142 CHAPTER 9 | Malnutrition in the Older Adult Box 9.1 Malnutrition Indicators31-33,49, 51-54


Insufficient energy intake Estimate and quantify intake from diet history, understanding that many older adults may overestimate their intake. Data can also be obtained from intake or meal records, family, or caregivers.


Track and quantify the timeliness of poor nutritional intake problems, along with substantial medical, surgical, and behavioral health events.


Track and quantify the history of protein intake, elimination of food groups, and fluid intake.


Document the difference (and percentage) between estimated energy intake and calculated energy needs.


Document the difference (and percentage) between estimated protein intake and calculated energy needs.


Note that energy-need calculations are not precise and should be considered with clinical judgment.


Weight loss


Weight data can be obtained from medical or weight records or verbal report from the individual or caregivers.


Percent weight change = [(Original weight − current weight)/original weight] × 100.


Once the percent change is calculated, match and document the descriptor, significant or severe, in describing the time frame of weight loss.51


State the individual’s actual


values. Here is an example: Severe weight loss of 20 lb (9%) in 3 months. Actual values are more clinically meaningful and understood by clinicians and auditors. The significance of weight loss is summarized as follows:


Significant weight loss 5% loss in 1 month


Severe weight loss > 5% loss in 1 month


10% loss in 6 months > 10% loss in 6 months Loss of muscle mass


The examination of muscle mass is performed by palpation and observation of specific muscles. Refer to the nutrition focused physical examination (NFPE) guides from the Academy of Nutrition and Dietetics 32


and the American Society for Parenteral and Enteral Nutrition (ASPEN).33


Loss of subcutaneous fat The examination of subcutaneous fat is performed by palpation and observation of specific fat sites. Refer to the NFPE guides from the Academy of Nutrition and Dietetics32 and ASPEN.33


Localized or generalized fluid accumulation


Data can be obtained from physical assessment, observation, or client or caregiver interview. Determining fluid accumulation is one of the more challenging features of the NFPE because it may be confounded by disease. Typically, fluid accumulation would be documented as a secondary indicator; however, various conditions, in addition to malnutrition, can cause fluid accumulation. Most clinicians advise obtaining and documenting two other indicators, in addition to edema, before stating that the individual is malnourished.51


Diminished functional status as measured by handgrip strength


Data can be obtained via a grip strength test or assessment from physical or occupational therapists. Handgrip strength is well researched as a measure of muscle function. When grip strength is reduced, it responds more quickly to deficits and refeeding than does muscle mass. The American Society of Hand Therapists provides the most common and validated method to measure grip strength.52,53


Identification of Sarcopenia


Sarcopenia may be defined as a decline in walking speed (performance) or handgrip strength (strength) associated with low muscle mass.58


There is inter-


national agreement on the use of handgrip strength and walking speed or distance, among other met- rics, to diagnose sarcopenia. Figure 9.1 reviews the SARC-F (strength, ambulation, rising from a chair, stair climbing, and history of falling) tool in screen- ing for sarcopenia,25


which can be administered by the nutrition practitioner assessing the individual’s


condition. Utilizing the recommendations of several international working groups can determine a defini- tive diagnosis of sarcopenia.


The Foundation for the National Institutes of Health (FNIH) recognizes an association of malnutri- tion with depression, falls, and fractures in high-risk older adults.59


The FNIH defines weakness by two


measures: low absolute grip strength (< 35.5 kg in males and < 20 kg in females) and slowness defined by low usual gait speed (< 0.8 m/s).60 Sarcopenia is recognized and may be diagnosed, treated, and billed with the use of ICD-10 code


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