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Chapter 9

# Assessment of Nutritional Status in the Elderly

Teresa Kokot1, Ewa Malczyk2, Ewa Ziółko1, Małgorzata Muc-Wierzgoń1 and Edyta Fatyga1,    1Medical University of Silesia in Katowice, Katowice, Poland,    2University of Applied Sciences, Nysa, Poland

## Abstract

Assessing the nutritional status of elderly patients is an integral component of a comprehensive geriatric assessment. Anthropometric measurements, body composition estimation, and questionnaires such as the MNA, MST, NRI, and PINI are useful methods for assessing nutritional status in seniors. The aim of this paper is to provide methods of nutritional status assessment. Although there are many methods for assessing seniors’ nutritional status, so far we have failed to develop a “gold standard” for such nutritional assessments.

### Keywords

Elderly; nutritional status; anthropometric measurements; senior questionnaires; biochemical tests

## Introduction

Nutritional status is the state of health resulting from the usual food intake, absorption, and utilization of food nutrients and from any pathology influencing these processes. It is determined by many factors, including age, sex, physical activity, comorbidities, used drugs or stimulants, and socioeconomic situation (Charzewska et al., 2010; Donini et al., 2007).

Assessing the nutritional status of the elderly is an integral component of a comprehensive geriatric assessment. It provides information on possible quantitative or qualitative deficiencies of nutrients, helps to identify the risk of protein-energy malnutrition (PEM), overweight, and obesity, and it helps to monitor effectiveness of the nutritional therapy (Ashwell et al., 2012). Assessment of the nutritional status in disabled and bedridden elderly patients presents particular challenges.

Most often, the same indicators and criteria used with adults can assess the nutritional status of the elderly (2006). However, an assessment must consider the physiological and pathophysiological distinctiveness of the aging process (Charzewska et al., 2010; Wojszel, 2011; Green and Watson, 2006; Antczak-Domagała et al., 2013). Proper assessment of the nutritional status in the elderly is carried out by qualified personnel (doctors, nurses, dietitians), and it requires a combination of several methods: medical history, with a particular emphasis on nutritional history; physical examination; anthropometric tests; and determination of biochemical parameters and surveys based on validated questionnaires for assessing nutritional status (Babiarczyk and Turbiarz, 2012).

## Medical History With a Particular Emphasis on the Nutritional History and Physical Examination

### Medical History

A medical history interview should be collected from a patient as well as from a family member, especially a caregiver. Additional help can be found in the medical records of the patient (results of specialist consultations, information cards, etc.). Questions about currently occurring acute and chronic disorders, painful conditions, incidents of fainting and falls, acute and chronic stress, recent hospitalizations, and medications and dietary supplements taken are particularly important. The taken pharmacological agents, often polypragmasic, in addition to side effects, also affect the absorption of various nutrients. The interview with the elderly patient should be deepened with questions on mood disorders, with particular emphasis on depression and cognitive impairment. It is also important to learn about the degree of a patient’s independence, his or her family and social situation (lack of support, discrimination), and present or completed mourning and economic factors.

The interview should also take into account symptoms that are characteristic of the so-called large geriatric problems: dementia, depression, falls and syncope, urinary incontinence, and malnutrition.

### Nutritional History

Questions regarding changes in appetite, diet, increases or decreases in body weight in the preceding 3 months, deviations in sense of taste and smell, disorders of the gastrointestinal tract (including dysphagia, odynophagia, diarrhea, and constipation) are important. Analysis primarily includes the amount and quality of meals with regard to food allergies and cultural and economic factors. It is important to check if food meets a person’s energy demands and whether it satisfies the requirements for essential nutrients.

Monitoring a patient while eating and noting consumed products in food diaries is used in the prospective assessment. The methodology considers an interview on the food consumption within the preceding 24 h, eating history, a 3-day noting method, and chemical analysis of the recreated daily food rations. The latter is relatively expensive and is not suitable for use with individuals in larger populations.

The 24-h dietary interview is the most commonly used and assesses the average energy value of a daily diet, the content of basic nutrients, and the consumption of selected minerals (calcium, magnesium, phosphorus, sodium). The interview is carried out once with each of the respondents, on any day of the week, and noting the proportions between common days and holidays. Photographs of the products included in a special album of servings and dishes are used during collection of the history.

### Physical Examination: Deviations

Physical examination should be carried out in accordance with the accepted medical standards. Particular attention should be paid to the accurate assessment of the skin and subcutaneous tissue atrophy and skin discoloration, enlarged veins, deficient or excess body fat, atrophy of skeletal muscles, impaired wound healing, susceptibility to the development of bedsores, brittle nails, hair loss, exudates from body cavities, and peripheral edema.

The oral cavity should also be subjected to a very accurate assessment, including missing teeth, dental caries, the presence or absence of dentures, inflammation of mucous membranes, and possible ulcerations.

## Anthropometric Tests

Anthropometric tests provide information on body weight, body fat distribution, and body proportions, as well as information on the body’s protein-energy reserves. They are noninvasive and easy to make. The measuring sets are highly available and relatively cheap and include a stadiometer (anthropometer) caliper, anthropometric tape, and a scale. An additional advantage is the lack of any contraindications (Antczak-Domagała et al., 2013). Tests include (1) determining body parameters (height and body mass; the circumference of the waist, hip, arm, and calf; and thickness of skin folds) and (2) determination of the body composition.

### Body Mass

Body mass is a measure of total body weight, including muscle mass, fat, bone, and water, but generally does not provide information on the relative proportions of each constituent. Body mass is measured in the morning after a person has emptied his or her bladder and without outerwear or footwear on a calibrated scales with an accuracy of at least 0.1 kg (Charzewska et al., 2010; Wronka et al., 2010).

Body mass is a single authoritative indicator of nutritional status and a particular indicator of the risk of PEM in the elderly (Babiarczyk and Turbiarz, 2012). Analysis of body weight changes in time is particularly important in assessing nutritional status (unintentional weight loss) (Charzewska et al., 2010; Blackburn et al., 1977; Charzewska, 2000). Serious weight loss of body mass is defined as >2% weight loss in 1 week, >5% in a month, >7% in 3 months, or >10% in 6 months (Blackburn et al., 1977).

Assessing the nutritional status of the elderly takes into account the percentage of body mass. The optimal body mass can vary within 10% of ideal body weight. A patient is diagnosed as overweight if the optimal body mass is exceeded by 10–20%, while obesity is diagnosed if the optimal body mass is exceeded by more than 20% (Blackburn et al., 1977; Szczygieł et al., 1994).

### Body Height

Body height is the distance from the base (the contact point of feet with the ground) to the highest anatomical point of the head (the vertex). The measurement is performed in the morning (due to fluctuations in the body height within a day) using a stadiometer or portable anthropometer with a precision of 0.1 cm. The person being measured should stand freely upright with knees and heels together and toes slightly apart. The result of measurements of the body height is a relatively constant parameter in adults, but with age it may change as a result of involution processes (e.g., osteoporosis). The difference can be as much as 10 cm (Wronka et al., 2010).

### Body Mass Index

Measurements of weight and height are the basis for determining body mass index (BMI). The measure is the ratio of body mass in kilograms to the square of height expressed in meters. BMI is widely used as a diagnostic indicator to identify abnormal nutritional status and has been recognized by the World Health Organization (WHO) as a measure of a person’s energy and protein nutritional status. A BMI less than 17 kg/m² indicates a risk of malnutrition; 18–24 kg/m² indicates a good nutritional status; 28–29 kg/m2 indicates a person is overweight; and more than 30 kg/m² indicates obesity (Charzewska et al., 2010; World Health Organization, 1995, 2010; Kvamme et al., 2012).

Many researchers point to malnutrition among older people with higher values of BMI (Babiarczyk and Turbiarz, 2012; Beck and Ovesen, 1998). BMI values between 24 and 27 kg/m2 are associated with reduced risk of mortality and an improved quality of life (Babiarczyk and Turbiarz, 2012; Kvamme et al., 2012).

Older people tend to lose muscle mass (Ness-Abramof and Apovian, 2008) as well as body height (Srikanthan et al., 2009), which can lead to an underestimation of BMI. Therefore, this indicator is a poor predictor of health problems related to body mass in the geriatric population (Kravitz, 2010).

### Measuring Body Composition

Assessment of the proportion of body fat to remaining body mass can determine an organism’s nutritional status (Charzewska, 2000).

### Assessing Fat Content in the Body

Assessing fat content in the body using anthropometric methods is performed by measuring the thickness of skin folds at defined anatomical points on the body: e.g., above the triceps and above the biceps; under the lower angle of the shoulder blades; over the iliac cress; on the belly, chest, and thigh; and above the gastrocnemius muscle (Wronka et al., 2010; Szczygieł et al., 1994).

These measurements (thickness of the skin folds) are carried out using a clipper on the right side of the upright body, with freely lowered upper limbs, at least twice in the same place, calculating an arithmetic mean from the measurements (Harrison et al., 1988).

Points and sites of measurements in the elderly are:

1. above the triceps in a vertical line midway between the acromion and the elbow ulna,

2. above the biceps of the arm in a vertical line midway between the acromion and the elbow ulna, and

3. on the belly in the diagonal, one-quarter of the distance between the navel and the front upper iliac thorn.

Measurement of the triceps skin-fold thickness above the triceps of a person’s nondominant arm is the most common way to measure and to determine a person’s nutritional status because it helps define the energy reserves of the body (Szczygieł et al., 1994) and calculate body density and the amount of body fat (Jackson and Pollock, 1978, 1985; Jackson et al., 1980; Durnin and Womersley, 1974; Siri, 1961).

The phenomenon of internalizing and centralizing body fat is commonly observed in the elderly, which is why measuring skin-fold thickness is not a diagnostic method (National Institutes of Health, 1998; World Health Organization, 2004).

### Indicators of Fat Tissue Distribution

The waist circumference, waist-to-hip ratio (WHR), and waist-to-height ratio (WHtR) are the measurements most often used to evaluate body fat distribution (Ashwell et al., 2012; Bolanowski et al., 2005; Lee et al., 2008).

### Waist Circumference

Waist circumference is a diagnostic indicator that reflects abdominal obesity. It is measured by applying a stretch-resistant tape at least twice between the bottom edge of the bottom rib and the top of the iliac crest and perpendicular to the vertical line of the trunk at the end of a gentle exhalation of a person standing with legs together and hands lowered freely (WHO, 2008). In the case of highly obese individuals whose measurements cannot be taken between the edge of the rib and the ridge of the hip, the waist circumference is measured at the navel (Ness-Abramof and Apovian, 2008; Browning et al., 2010; Roszkowski and Chmara-Pawlińska, 2003).

### Waist-to-Hip Ratio

When measuring WHR, waist circumference is measured at least twice at the widest part of the buttocks perpendicular to the vertical line of the trunk at the end of a gentle exhalation of a person standing with legs together and hands lowered freely (Welborn and Dhaliwal, 2007). WHR is a measurement of the fat tissue distribution in an organism (Ashwell et al., 2012; Ness-Abramof and Apovian, 2008; Srikanthan et al., 2009; Kravitz, 2010; Browning et al., 2010).

### Waist-to-Height Ratio

WHtR is the ratio of waist circumference to body height. In addition to WHR and waist circumference, it is also a measure of fat distribution (Ashwell et al., 2012). Values of WHR higher than 0.50 indicate an increased risk of cardiovascular diseases associated with obesity. WHtR is correlated with the abdominal obesity.

### Measuring Lean Body Mass

The elderly are exposed not only to metabolic diseases but also to sarcopenia, protein malnutrition, and vitamin and mineral deficiencies (WHO, 2008; Leischker et al., 2010; Fairweather-Tait et al., 2014). Therefore, measurements of lean body mass, which can be measured by anthropological methods, are also included in any assessment of nutritional status.

### Arm Circumference and the Volume Index of the Arm Muscle Area

Measurement of the arm circumference (mid-arm circumference) is performed midway between the anatomical points of the acromion and the olecranon on the nondominant side of the body. A circumference below 21 cm indicates a shortage of muscle tissue and therefore protein malnutrition.

In determining the arm muscle circumference (mid-arm muscle circumference) and arm muscle area (mid-arm muscle area), skin-fold thickness is measured above the nondominant triceps.

### Calf Circumference

Calf circumference also provides information about normal muscle mass. It can reflect a decrease in muscle mass with limited physical activity. A result of more than 31 cm is considered normal (Tsai et al., 2008). When measuring the circumference of the arm and calf in the diagnosis of sarcopenia, one should be aware that these measurements may be affected by errors of interpretation due to the presence of edema and possible connective and adipose tissue in place of muscle tissue (Strzelecki et al., 2011). There are no clear standardized criteria in the diagnosis of sarcopenia (Krzymińska-Siemaszko and Wieczorowska-Tobis, 2012).

## Biochemical Tests

Laboratory tests are also components of any thorough nutritional status assessment. Based on the results of laboratory tests and patient body mass, one can qualify a person as having normal nutritional status or different degrees of malnutrition. No laboratory test, however, clearly indicates malnutrition in the elderly.

The biochemical tests include the following:

blood counts—numbers of leukocytes, red blood cells, platelets, hemoglobin concentration, hematocrit, and total lymphocyte counts;

concentration of albumin, prealbumin, and transferrin in plasma;

concentration of creatinine, glucose, iron, vitamin B12 in serum;

thyroid-stimulating hormone;

acute phase protein; and

lipids.

## Survey Methods

Many questionnaires can assess the nutritional status of the elderly, including validated nutritional status questionnaires such as Nutritional Risk Screening (NRS 2002), Mini-Nutritional Assessment (MNA), Subjective Global Assessment (SGA), Seniors in the Community Risk Evaluation for Eating and Nutrition (SCREEN II), Nutritional Risk Index (NRI), and Prognostic Inflammatory and Nutritional Index (PINI) (Phillips et al., 2010; Guigoz and Vellas, 1998; Ożga and Małgorzewicz, 2013; Walsh, 2003; Al-Najjar et al., 2012; Bonnefoy et al., 1998).

### Nutritional Risk Screening 2002

The NRS 2002 is a screening method that can assess nutritional status. In hospitalized patients, the scale shows from 39% to 70% sensitivity and from 83% to 93% of specificity. The point survey takes into account inter alia such factors as BMI <20.5 kg/m2, the percentage of body mass loss (>5% in the last 3 months), changes in food consumption within the preceding week, and the occurrence of severe comorbidity factors (e.g., stroke, liver cirrhosis, chronic obstructive pulmonary disease, and renal failure), the medical treatment (e.g., extensive abdominal surgery, chemotherapy, bone marrow transplantation), and a patient’s age. Patients who score three or more points require nutritional therapy. In the case of more than three points, a conservative approach is implemented or the questionnaire is repeated in a week (Ożga and Małgorzewicz, 2013).

### Mini-Nutritional Assessment

The MNA is the most widely used questionnaire (developed by Guigoz et al.) for evaluating nutritional status in the elderly (Guigoz and Vellas, 1998). It shows the highest sensitivity (>83%) and specificity (>90%). It consists of a screening part (6 questions) or a patient assessment (12 questions) or both. The survey includes questions on meals, usual body mass, neurological disorders, stress history over the preceding 3 months, BMI measurement, and calf circumference. Rating a patient also means determining frequency of consumption of various food groups and medications, housing quality, and a person’s subjective perception of his or her own health and nutritional status. The maximum number of points a patient can get is 30. Scores in the range of 24–30 indicate a normal nutritional status. A range of 17–23 indicates a risk of malnutrition, and below 17 points suggests malnourishment (Ożga and Małgorzewicz, 2013).

### Subjective Global Assessment

The SGA is considered a nutritional assessment scale and consists of three parts: history, physical examination, and opinion about the risk of malnutrition.

As part of the interview, a doctor establishes, among other things, whether there has been any recent weight loss (defined as a percentage), whether a patient follows a specific diet or has changed the diet recently, whether there are unwanted gastrointestinal symptoms (nausea, vomiting, anorexia, diarrhea), what the patient’s physical capacity is (working, reclining), and whether the main disease increases metabolic demand. During the physical examination, the doctor will assess whether there has been a loss of subcutaneous adipose tissue or muscle (quadriceps, deltoid) and whether the patient has ascites or edema (ankle, above the sacrum). The final SGA conclusion establishes whether the tested person exhibits normal nutritional status, suspected malnutrition or moderate malnutrition, a high risk of malnutrition, or emaciation (Ożga and Małgorzewicz, 2013; Walsh, 2003).

### Seniors in the Community: Risk Evaluation for Eating and Nutrition

The SCREEN II questionnaire is particularly useful with older people living in their own homes. Its 17 questions assess the risk of malnutrition based on the amount of food intake, physiological problems with the intake of food, changes in body weight, and social aspects of eating.

NRI and PINI are useful indicators of the risk of malnutrition in hospitalized elderly patients (Ożga and Małgorzewicz, 2013; Al-Najjar et al., 2012).

### Nutritional Risk Index

The NRI is calculated from the following formula:

$\text{(1}\text{.5}\text{×}\text{albumin concentration[g/L])}\text{+}\text{current body mass(kg)/due body mass}$

A good nutritional status is recognized if the NRI is in the range of 97.5–100. Moderate malnutrition is determined when the NRI ranges from 83.5 to 97.5, and severe malnutrition is determined when the NRI is less than 83.5 (Ożga and Małgorzewicz, 2013).

### Prognostic Inflammatory and Nutritional Index

The PINI allows the evaluation of the ratio of acute phase catabolic proteins (alpha 1-acid glycoprotein, CRP) to anabolic proteins (albumin and prealbumin). Life risk is diagnosed when a PINI score is >30; high risk is seen for 21–30, an average risk for 11–20, and a low risk when PINI is in the range of 1–10 (Ożga and Małgorzewicz, 2013; Al-Najjar et al., 2012; Bonnefoy et al., 1998).

## Conclusion

The biggest nutritional problems with the elderly are malnutrition and severe obesity.

Assessing nutritional status requires only basic medical skills although there is no simple tool for this assessment. Each time the results of a subjective and objective examination and additional tests must be analyzed globally and critically. The nutritional assessment scales are also helpful but do not substitute for a medical conclusion.

There are many methods to assess seniors’ nutritional status. Unfortunately, so far we failed to develop a gold standard that will allow us to assess the nutritional status of all elderly patients. Such an evaluation is complex and requires a compilation of many different studies. The results of any nutritional assessment should be documented and completed with proposals on how to proceed, depending on the existing nutritional risk.

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