138 CHAPTER 9 | Malnutrition in the Older Adult
A multitude of physiological, social, environmen- tal, behavioral, and financial factors (potentially in conjunction with additional medical diagnoses and unwieldy systems of care) contribute to the lack of timely nutrition risk screenings and malnutrition diagnoses. Older adults may find it difficult to coor- dinate care, attend appointments, or communicate with the health care team. They also may find it dif- ficult to either alter or adopt certain behaviors and may lack access to health care professionals, such as a registered dietitian nutritionist (RDN). In addition, older adults may not receive routine malnutrition and sarcopenia risk screenings or have access to practi- tioners knowledgeable in nutrition or gerontology. These complex problems apply to all economic and social demographics but are more prevalent in under- served populations.10,11
Complex circumstances can
lead to delayed nutrition interventions that may have been effective to prevent further health declines if implemented earlier.10,12
The ongoing underdiagnosis
of malnutrition, sarcopenia, and frailty misrepresents the prevalence of these problems to health economists and government agencies. Subsequently, there is also less research connected to the associated downstream economic costs and increased resource utilization resulting from these untreated conditions.13
Despite
this, it is possible for older adults, caregivers, health care professionals, and health care systems to prevent some conditions that can contribute to the develop- ment of malnutrition, sarcopenia, and frailty. Awareness of malnutrition is increasing, as
reflected in the Supporting Older Americans Act of 2020, which includes support for malnutrition pro- grams for individuals aged 60 years or older.14
This
law adds support for activities that address commu- nity program–based screening for malnutrition and for recognizing nutrition and food insecurity and their relationship to malnutrition. The recognition of malnutrition in these laws is an important step for- ward for the public health community. The American Society for Parenteral and Enteral Nutrition (ASPEN) organizes an annual Malnutrition Awareness Week to educate and provide resources for advocates.15 Important contributors in the fight against mal- nutrition in community living situations and acute care facilities include food quality, skills of the service staff, and the overall environment. The importance of
quality food, proper temperatures, appealing textures, and sanitary serving conditions cannot be overstated. Staff cooking skills, menu planning, food variety and quality, communication skills, and the social and physical environments in community living situa- tions can contribute to improvements or declines in the nutritional status of older adults.16-19 A common and ongoing barrier to diagnosing
protein-energy malnutrition is the perception by some health care professionals that a person with overweight or obesity cannot be malnourished. As a result of obesity prevalence and a lack of awareness of visceral fat, subcutaneous fat, and muscle body composition, low-energy diets are sometimes inappropriately pre- scribed for older adults with obesity or overweight. The older adult with overweight or obesity may have disease-related or disease-associated protein-energy malnutrition. Older adults with a history of bariatric surgery are especially at risk of sarcopenic obesity (a clinical and functional condition characterized by the coexistence of excess fat mass and sarcopenia) and micronutrient deficiencies, depending on the level of commitment to ongoing lifestyle management.20 Food insecurity can affect diet quality and contribute to sarcopenic obesity. Individuals may have a combi- nation of sarcopenic obesity and malnutrition, among other nutrition concerns.21
Risk Factors for Malnutrition
Many factors can increase the risk of malnutrition among older adults. Increasing age, living alone, dif- ficulty walking 100 m, difficulty climbing stairs, and hospitalization in the previous year are some contrib- uting factors to malnutrition risk. In females, factors predicting malnutrition include cognitive impairment or use of social support. In males, factors include fall- ing in the previous 2 years, hospitalization in the past year, and self-reported difficulty climbing stairs.22 In addition, older adults may have insufficient
or incorrect knowledge about appropriate nutrition. Misinformation regarding nutrition and healthy diets is widespread and can lead to older adults consuming unbalanced meals and engaging in poor eating patterns. Many seniors have medical or economic conditions that limit their ability to be independent and must rely on family members or caregivers and their shopping,
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