Malnutrition is the body's physiological condition characterized by the lack or absorption, if compared to the needs, of nutritional intake over time. Among the different causes of malnutrition such as poverty, mental disorders, infections and cancers, there are also several metabolic diseases related to:
- proteins and amino acids;
- minerals and trace elements;
- vitamin deficiencies.
The protein-calorie malnutrition, along with the deficiency of minerals and vitamins, is particularly frequent in the elderly. The category that is most at risk of malnutrition is represented by the frail elderly. The frail elderly person is the one of advanced or very advanced age, suffering from various chronic diseases, clinically unstable, often disabled, and very often experiencing socio-economic problems which are mainly loneliness and poverty. Balanced nutritional habits and an ability to feed themselves adequately are two things that are often compromised in the frail elderly. A severe protein-calorie malnutrition was observed in 10-38% of nonhospitalized elderly, in 5-12% of those living in their own homes, in 26-65% of those hospitalized and in 5-85% of institutionalized individuals.
CAUSESBelow are identified the main causes of malnutrition.
Organic age-related causes Aging causes several physiological changes including atrophy of the mouth and tongue mucosa resulting in deficient digestion, deficient sensitivity to tastes and deficient absorption of nutrients. Chewing defects due to the loss of teeth are widespread and are often ascribed to erroneous dietary and hygienic habits as well as to critical socioeconomic conditions. The physiological anorexia of the elderly is linked to the increased levels of cholecystokinin and to the delayed gastric emptying.
Organic disease-related causes In the frail elderly population swallowing disorders are widespread: the dysphagia is attributed to 20-50% of institutionalized patients. The organ failure (heart failure, advanced chronic renal failure, respiratory failure, etc.), together with the neoplasia, constitutes the second most widespread disorder and can be the cause of the increased nutritional requirements and anorexia. In addition, many medications undertaken by the elderly may interfere with the absorption (antacids, laxatives) or renal excretion (diuretics) of certain substances, and can cause taste disorders.
Social, environmental and psychological causes Economic hardship, isolation, loneliness and/or institutionalization may elicit an inadequate food intake. Malnutrition has a negative impact on the nutritional and psycho-social states of the person and is linked to the deterioration of chronic diseases, increased incidence of infections, bedsores and falling down. In the elderly the malnutrition is particularly linked to the loss of autonomy, therefore, the deteriorating quality of life.
TREATMENTThe first phase of nutritional intervention is designed to verify the possibility of oral feeding. The aim of the phase is to adjust and enhance the protein-calorie nutritional supply with natural foods, and it heavily relies on nutritional advice, food fortification and supplement use. In case of failure to achieve the oral nutrition, it becomes necessary to resort to artificial enteral nutrition (NE) via nasogastric tube (CNS), percutaneous endoscopic gastrostomy (PEG) or percutaneous endoscopic jejunostomy (PEJ), and / or parenteral (NP).
Nutrition tips In case of lack of appetite, premature fullness in the stomach or fatigue during the digestion, the first nutritional intervention consists of a fractionated diet by eating high-calorie food in small portions, at least 4 or 5 times per the day. Its purpose is to provide more energy and proteins by eating limited amounts of food.
Food fortification It might be helpful suggesting to patients to enhance their consumed food with condiments (oil, butter), sauces (cream, mayonnaise, “besciamella” (white sauce) ), whipped cream, ice-cream, sugar, honey, jam, syrups, fruit juices as a source of calories, milk (even in the form of condensed powder), cheese, and eggs as a protein source.
Oral supplements Together with an additional share of nutrients, the intake of oral supplements covers the nutritional needs for patients who are still able to feed themselves normally. In this way it is possible to avoid using more evasive nutritional support techniques such as enteral or parenteral nutrition. The oral supplements may be useful either for already-malnourished patients or the ones at risk of it, for whom the supplementation with natural foods (food fortification) is not adequate but still fulfills at least half of their food requirements. In recent years the range of oral supplements has spread widely both in terms of their bromatological composition and the variety of tastes. This has enabled a more nutritionally-focused usage as well as has fostered the compliance to the product on the long run. The use of supplements is highly recommended for the elderly (Level of evidence A) by the artificial nutrition guidelines: "oral supplementation is clearly recommended to ensure the intake of energy, proteins and micronutrients, to maintain or improve the nutritional status as well as rescue those that are malnourished or at risk of it". As one recent meta-analysis statistically demonstrated, when the malnourished elderly are treated with oral protein-calorie supplements, we can observe a significant body weight increase and the reduced mortality. The guidelines clearly highlight that, oral supplements, especially those rich in proteins, can also reduce the risk of pressure ulcers. In case of failured oral nutrition, it becomes necessary to resort to artificial enteral nutrition (EN) and / or the parenteral one (PN).