PRACTICAL NUTRITIONAL ASSESSMENT FOR ELDERLY PATIENT IN THE HOSPITAL AND COMMUNITY: WHICH ONE SHOULD BE CHOSEN

RA Tuty Kuswardhani
Geriatric Department Sanglah Hospital Denpasar , Bali, Indonesia/ Geriatric Division Internal Medicine School Medicine of Udayana University

The diagnostic nutrition in elderly can use measure by offer measurement like: anthropometry, upper arm anthropometry, bioelectrical impedance, other body composition techniques, blood parameters, immune function, serum proteins, serum cholesterol, urinary creatinine, and leptin Weight loss and malnutrition have been shown to result in a loss of muscle mass, causing a further decrease in strength which may impair mobility and the ability to care for oneself. It is also clear from scientific and medical research that poor nutrition leads to a slower recovery from illness, increased risk of infection and complications of surgery or hospitalization and poor healing.

The lifestyles of the elderly are changing as well. This is an important consideration because the nutritional needs of people living in chronic care institutions differ somewhat from those living independently. Undernutrition is one of the most common and devastating conditions in the older population. Thirty to forty percent of men and women over the age of 75 are at least ten percent underweight. Full-blown undernutrition occurs in 5% to 12% of community-dwelling older persons, in 11% of medical outpatients, and in 20% of higher risk community-dwelling populations. Weight loss and malnutrition have been shown to result in a loss of muscle mass, causing a further decrease in strength which may impair mobility and the ability to care for oneself. It is also clear from scientific and medical research that poor nutrition leads to a slower recovery from illness, increased risk of infection and complications of surgery or hospitalization and poor healing. Healthy eating and nutrition in the elderly is greatly influenced by several factors, one of them being a change in body composition. The morbidity and longevity are not being seen globally, with exceptions related to: poverty, educational disadvantage, ethnicity , status of women (who generally live longer than men), food security, health services, status of aged, cultural resilience, housing, community support and organization, substance abuse (tobacco, alcohol, self-medication) and opportunity for and interest in physical activity. Nutritional factors play a role in both the cause and treatment of atherosclerosis, congestive heart failure, diabetes mellitus, osteoporosis, renal disease, chronic obstructive pulmonary disease and many cancers. The elderly are highly heterogeneous group, with many different medical diagnoses and broad variations in both mental and functional status. A patients ability or inability to perform the activities of daily living can serve as screening test for both the prevention and detection of illness. Impairment of functional status should signal the physician to consider the nutritional implications of disability.

The nutritional assessment can easily be incorporated into medical practice in the office as well as in other environments, including the home, the hospital and the nursing home.
Table 1: ABCD: The Components of Nutritional Assessment (Johanna T.D, et. al, 1993) A Anthropometric measurements such as height and weight B Biochemical parameters such as serum albumin, hemoglobin, and vitamin. C Clinical evaluation, including an assessment of functional, social and mental status, the medical history, and the physical examination. D Dietary history, based on answers to questions about nutritional supplements and the adequacy of the diet.

Goal Improvement in indicators of nutritional status in order to optimize functional status and general well being and promote positive nutritional status. Parameters of Assessment Nutrition in Elderly During routine nursing assessment, any alterations in general assessment parameters that influence intake, absorption, or digestion of nutrients should be further assessed to determine if an older adult is as nutritional risk. Including: subjective assessment, social history, drug nutrient interactions, functional limitations, objective assessment, dietary intake, anthropometry, and visceral proteins. The diagnostic nutrition in elderly can use measure by offer measurement like: anthropometric measurement. Aging is associated with changes in weight, height, and body composition. Exaggerated changes lead to a significant increase in morbidity and mortality. In addition to the decrease in the fat-free mass that starts by middle age, the total fat mass also decreases after age 70 years. The body mass index (BMI) has been established as a useful parameter of overor underweight. The BMI has been shown to predict total adipose tissue with an error of 10% or less when compared with computed tomography. The BMI is calculated by dividing body weight in kilogram by the square of the height in meter Upper Arm Anthropometry Triceps skin fold (TSF) thicknesses (measured by calipers) and midd arm circumferences (MAC) provide estimates of body fat and skeletal muscle, respectively. TSF measurement increase 14% in women and decrease 8% in men. Bioelectrical Impedance Bioelectrical impedance analysis (BIA) is a noninvasive method of determining (a) the relative proportion of fat to lean tissue and (b) total body water and its place in the body, i.e., extra cellular, intracellular, or third space water. Other Body Composition Techniques Nuclear magnetic resonance (NMR), radiographic imaging, dilution methods are useful in determining muscle diameter and area.
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Blood Parameters Measurement, such as blood urea nitrogen (BUN), creatinine, hemoglobin, hematocrit, serum, iron and total iron binding capacity, sodium, potassium, albumin, prealbumin, and cholesterol are useful to monitor the impact of nutrition therapy and targeting those at risk of malnutrition. Immune Function There is mounting evidence about the relationship between undernutrition and immunologic dysfunction. T-lymphocyte count has been proposed as a useful indicator of nutritional status and outcome. Regardless of age, a decrease in total lymphocyte count (TLC) to less than 800/mm3 reflects severe undernutrition Serum Protein Serum protein levels are important markers of the body protein pool. Protein with a long half-life are most useful in evaluating chronic nutritional changes in the outpatient setting, whereas proteins with a short half-life are most useful in the acute or sub acute settings. Serum albumin level is the defining value for determining the diagnosis of kwashiorkor and is a screening indicator for undernutrition when its value drops below 38 g/L. Serum Cholesterol Serum cholesterol levels lower than 160 mg/dL have been considered a reflection of low lipoprotein and thus of low visceral protein levels. Hypocholesterolemia seems to occur late in the course of malnutrition, limiting the value of cholesterol as a screening tool. Leptin Leptin is a hormone produced by fat cells that in turn causes a decrease in food intake and an increased metabolic rate in animals. The leptin level correlates better with subcutaneous fat than with visceral fat Urinary Creatinine Twenty four hour urinary creatinine excretion may be used to reflect LBM, as 98% of total body creatinine lies within the muscle. From age 25 to 75 there is a decline in creatine of 36% in women and 30% in men. Creatinine excretion decrease quickly mal nourished or wasted state in a absence of renal failure because of reduction in muscle mass. Factor as low meat consumption that are prevalent among the elderly may cause a further depreciation in creatinine muscle concentration

NUTRITION ASSESSMENT
Check list of nutritional health Circle the number in the YES column for those apply to you YES I have an illness or condition that made me change the kind and/or amount of food I eat. I eat fewer than 2 meals per day. I eat few fruits or vegetables, or milk products. I have 3 or more drinks of beer, liquor or wine almost every day. I have tooth or mouth problems that make it hard for me eat. I dont always have enough money to buy the food I need. I eat alone most of the time. I take 3 or more different prescribed or over the counter drugs a day. Without wanting to, I have lost or gained 10 pounds in the last 6 months. I am not always physically able to shop, cook and/or feed my self. Total the circled numbers TOTAL 2 3 2 2 2 4 1 1 2 2

If the total is: 0-2 GOOD. Recheck your nutritional score in six months 3-5 YOU ARE AT MODERATE NUTRITIONAL RISK. See what can be done to improve your eating habits and lifestyle. Your office on aging, senior nutrition program, senior citizens center or health department can help. Recheck your nutritional score in 3 months. YOU ARE AT HIGH NUTRITIONAL RISK. Bring this checklist the next time you see your doctor, dietitian or other qualified health or social service professional. Talk them about any problems you may have ask for help to improve your nutritional.

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Developed by the Nutrition Screening, Inniactive, a project of the American Academy of Family Physicians, The American Dietetic Association, and the National council on the Aging. Inc.

To Be Choice the Strategy for Parameters of Nutrition Assessment in Elderly In outpatient hospital Anthropometric indices, such as body weight and the body mass index, are the most widely recommended methods of nutritional monitoring. The use of biochemical markers as a guide to assessing and treating nutritional risk should be discouraged, because these indices have poor predictive value. Research into the diagnosis and classification of nutritional status has been notably enhanced by the advent of more sophisticated technology. Available clinical data comparing the predictive value of simple measurements, such as body weight and body mass index, with that of more sophisticated anthropometric tools fail to demonstrate any significant difference. The nutritional surveillance program is the ability to detect impending nutritional compromise long before abnormal laboratory indices are sought. For practical clinical purposes, the most cost-effective parameter of proven clinical usefulness in monitoring nutritional status is body weight measurement Preoperative nutritional evaluation of elderly patients Age and malnutrition are each surgical risk factors has been specifically designed for assessing the nutritional status of elderly patients, it can be used for preoperative nutritional evaluation.

Every patient over 60 years of age, scheduled for elective surgery, was seen in anesthesiology consultation and was submitted to MNA (Mini Nutritional Assessment). The MNA is a clinical score consisting of four additive items: Anthropometric assessment based on BMI, mid-arm and calf circumferences, weight loss; global evaluation; dietetic assessment, and subjective assessment. The MNA stratifies patients in the following categories: well-nourised (24<- MNA 30), at risk of malnutrition (17 MNA 23.5), and undernutrition (MNA < 17). Also recorded were: age, gender, type of scheduled operation, and the American Society of Anesthesiologists (ASA) physical status Score. In the nursing home In the nursing home setting, anthropometric data specifically height and body weight, are the most accessible and most descriptive parameters of nutrition assessment. These data can be used to evaluate nutrition care, to anticipate nutrition problems. Nursing home regulations in most states require measurement of body weight monthly. Height can be more difficult to obtain because many nursing home residents cannot stand erect due to curvature of the spine or do not have the strength to stand for a measurement. The use of knee height to estimate stature has been validated and should be used. In home nutritional assessment elderly In home nutritional assessment elderly methods of home assessment have been used to examine the extent to which a home delivered meals program meets the nutritional needs of recipients, it has been possible to demonstrate that meals recipients show less food insecurity than a comparison group on waiting lists to receive meals. SUMMARY The diagnostic nutrition in elderly can use measure by offer measurement like: anthropometry, upper arm anthropometry, bioelectrical impedance, other body composition techniques, blood parameters, immune function, serum proteins, serum cholesterol, urinary creatinine, and leptin Weight loss and malnutrition have been shown to result in a loss of muscle mass, causing a further decrease in strength which may impair mobility and the ability to care for oneself. It is also clear from scientific and medical research that poor nutrition leads to a slower recovery from illness, increased risk of infection and complications of surgery or hospitalization and poor healing. Refferences
Cederholm T. Assessment of nutritional status in elderly: ethodology and problems. ScandinavianJournal of Nutrition 1999;43:236. Cottee M, Lee C, Bell A. Screening nutritional status in outpatients. In: First Congress of theInternational Academy on Nutrition and Aging. Paris: J Nutr Health Aging 2002;6(Suppl): 19 20. Coutaz M, Morisod J, Biselx S, et al. [Comparison of elderly persons nutritional status living at home, in an institution, or in a semi-rural hospital] Rev Med Suisse Romande 1997;117:691 5 [in French] Dwyer T.J, Gallo J.J, Reichel W. American Family Physician. Assesing nutritional status in elderly patients, 1993, Feb. Ek AC, Unosson M, Christensson L, et al. Identifying patients at nutritional risk. In: Clinical Nutrition and metabolism. Stockholm, Sweden: Educational Supplement. 21st ESPEN Congress; 1999. p. 935 Exton-Smith AN. Nutritional status: diagnosis and prevention of malnutrition. In: Caird FI, editor. Metabolic and nutritional disorders in the elderly. Bristol: John Wright & Sons Ltd; 1980. p 67 76.

Hrabinska L, Krajck S, Sobolova A, et al. MNA in residential home residents. In: Vellas B, Gerry PJ, Guigoz Y, editors. Nestle Nutr Workshop Ser Clin Perform Programme. Basel: S. Karger AG; 1999. p. 169. Lauque S, Guyonnet S, Nourhashemi F, et al. Nutritional status of institutionalized elderly persons with or without dementia. Rev Geriatr 1999;24:115 9. Molaschi M, Massaia M, Pallavicino di Ceva A, et al: Mini Nutritional Assessment in nursing home residents. In: Vellas B, Gerry PJ, Guigoz Y, editors. Nestle Nutr Workshop Ser Clin Perform Programme. Basel: S. Karger AG; 1999. p. 159. Omran ML, Morley JE. Assessment of protein energy malnutrition in older persons, part I: history, examination, body composition, and screening tools. Nutrition 2000;16:50 63. Saletti A, Lindgren EY, Johansson L, et al. Nutritional status according to Mini Nutritional Assessment in an institutionalized elderly population in Sweden. Gerontology 2000;46:13945. Saletti A, Johansson L, Cederholm T. Mini Nutritional Assessment in elderly subjects receiving home nursing care. J Hum Nutr Diet 1999;12:381 7.