N U R SI N G T H E O R Y A N D C O N C E PT D E V E L O P M E N T O R A N A L Y SI S

A concept analysis of malnutrition in the elderly

Cheryl Chia-Hui Chen RN MSN GNP
Doctoral Student, Yale University School of Nursing, New Haven, Connecticut, USA

Lynne S. Schilling RN MN PhD

Associate Research Scientist, Yale University School of Nursing, New Haven, Connecticut, USA

and Courtney H. Lyder ND FAAN

Associate Professor and Director, Adult, Family, Gerontological and Women's Health Specialty, Yale University School of Nursing, New Haven, Connecticut, USA

Submitted for publication 27 December 2000 Accepted for publication 27 June 2001

Correspondence: Cheryl Chia-Hui Chen, Yale University School of Nursing, 100 Church Street South, PO Box 9740, New Haven, CT 06536-0740, USA. E-mail: chia-hui.chen@yale.edu

C H E N C .C ..- H ., S C H I L L I N G L .S . & L Y D E R C .H . ( 2 0 0 1 )

Journal of Advanced

Nursing 36(1), 131142 A concept analysis of malnutrition in the elderly Purpose. Malnutrition is a frequent and serious problem in the elderly. Today there is no doubt that malnutrition contributes signicantly to morbidity and mortality in the elderly. Unfortunately, the concept of malnutrition in the elderly is poorly dened. The purpose of this paper is to clarify the meaning of malnutrition in the elderly and to develop the theoretical underpinnings, thereby facilitating communication regarding the phenomenon and enhancing research efforts. Scope, sources used. Critical review of literature is the approach used to systematically build and develop the theoretical propositions. Conventional search engines such as Medline, PsyINFO, and CINAHL were used. The bibliography of obtained articles was also reviewed and additional articles identied. Key wards used for searching included malnutrition, geriatric nutrition, nutritional status, nutrition assessment, elderly, ageing, and weight loss. Conclusions. The denition of malnutrition in the elderly is dened as following: faulty or inadequate nutritional status; undernourishment characterized by insufcient dietary intake, poor appetite, muscle wasting and weight loss. In the elderly, malnutrition is an ominous sign. Without intervention, it presents as a downward trajectory leading to poor health and decreased quality of life. Malnutrition in the elderly is a multidimensional concept encompassing physical and psychological elements. It is precipitated by loss, dependency, loneliness and chronic illness and potentially impacts morbidity, mortality and quality of life. Keywords: malnutrition, elderly, quality of life, nutritional status, weight loss, ageing, chronic illness, assessment, older adult, concept analysis

Introduction
Malnutrition is a frequent and serious problem in the elderly (Seiler & Stahelin 1999). In the United States of America (USA), it is estimated that 40% of nursing home residents and
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50% of hospitalized elderly patients are malnourished (Nutrition Screening Initiative 1993). Slightly lower prevalence rates were reported in Europe and Asia. Reported prevalence of malnutrition in the elderly ranges from 10% to 85% (Mion et al. 1994, Sullivan 1995, Clarke et al. 1998,
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Thomas 1999). The variance in this gure is the result of the differences in the study methods employed, the type of setting in which the study was conducted, and the operational indicators used for dening malnutrition. Table 1 presents the prevalence studies of malnutrition in the elderly and the criteria used for dening malnutrition. This concept was selected because of its seemingly complex and ambiguous nature, which is in evidence both in the literature and in the clinical arena. Although, research has been conducted primarily in the USA and Europe, malnutrition in the elderly has signicant implication worldwide. This is largely because of the growing number of elderly population across nations. This critical review of the literature was conducted to clarify the meaning of malnutrition in the elderly and to develop the theoretical propositions, thereby facilitating communication regarding the phenomenon and enhancing research efforts. It was intended that attributes of malnutrition in the elderly, and its antecedents and consequences would be illuminated during the analysis. A critical review of the literature provided the theoretical schema for the process. The strategy was chosen, as rigorous, systemic reviews of the literature are critical to developing a substantial knowledge base about a concept (Broome 1993).

Approaches to denition
The review of literature reveals that the denitions of malnutrition can differ among institutions, disciplines, and cultures. Keller (1993) notes that malnutrition is an overall term, encompassing: (1) undernutrition resulting from insufcient food intake, (2) overnutrition caused by excessive food intake, (3) specic nutrient deciencies and (4) imbalance because of disproportionate intake. The terms `malnutrition' and `undernutrition', however, tend to be used interchangeablely in the literature. Although there are health consequences of nutritional excesses for the aged, this review examines the issues of undernutrition, as it is now the agreed area of concern regarding malnutrition in the elderly (Lehmann 1991). In the literature, there are two clinical approaches to dene malnutrition in the elderly. The rst denition characterizes malnutrition as any insufcient dietary intake among essential nutrients. Presumably, an inadequate dietary pattern will result in malnutrition. With this approach, the researchers operationally dened malnutrition as dietary intake below the recommended dietary allowance (RDA) (Walker & Beauchene 1991, Posner et al. 1994) or the elderly person's calculated maintenance energy requirements (Sullivan et al. 1999).
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The second approach refers to malnutrition as proteinenergy undernutrition (PEU) (or protein-caloric malnutrition, PCM). Protein-energy undernutrition is the progressive loss of both lean body mass and adipose tissue resulting from insufcient consumption of protein and energy, although one or the other may play the dominant role in the elderly. There are three types of PEU: marasmus, kwashiorkor (hypoalbuminemia), or a mixture of both. Marasmus is a clinical syndrome characterized by weight loss that is accompanied by marked depletion in both fat stores and muscle mass (Morley et al. 1998). The serum albumin is within normal laboratory ranges and visceral organ function remains intact. Marasmus is caused by an inadequate intake of energy relative to needs. The diagnosis of marasmus is made by the demonstration of weight loss, below normal mid-arm circumference (MAC), and/or skinfold measurements. Immune function is often preserved early in the course of marasmus. Kwashiorkor presents with a decrease in serum albumin and other visceral proteins. Serum albumin levels are normally above 40 g/dL in ambulatory elderly. When kwashiorkor is suspected, the diagnosis is usually conrmed by an albumin level less than 3530 g/dL (Morley & Sliver 1994). Kwashiorkor is often precipitated by an acute infection or illness. Table 2 presents the comparison of marasmus and kwashiorkor. In many cases, however, the elderly often have a mixed picture of kwashiorkor and marasmus. Based on these two clinical approaches for dening malnutrition in the elderly, several measurement systems have emerged from the literature.

Approaches to measurement
From the literature reviewed, three measurement systems have been utilized in identifying malnutrition in the elderly, including dietary intake, biochemical indices and anthropometrics. Some researchers dening malnutrition have used the combination of these assessments, and most nutritional assessment instruments also utilize all three aspects of measurement plus some clinical assessment such as anorexia or co-morbid conditions. Mini-Nutritional Assessment (MNA) is an example of this mixing of measurement systems (Guigoz et al. 1996). Table 3 presents the measurement systems of malnutrition in the elderly. It should be noted that, to date, no single measurement has emerged as optimal in dening malnutrition in the elderly. This makes the diagnosis of malnutrition in the elderly extremely difcult. The so-called `gold standards' have ultimately had an element of `fool's gold' mixed in (Morley et al. 1998). Malnutrition is a continuum. It becomes clear

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Nursing theory and concept development or analysis Table 1 Prevalence studies of malnutrition in the elderly Reference Bistrian et al. (1976) Setting Acute Hospital, USA n 251

Analysis of malnutrition in the elderly

Diagnosis criteria Weight for height < 80% TSF < 80% MAC < 80% Serum albumin < 35 g/L Serum albumin < 35 g/L Anemia Weight for height TSF Serum albumin Anemia Any two of Weight for height < 90% MAC < 90% Serum albumin < 35 g/L And transferrin < 20 g/L Combination of Serum albumin TSF MAC Serum albumin < 35 g/L < 80% Average weight TSF < 5 percentile MAC < 5 percentile Any of the following Albumin < 30 mg/L TLC < 15 cells/mm3 BMI < 5 percentile Loss of > 5% body weight/6 month MAC < 264 cm Below ideal weight Serum albumin < 30 g/L Weight < 80 Serum albumin < 35 g/L BMI < 22 kg/m2 BMI < 20 Anemia Albumin < 35 mg/dL MAC < 10 percentile or Albumin < 35 mg/dL Both below Composite Including BMI < 20, AMC, TSF < 5 percentile

Prevalence (%) 24 70 24 45 15 22 43 37 32 52 (M) 14 (F) 61

Stiedmann et al. (1978) Shaver et al. (1980)

Long-Term Facility, USA Long-Term Facility, USA

46 115

Bienia et al. (1982)

VA Hospital, USA

59

Pinchcofsky-Devin and Kaminski (1986)

Long-Term Facility, USA

232

73 Severe 52 Moderate

Agarwal et al. (1988) Sliver et al. (1988)

Acute Hospital, USA Long-Term Facility, USA

27 88

35 23 0 62 (M) 100 (F) 39

Sullivan et al. (1989)

VA Hospital, USA

250

Miller et al. (1991) Abbasi and Rudman (1993)

VA Outpatients, USA Long-Term Care, USA

183 2811

19 11 6 12 28 16 15 5257 2 30 (M) 41 (F) 156 (M) 214 (F) 18 Severe 28 Moderate

Ponser et al. (1994) Euronut-SENECA (1991)

Community-Dwelling, USA Community-Living, Europe Acute Hospital, France

1156 2332

Constans et al. (1992)

324

Keller 1993

Long-Term Care, Canada

200

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C.C.-H. Chen et al. Table 1 (Continued) Reference Miller et al. (1996) Ritchie et al. (1997) Marshall et al. (1999) Setting Inner City Older Black, USA Home-Bound Elders, USA Rural Elders, USA n 400 49 (86% AA) 1006 Diagnosis criteria NSI alike tool BMI < 24 Albumin < 35 mg/dL NSI Prevalence (%) 48 High risk 63 (M), 29 (F) 20 (M), 19 (F) 3941 Moderate risk 1624 High risk 21 37 at risk 2 malnourished

Sullivan et al. (1999) Criep et al. (2000)

VA Hospital, USA Retired Home, Belgium

497 81

Intake < 50% requirement MNA

AA, African American; AMC, Arm muscle circumference; BMI, Body mass index; MAC, Mid-arm circumference; MNA, Mini-nutritional assessment; NSI, Nutritional screening initiative; TLC, Total lymphocyte count; TSF, Triceps skin-ford; VA, Veteran affairs.

Marasmus Clinical causes Clinical features Insufcient calorie intake Starved appearance Wt < 80% standard for Ht. TSF < 3 mm MAMC < 15 cm Creatinine-height index < 60% norm Months

Kwashiorkor Insufcient protein intake during stress/illness Well-nourished appearance Easy hair pluckability Oedema Albumin < 35/30 g/dL Weeks

Table 2 Comparison of Marasmus and Kwashiorkor

Laboratory data Time to develop

Wt, Weight; Ht, Height; TSF, Triceps skinfold; MAMC, Mid-arm muscle circumference.

Dietary Intake

< 75% of RDA in 3 key nutrients < 2/3 of RDA in > 4 nutrients < 50% of calculated maintenance energy requirement Serum albumin < 35 mg/dL Serum albumin < 30 mg/dL Serum transferrin < 20 g/L Total lymphocyte count < 15 cells/mm Body mass index < 5 percentile Body mass index < 24 Body mass index < 20 Mid-arm circumference < 5 percentile Arm muscle circumference < 5 percentile Triceps skinfold < 5 percentile Weight < 75% standard weight for height Weight < 80 percentile standard weight for height < 90 percentile standard weight for height Loss of > 5% of weight in 6 months

Table 3 Measurement systems for malnutrition in the elderly

Biochemical indices

Anthropometrics

RDA, Recommended daily allowance. 134 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 36(1), 131142

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that a major difculty in dening malnutrition hinges on whether it is the process associated with poor dietary intake or the state an elderly person reaches after being malnourished (Roy 1994). In other words, do you measure `risk' or `status'?

Critical attributes
Attributes are dening characteristics or salient features that assist in identifying the occurrence of a concept. After reviewing the literature, ve critical attributes emerge, including insufcient dietary intake, muscle wasting, weight loss, poor appetite, and downward trajectory.

However, the literature is quite variable regarding the amount of weight loss and the unit of time that should prompt clinical investigation. The most accepted denition for clinically important weight loss has been about 5% over 612 months (Wallace & Schwartz 1997). Although it may be helpful to inquire if weight loss was volitional, one study has suggested that weight loss, whether voluntary or involuntary, is positively associated with increased mortality (Wallace et al. 1995). In addition, the ICD9 denition of malnutrition is body weight less than the 90th percentile, irrespective of history or cause (Roy 1994).

Poor appetite
It is now well established that with advancing age, humans experience a physiologic reduction in food intake. This has been designated as the anorexia of ageing (Morley 1997). The physiologic anorexia of ageing places the elderly at a greater risk for developing a marked decrease in energy intake and the subsequent development of malnutrition when a disease process develops. Loss of appetite, as an item, has been assessed in many nutritional assessment tools (Guigoz et al. 1996, Payette et al. 1996).

Insufcient dietary intake

Malnutrition is characterized by an insufcient dietary intake to meet requirements for energy or protein needs (Roy 1994). Two major causes of unmet requirements are increasing demand and decreasing intake. Malnutrition is either caused by lack of adequate food intake containing the essential nutrients or by an adequate intake in the face of illness or medical treatment, where nutrients cannot be ingested, absorbed, or metabolized adequately, or the rate of utilization of external losses is excessive (Rudman 1987). Some researchers operationally dene malnutrition as dietary intake below between 50% and 75% of the recommendation or minimal requirement of essential nutrients such as energy or protein (Stevens et al. 1992, Posner et al. 1994, Sullivan et al. 1999).

Downward trajectory
Studies have shown that malnutrition, once established, places patients at increased risk of developing subsequent adverse health outcomes. Malnutrition leads to increased susceptibility to infection, delayed wound healing, reduced rate of drug metabolism, and impairment of both physical and cognitive function (Sullivan 1995). Malnourished elderly often get into a cycle of progressive clinical deterioration. Additionally, deterioration in nutritional status appears to be a rapid and hard-to-reverse process (Abbasi et al. 1992). Previous experimental studies have shown that advanced malnutrition is much more difcult to correct in the elderly than in younger adults (Fiatarone et al. 1994).

Muscle wasting
Skeletal muscle comprises approximately 30% of the lean body mass and atrophies progressively in protein-energy malnutrition (Rudman 1987). From the MAC and the width of the adipose layer (equal to one-half the triceps skinfold), mid-arm muscle and fat areas can be calculated. The mid-arm muscle and fat areas are indicators of the body's mass of skeletal muscle and adipose tissue, respectively (Rudman 1987). When an individual has less than required nutrition intake, particularly in protein, the muscles are going to be wasted, and subcutaneous fat will reduce (Latham 1997). By monitoring the mid-arm muscle areas, malnutrition can be identied.

Antecedents of malnutrition in the elderly

Antecedents are the factors that occur prior to the concept of interest, whereas consequences are the result of the concept of interest. It is through the identication of the antecedents and consequences that the attributes of the concept become clearer, because attributes can be neither antecedents nor consequences (Walker & Avant 1988). Loss, dependency, loneliness, and chronic illness were identied as antecedents of malnutrition in the elderly.
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Weight loss
Weight loss per unit of time is believed to be a major indicator of malnutrition in the elderly (Barrocas et al. 1995).

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Loss
Normal ageing is characterized by loss loss of lean body mass, bone density, proprioception, and sense of smell and taste. In short, losses occur in every body system with ageing (Masoro 1999). It is well recognized that ageing has denite effects on nutritional status that become particularly signicant when the elderly become ill. Age-related declines in oral health, body composition and sensory function are important considerations in malnutrition in the elderly (Morley 1997). Loss of optimal body composition Advanced age is associated with a remarkable number of changes in body composition, including reduction in lean body mass and increase in the body fat, which have been well documented. The nutritional implications of this change are many. The energy requirements diminish by approximately 100 calories per decade (Rosenberg 1994). With lower energy intake, it becomes very difcult for elders to satisfy all the micronutrient needs through diet alone. In addition, decreased lean body mass occurs primarily as a result of losses in skeletal muscle mass. This age-associated loss in muscle mass has been termed `sarcopenia' and it is a direct cause of an age-related decrease in muscle strength (Evans & Cyr-Campbell 1997). In other words, functional status will decline with advanced age, which serves as a major risk factor for malnutrition in the elderly in some studies (Unosson et al. 1991, Ritchie et al. 1997). However, nonsignicant relationships between functional status and malnutrition also are evidenced in the literature (Posner et al. 1994, Griep et al. 2000). Loss of optimal oral health In early studies, many changes in the oral cavity were considered as normal ageing. These changes included decreased salivary ow, atrophy of mucus membranes and loss of taste buds (Cooper et al. 1959, Massler 1986). However, recent investigations indicate there are no such signicant oral changes in healthy elderly. Most of the early studies included elderly with some disease or who were taking medications that affect oral health (Baum 1981, Martin 1999). Lack of research on oral health and ageing, unfortunately, limits further discussion. Oral health and nutritional status are inextricably linked (Henshaw & Calabrese 2001). The elderly who experience mouth pain, chewing or swallowing difculties, poor dentition, ill-tting dentures, dry mouth, or other symptom that makes eating uncomfortable are at risk for developing malnutrition (Saunders 1997). Missing teeth can have
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negative effects on mastication, oral health, and nutrition (Shay & Ship 1995). Impaired mastication alters the sensory and psychological aspects of eating, causing restrictions in food selection. Edentulos individuals are more likely to have an atherogenic diet that is high in fat and cholesterol (Appollonio et al. 1997). One recent study shows the risk of malnutrition increases with the loss of natural teeth and wearing of dentures (Griep et al. 2000). Loss of optimal sensory function Smell and taste contribute to appetite and food intake (Baez-Franceschi & Morley 1999). Loss of smell and taste can result from normal ageing, certain disease states, medication, surgical interventions, and environmental exposure (Schiffman 1997). Losses in these chemical senses not only reduce the pleasure from food, but also represent risk factors for malnutrition. Visual and hearing losses may make preparing foods difcult or impossible and resulting in malnutrition. Olfaction contributes to nutritional status and food enjoyment by mediating the perception of food odours through the nostrils (orthonasal route) and food favours through the oral cavity (retronasal route) (Schiffman 1997). Retronasal olfactory perception allows us to identify exactly what we eat, whereas true taste permits only the detection of salt, sweet, sour, and bitter (Duffy et al. 1995). Conditions that impair chewing, mouth and swallowing movements could diminish retronasal perception, even with an intact olfactory system (Burdach & Doty 1987). In other words, poorly tting dentures can further decrease olfactory perception in the elderly. In animal studies, olfactory dysfunction contributes to loss of appetite and weight. Clinically, the relationship between appetite and olfactory dysfunction is not consistent (Mattes & Cowart 1994, Duffy et al. 1995). However, most studies suggest that the sense of smell is even more impaired by ageing than the sense of taste, and the complaints of taste loss usually reect loss of smell function. Data from the University of Pennsylvania Smell and Taste Center serve as compelling evidence in support of this. Of the 750 individuals presenting with the complaints of taste loss, less than 4% had measurable taste impairment, while 71% had measurable olfactory dysfunction (Deems et al. 1991). Researchers appear to agree that ageing is associated with elevated taste thresholds, both detection and recognition (Murphy 1986). Compared with a younger cohort, the average detection thresholds for the elderly with one or more medical conditions and taking an average of 34 medications were 116 times higher for sodium salts, 43 times higher for acids, 70 times higher for bitter compounds, and 27 times higher for sweeteners (Schiffman 1993). Clinical studies of

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the elderly with malnutrition indicate that taste loss at the threshold level is even more severe (Schiffman & Wedral 1996). Taste cells constantly reproduce themselves with a life span of approximately 10105 days. This continuous renewal process makes the sense of taste vulnerable to malnutrition, which can impair reproduction of taste cells and reduce taste sensitivity (Schiffman 1993). It should be noted that chemicals from food stimulate taste buds during chewing and swallowing, which can prolong or improve taste sensations on the soft palate. The elderly with dentures that cover the soft palate can lose sensory input from food in this mouth region, which reduces the motivation to eat (Duffy 1999). Vision loss restricts activity, fosters dependency, and diminishes the sense of well-being in the elderly (Carabellese et al. 1993, Rovner & Ganguli 1998). Several community studies have found that visual impairment predicts functional disability among the elderly and leads to high levels of handicap and emotional stress (Branch et al. 1989, Rudberg et al. 1993, Rubin et al. 1994). Visual impairment is related to increased morbidity. Those with visual loss have an increased risk for falls, hip fractures, physical disability, and depression (Nevitt et al. 1989, Rovner et al. 1996, Lord & Dayhew 2001). Hearing loss, particularly that caused by presbyacusis, is the most common disorder affecting the elderly (Reuben et al. 1998). The mental and cognitive health, social isolation, quality of life, and functional impact of hearing loss in the elderly has been demonstrated in numerous studies (Weinstein & Ventry 1982, Thomas et al. 1983, Mulrow et al. 1990). Visual or hearing losses may make obtaining or preparing foods difcult or impossible. The elderly may decrease social interaction because of the visual and hearing losses and this may further decrease their chances of sufcient nutrition intake. Loss of roles function Social and environmental losses may also affect nutritional status in the elderly. The losses in role function accompanying retirement and the death or departure of family, friends, and condantes is frequently overlooked. Additionally, the loss of a family support network, loss of space and place as a result of diminished functional capacity and economic resources, as well as change in neighbourhood and community, might further hamper the psychosocial wellbeing of the elderly (Newbern & Krowchuk 1994).

forming new attachments, in coping, and in caring about life. Financial and functional dependencies have been linked to malnutrition in the elderly. Financial dependency is common in this population. The elderly at greater risk of malnutrition are those who live in poverty or have incomes that limit their ability to maintain their lifestyles (Pearson et al. 1998). As many as 40% of the elderly are reported to have incomes of less than $6000 per year (in 1990) and are spending $25 to $30 per week on food. One USA study showed that 2435% of inner-city-dwelling older black Americans were reporting not having enough money for food, and it was signicantly correlated to their nutritional status (Miller et al. 1996). When the elderly experience difcult economic circumstances, utilities and medications may take precedence over food purchases. Financial dependency may force the elderly to obtain less than adequate nutrition. Functional dependency is another concern for the elderly. According to the USA Department of Health and Human Services (1996), approximately 23% of the elderly have difculties with one or more activities of daily living (bathing, dressing, toileting, continence, feeding, mobility). Twentyeight percent have difculty with one or more instrumental activities of daily activities (shopping, preparing meals, taking medication, handling nances, etc.). Decits in any of these areas of function have long been considered as risk factors for malnutrition in the elderly (Unosson et al. 1991, Ritchie et al. 1997), although research ndings are inconsistent.

Loneliness
Humans are innately social animals. Loneliness is linked to negative affects, including boredom, restlessness, and unhappiness, and to dissatisfaction with social relationships in elders (Perlman et al. 1978). Often when the elderly lose a spouse, they are prone to suffer consequences of social isolation, loneliness, depression, nancial worries, and malnutrition (Hansson et al. 1990). Walker and Beauchene (1991) found that loneliness was related to dietary inadequacies in a group of free living elderly. An increase in social interaction at meal times improves dietary intake for the elderly (Hansson 1978, de Castro et al. 1990). Social isolation, therefore, can play an important role in decreased food intake, and it is detrimental to health (McIntosh et al. 1989). Social isolation also has been linked to increased mortality (Blazer 1982). Although the exact mechanisms by which this connection exists is poorly understood, a growing body of literature has suggested direct links between social support and physiological functioning.
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Dependency
When the supports the elderly have relied upon are lost or diminished in their old age, the elderly may have difculty in

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However, one study showed that whether the elderly belong to a social club has no relationship with nutritional status (Posner et al. 1994). In Walker and Beauchene's study in 1991, the number of social contacts did not correlate to dietary adequacy in their elderly subjects. Revenson and Johnson (1984) suggested that the quality of relationships might be more powerful than the number of contacts. Depression has been linked to weight loss in the elderly (Thompson & Morris 1991, Morley 1998). In the elderly with depression, about 90% lose weight compared with 60% of younger persons with depression (Blazer et al. 1987). Depression is common as physical abilities and social networks diminish. Morley (1998) has written about the effects of bereavement on appetite. He suggested that grieving-associated dysphoria can lead to reduced food intake, which in turn results in ketosis. The ketone bodies produced further suppress appetite, thus triggering a vicious cycle.

for malnutrition in the elderly (Kerstetter et al. 1992, Griep et al. 2000).

Consequences of malnutrition in the elderly

Studies from a variety of institutions reveal that malnutrition is a common, potentially serious nding among the elderly (Clarke et al. 1998). The alarmingly high rate of malnutrition among elders has severe consequences for both individuals and the health care system. In 1993, the elderly accounted for 48% of all days of care in hospitals, with an average length of stay that was 3 days longer than for younger populations. The malnourished elderly patients experienced 2 to 20 times more complications, have up to 100% longer hospital stays, and compile hospital costs $2000 to $10 000 higher per stay (Hart Research Associates 1993). These longer and costlier hospitalizations, along with more frequent re-admissions, delayed recovery times, and premature nursing home placements, escalate societal costs signicantly (Sullivan 1992, Cederholm et al. 1995, Covinsky et al. 1999). In short, malnutrition in the elderly increases morbidity and mortality, and decreases quality of their life (Jordan et al. 1999).

Chronic illness
It is well recognized that with advancing age there is a higher incidence of chronic illness, and increasing evidence points to the importance of nutrition in the occurrence of and susceptibility to morbidities (Millen 1999). Approximately 85% of Americans 65 and older have at least one chronic illness, and 60% of those over 85 have two or more chronic illness (US Bureau of the Census 1996). In July 1992, the president of the American Dietetic Association testied before the House Select Committee on Ageing and raised the concerns of greater likelihood of chronic illness among the elderly and their high risk of malnutrition which could benet from nutritional services (ADA testimony 1992). With multiple chronic illnesses, the elderly are prone to take multiple medications. As a result, they are at greater risk for adverse drug reactions and drug-induced malnutrition (Varma 1994, Lyder et al. 2001). Community-dwelling older Americans take an average of 2742 prescription and over-the-counter medications (Hanlon et al. 2001). Nursing home residents consume an average of eight drugs (Beers et al. 1991). A major consequence of polypharmacy is the risk of nutritional deciencies induced by drugs (Roe 1994, Varma 1994). Mechanisms of drugnutrient interactions include reduced food intake caused by side effects such as anorexia, nausea, vomiting, and altered taste perception. Furthermore, medications can interfere with nutrient absorption, cause alteration in nutrient metabolism and increase nutrient excretion (Roe 1992, Varma 1994, Blumberg & Couris 1999). There is growing evidence that polypharmacy is one of the strongest predictors

Increase in morbidity and mortality

Based on both animal models and human investigations, it is known that malnutrition has serious effects on the function of virtually every organ system (Silberman 1989). Nearly every aspect of the immune system is compromised by malnutrition. Cellular immunity, production of specic antibodies and complement, secretory and mucosal immunity are impaired (Lesourd 1995). As a result of these changes in organ function, malnutrition leads to increased hospital length of stay, complications, hospital readmission, early institutionalization, and decreased survival time (Bienia et al. 1982, Sullivan & Walls 1994, Incalzi et al. 1998, Dardaine et al. 2001).

Decrease in quality of life

Nutritional considerations are fundamental to our understanding of healthy development and successful ageing (Dwyer 1991). The World Health Organization's denition of health as a state of complete physical, mental, and social well being provides a framework for conceptualizing quality of life in a health context. Malnutrition in the elderly diminishes quality of life by contributing to serious illness, decreased functional capacity, altered self-perception of health, and precipitated chronic disability (Millen 1999).

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Denition of malnutrition in the elderly

The following denition of malnutrition in the elderly is derived from the attributes identied in this critical literature review. Malnutrition in the elderly: Faulty or inadequate nutritional status; undernourishment characterized by insufcient dietary intake, poor appetite, muscle wasting and weight loss. In the elderly, malnutrition is an ominous sign. Without intervention, it presents as a downward trajectory leading to poor health and decreased quality of life. Malnutrition in the elderly is a multidimensional concept encompassing physical and psychosocial elements. It is precipitated by loss, dependency, loneliness and chronic illness and potentially impacts morbidity, mortality and quality of life.

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Conclusion
It is a sad reection on our society if some of our elders are malnourished and starved in the midst of plenty. Ageing cannot be adequately studied without recognition of the inuence of psychosocial and behavioural factors in the progression and management of physical changes, and nurses historically have such interdisciplinary problem-solving in their professional training. The future holds many possibilities for nursing research into the phenomenon of malnutrition in the elderly. Malnutrition in the elderly is a multidimensional issue on which nurses can take the lead and make a difference. Nurses encounter elderly people in all settings including primary care, acute care, and long-term care. Methods or protocols regarding the detection, assessment and intervention of malnutrition among the elderly across different settings and cultures need to be developed and empirically tested. By conducting this critical conceptual review, an in-depth understanding of the phenomenon has emerged. It is hoped that the conceptualization of malnutrition in the elderly will facilitate productive debate, analysis, and research. However, this is just the beginning. The ndings of this review provide the groundwork for philosophic and empirical analyses of malnutrition in the elderly.

Acknowledgements
The authors would like to thank Dr Deborah Chyun, RN PhD from Yale University School of Nursing for her helpful comments and assistance on the manuscript preparation.

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