society of geriatrics and gerontology nutrition work group. Maturitas (2015), http://dx.doi.org/10.1016/j.maturitas.2015.04.018
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• Certain biochemical parameters can change due to illness as well as to malnutrition, so it is advisable to use more than one marker, bearing the situation of each patient in mind. • In is necessary to re-assess patients systematically and routinely due to the high prevalence and incidence of undernutrition related to illness • Undernutrition can alter independence in the basic activities of daily living, affect quality of life, increase susceptibility to infection, foster the onset of pressure ulcers, prolong hospital stay, increase morbid-mortality and health costs. Contributors All authors were fully involved in writing the manuscript and take responsibility for this work. Each of the authors has read and concurs with the content in the final version. Rosa Lopez Mongil is the coordinator of the group and Virtudes ˜ Martín is the secretary. Nino Competing interests None Funding None. Provenance and peer review Provenance and peer review: not commissioned and externally peer reviewed. Acknowledgements The Group would like to thank the Spanish Society of Geriatric and Gerontology (Sociedad Espa˜ nola de Geriatría and Gerontología) for their support during the drafting and writing of this document. Special thanks to Belen Royo for her logistics and organizational support. References [1] Svedbom A, Hernlund E, Ivergard M, et al. Osteoporosis in the European Union: a compendium of country-specific reports. Arch Osteoporos 2013;8(1–2):137 [013-0137-0. Epub 2013 Oct 11]. [2] Kinosian B, Jeejeebhoy KN. What is malnutrition—does it matter. Nutrition 1995;11(2):196–7. [3] Lochs H, Allison SP, Meier R, et al. Introductory to the ESPEN guidelines on enteral nutrition: terminology, definitions and general topics. Clin Nutr 2006;25(2):180–6. [4] Abizanda Soler P, Paterna Mellinas G, Martinez Sanchez E, Lopez Jimenez E. Comorbidity in the elderly: utility and validity of assessment tools. Rev Esp Geriatr Gerontol 2010;45(4):219–28. [5] Kane RL, Shamliyan T, Talley K, Pacala J. The association between geriatric syndromes and survival. J Am Geriatr Soc 2012;60(5):896–904. [6] Schaible UE, Kaufmann SH. Malnutrition and infection. Complex mechanisms and global impacts. PLoS Med 2007;4(5):e115. [7] Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol Ser A: Biol Sci Med Sci 2001;56(3):M146–56. [8] Starr M, Dominiak L, Aizcorbe A. Decomposing growth in spending finds annual cost of treatment contributed most to spending growth, 1980–2006. Health Affairs (Project Hope) 2014;33(5):823–31. [9] Thorpe KE, Ogden LL, Galactionova K. Chronic conditions account for rise in medicare spending from 1987 to 2006. Health Affairs (Project Hope) 2010;29(4):718–24. [10] Mudge AM, Ross LJ, Young AM, Isenring EA, Banks MD. Helping understand nutritional gaps in the elderly (HUNGER): a prospective study of patient factors associated with inadequate nutritional intake in older medical inpatients. Clin Nutr (Edinb, Scotl) 2011;30(3):320–5. [11] Watterson C, Fraser A, Banks M, et al. Evidence based practice guidelines for the nutritional management of malnutrition in adult patients across the continuum of care. Nutr Diet 2009;66:S1–34.
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