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Volume 14, Number 5, 2010

JNHA: GERIATRIC SCIENCE

UNDIAGNOSED MALNUTRITION AND NUTRITION-RELATED PROBLEMS

IN GERIATRIC PATIENTS
D. VOLKERT1, C. SAEGLITZ2, H. GUELDENZOPH3, C.C. SIEBER1, P. STEHLE2
1. Institute for Biomedicine of Aging, University of Erlangen-Nrnberg, Germany (DV, CCS); 2. Department of Nutrition and Food Sciences (IEL) Nutrition Physiology, University of
Bonn, Germany (CS, PS); 3. Department of Geriatric Medicine, Malteser-Hospital, Bonn, Germany (HG). Address for correspondence: Prof. Dr. Dorothee Volkert, PhD, Institute for
Biomedicine of Aging, University of Erlangen-Nrnberg, Heimerichstrae 58, 90419 Nrnberg, Germany, Phone +49 - 911 30005-17, Fax +49 - 911 30005-25
E-Mail: dorothee.volkert@aging.med.uni-erlangen.de

Abstract: Background & aims: Malnutrition is common in geriatric patients and associated with poor outcome.
If recognised, effective treatment is possible. In recent years, low nutritional awareness among health care
professionals (HCPs) has been deplored with respect to the general hospital population. The aim of the present
cross-sectional study was to assess to which extent malnutrition and nutrition-related problems are documented
by physicians and nursing staff in geriatric patients and whether nutrition support is used in daily clinical routine.
Methods: Patients characteristics, nutritional status (BMI, Subjective Global Assessment, Mini Nutritional
Assessment) and several nutrition-related problems (e.g. weight loss, poor appetite, chewing and swallowing
problems) were assessed in 205 patients consecutively admitted to the geriatric ward of a community hospital on
the first day after admission. After discharge, all documented information in the medical folders about nutritional
status, nutrition-related problems and nutrition support was systematically collected. Results: According to BMI
(< 22 kg/m) and Subjective Global Assessment (C), malnutrition was observed in 25.4 %, according to Mini
Nutritional Assessment (<17 points) in 30,2 % of the patients. In daily routine, clinical judgement of nutritional
status by physicians was performed in 187 patients (91.2 %) of whom 6.4 % (5.9 % of all) were classified as
malnourished. Weight was documented in 54.1 %, height in 25.9 %. BMI was not calculated. Nutrition-related
problems were present in up to half of the patients and only partly documented by HCPs. Seventeen patients
(8.3 %) received nutrition support, mostly in the form of oral supplements (3.9 %), followed by enteral (2.9 %)
and parenteral nutrition (1.5 %). Conclusion: Despite high prevalence rates among geriatric patients, malnutrition
and nutrition-related problems are rarely recognised and treated. In order to improve nutritional care, routine
screening and standard protocols for nutritional therapy should be implemented in geriatric hospital wards.

Key words: Malnutrition, awareness of malnutrition, nutriton-related problems, geriatric patients, routine
documentation, management.

Non-standard abbreviations: ADL: activities of daily living; CJ: clinical judgement of nutritional status; GDS:
Geriatric Depression Scale; HCPs: health care professionals; MMSE: Mini Mental Status Examination; MNA:
Mini Nutritional Assessment; SGA: Subjective Global Assessment.

Introduction overlooked and not realized in the general hospital population.

Malnutrition is a well-known attendant syndrome in geriatric
patients. Within observational studies, malnutrition has
frequently been diagnosed in the elderly admitted to hospital
and is associated with serious health problems and poor
outcome (1, 2). Several age-related problems like poor appetite,
chewing and swallowing problems or difficulties cutting food
adversely affect dietary intake in the elderly and contribute to
the worsening of nutritional status. If recognized, effective
treatment of malnutrition as well as elimination of the
underlying causes are possible, resulting in improved
nutritional status and outcome (3, 4).
For a long time, the low nutritional awareness by health care
professionals (HCPs) has been deplored by several authors (5-
13). Malnutrition and nutrition-related problems are often
Consequently, evidence-based concepts of nutritional therapy
are not integrated in clinical routine. Nutrition support is
underutilised and malnutrition therefore often remains
untreated.
Based on the fact that geriatric patients are known to be at
especially high risk of malnutrition, it could be argued that
nutritional awareness is better in HCPs caring for geriatric
patients than for the general hospital population. Up to now the
extent to which malnutrition and nutrition-related problems are
realized, diagnosed and treated in geriatric patients is not
known.
Thus, the aim of the present cross-sectional study was, to
assess to which extent malnutrition and nutrition-related
problems in geriatric patients are detected and documented by
physicians and nursing staff, and whether nutrition support is

Received April 29, 2009

Accepted for publication August 18, 2009
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UNDIAGNOSED MALNUTRITION IN GERIATRIC PATIENTS
used in daily clinical routine.
Patients and methods
Study design
All geriatric patients consecutively admitted to the geriatric
ward of a community hospital (Malteser-Hospital, Bonn,
Germany) from August 2003 to April 2004 were candidates for
enrollment in this cross-sectional study. Inclusion criteria were:
age 75 y, not in a terminal disease state, expected length of
stay longer than 48 h (judged by physician on duty), first
admittance and no participation in another study. Due to
capacity reasons, not all patients fulfilling the criteria could be
enrolled. Study recruitments were limited to 2 patients per day
(random selection). The study was approved by the local ethics
committee and all participating subjects gave a signed consent.
If the patient was unable to sign, relatives ore another proxy
were consulted.
Patients characteristics, nutritional status and several
nutrition-related problems were assessed on the first day after
admission by research staff outside of clinical routine. Results
were not transferred to the clinical staff. Information about
routine assessment and documentation of nutritional status,
nutrition-related problems and nutrition support by physicians
and nursing staff in the same patient group was collected from
the medical folders after discharge of the patients.
Patients characteristics
Patients characteristics included date of birth, gender, living
situation before admission, route of admission (via general
practitioner or another hospital) and the severity of the
underlying disease (subjectively judged by the physician on
duty as slight, moderate or severe). The ability to perform basic
activities of daily living (ADL) was recorded according to
Mahoney and Barthel (14), and patients were classified as
severely functionally impaired (30 points), in need of help
(35-65 points) or independent (70 points). Mental status was
assessed using the Mini Mental Status Examination (MMSE)
(15) and depressive symptoms were detected with the Geriatric
Depression Scale (GDS) (16). Main and secondary diagnoses
were collected from the clinical folders at discharge.
Nutritional status
Body-Mass-Index (BMI). Patients were weighed with a
digital chair scale (Seca, Hamburg, Germany) to the nearest 0.1
kg. Height was measured with a measuring rod to the nearest
0.1 cm with the patient standing. When patients were bed-
ridden height was measured with the patient lying in bed in a
straight position. When measurements of height or weight were
not possible self-reported values were used. Body mass index
(BMI) was calculated as weight/(height) 2 . A patient was
considered as malnourished if his or her BMI was less than 22
kg/m2. This value corresponds to the 10th percentile of data
recently assessed in a population of healthy non-Hispanic white
elderly (17).
388
Subjective Global Assessment (SGA). According to Detsky
et al. (18) patients were categorised as well nourished (A),
moderately malnourished (B) or severely malnourished (C) on
the basis of medical history (weight loss during the last six
months, dietary change) and physical examination of
subcutaneous fat, muscle mass and edema.
Mini Nutritional Assessment (MNA). This questionnaire,
specifically designed for the elderly, consists of 18 questions
with given weighted answers that sum up to a maximum score
of 30 points. Patients are classified as well nourished ( 24
points), at risk of malnutrition (17-23.5 points) or malnourished
(<17 points) (19).
All measurements and assessments were performed by the
same trained person (CS).
Nutrition-related problems
Using a standardized questionnaire, the following nutrition-
related problems were assessed in a personal interview: recent
weight loss (noticeable in the last 6 months), poor appetite,
chewing problems (always or with hard food), swallowing
problems, difficulties in cutting food, need of help with eating,
problems with food supply at home. Answers were rated yes or
no. If the patient was unable to answer the questions due to
mental impairment or somnolence, relatives were asked.
Nutritional assessment and documentation in clinical
routine
In clinical routine, assessment and documentation of
nutritional status and nutrition-related problems was partly
performed by physicians and by nurses. Physicians on duty are
supposed to document their subjective clinical judgement (CJ)
of nutritional status (malnourished, normal, obese), body height
and weight, weight changes and appetite changes as part of the
initial examination of each patient. Nursing staff is responsible
for weighing the patients at admission and discharge with a
digital chair scale and for the documentation of nutrition-related
problems. These are only documented if observed. No specific
guidelines for nutritional assessment were established. All
nutritional information in the medical folders was collected
systematically after discharge of the patients.
Nutrition support
Information about nutrition support included whether a
patient received oral supplements, enteral and parenteral
nutrition or not, and was also collected from the medical folders
after discharge of the patients.
Evaluation and Statistics
Data were analyzed in a descriptive manner using SPSS
version 12.0 (SPSS Software, Munich, Germany). Prevalence
rates of malnutrition and nutrition-related problems assessed by
research staff and prevalence rates of malnutrition, nutrition-
related problems and nutrition support documented by HCPs
are reported. Categorical variables are shown as absolute
numbers and percentages. For continuous variables mean and
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JNHA: GERIATRIC SCIENCE

standard deviation (SD), median and range are presented. Chi- 34.6 % moderately malnourished. As classified by the MNA,
square testing was used to detect significant differences in the 30.2 % were malnourished and 60.0 % at risk of malnutrition.
prevalence of nutrition support between malnourished and
well-nourished patients. P-values below 0.05 were considered Nutrition-related problems
statistically significant. Most of the patients were able to answer the questions by
themselves, in 12.2 % relatives had to be asked. The prevalence
Results of nutrition-related problems is shown in Table 2 (left column).
Recent weight loss was the most frequently occurring problem
Patients characteristics (47.8 %), followed by difficulties in cutting food (45.9 %).
205 patients (142 females, 69.3 %) were enrolled in the Problems with food supply (9.3 %) were most uncommon.
study. The mean age was 83.0 4.7 (median 82.0; range 75-95)
years. All patients had multiple diseases with fractures being Table 2
the most prevalent primary diagnosis (27.3 %), followed by Prevalence of nutrition-related problems as assessed in a
cardiac and circulatory disorders (19.0 %), neuropathies (13.7 standardised interview by research staff and documentation by
%), and muscle and skeleton disorders (13.7 %). Seventy health care professionals (HCPs) (n=205)
percent of the patients had five or more secondary diagnoses
with a median of 7 (range: 0-19). Three quarters (74.1 %) were Interview Documentation
admitted from other hospitals. About one quarter, respectively, by research staff by HCPs
had a severe disease, were severely functionally impaired, had
Recent weight loss 47.8 % 24.4 %
mental disorders or showed depressive symptoms. Main Poor Appetite 20.5 % 13.7 %
characteristics are shown in Table 1. Chewing problems 32.2 % 3.9 %
Swallowing problems 23.9 % 9.8 %
Table 1 Difficulty in cutting food 45.9 % 33.7 %
Need of help while eating 22.4 % 9.8 %
Main characteristics of patients at admission (n = 205) Problems with food supply 9.3 % 0.0 %
(MMSE = Mini Mental State Examination (14))
Nutritional assessment and documentation in clinical
n % routine
Living situation Body weight at admission was documented in 111 patients
Alone 96 46.8 (54.1 %). In about three quarters (73.9 %) of the documented
With family members 78 38.0 cases, weight was measured and in one quarter (26.1 %) it was
Assisted living 15 7.3 asked for. Body height was documented in 25.9 % of the
Nursing home 16 7.8
Severity of disease patients and was based in all cases on self-reported values. Data
Severe 57 27.8 for both weight and height were recorded for 24.4 % of the
Moderate 105 51.2 patients. BMI was calculated in no single case.
Slight 43 21.0 Clinical judgement of nutritional status by physicians was
Activities of daily living (ADL (13))
Severely impaired (< 35 p.) 50 24.2 performed in 187 patients (91.2 %). Of these, 6.4 % (12
In need of help (35 65 p.) 80 39.0 patients; 5.9 % of all) were classified as malnourished. Figure 1
Independent (> 65 p.) 75 36.6 shows the prevalence of malnutrition by clinical judgement of
Mental status the physicians compared to the prevalence rates detected by the
Reduced (MMSE 22 p. or
clinical diagnosis of dementia) 56 27.3 other methods performed by research staff. The mean BMI of
Test not feasible 25 12.2 those 12 patients recognized as malnourished was 19.0 2.5
Geriatric Depression Scale (GDS (15)) kg/m - compared to 25.5 4.3 kg/m in the remaining
Depressive symptoms (GDS 7 p.) 56 27.3 (p<0.001). Ten of these patients had a BMI below 22 kg/m, 10
Test not feasible 25 12.2
were also malnourished according to the MNA, 7 were judged
to be severely and 5 to be moderately malnourished according
Nutritional status to the SGA. 5 were judged to be severely and 7 moderately ill.
In 25 patients (12.2 %), height was measured recumbent. In Weight change was documented by the physicians in 120
24 patients (11.7 %), measurement of height and in 17 patients patients (58.5 %), and 41.7 % of these (24.4 % of all) reported
(8.3 %) measurements of weight was not possible and, thus, a recent weight loss. Appetite was asked for in 139 patients
self-reported values were used. In 2 patients no information (67.8 %) of whom 20.1 % (13.7 % of all) reported a poor
about body weight could be obtained. Mean BMI was 25.1 appetite. The prevalence of nutrition-related problems
4.4 kg/m (median 24.7; range 14.9 - 40.2 kg/m). In about a documented by nursing staff ranged from 0 % (problems with
quarter of the patients (25.4 %) BMI was below 22 kg/m. food supply) to 33.7 % (difficulties in cutting food) (Table 2).
According to SGA, 25.4 % of the patients were severely and

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UNDIAGNOSED MALNUTRITION IN GERIATRIC PATIENTS
Figure 1
Prevalence of malnutrition in geriatric patients (n=205) as
assessed by clinical judgement by the physician on duty (CJ)
and by research staff using different methods
(BMI = Body-Mass-Index; SGA = Subjective Global Assessment; MNA = Mini
Nutritional Assessment)
Figure 2
Prevalence of nutrition support in geriatric patients with and
without malnutrition assessed by different methods (number of
subjects in brackets)
(BMI = Body-Mass-Index; SGA = Subjective Global Assessment; MNA = Mini
Nutritional Assessment; CJ = clinical judgement of physician on duty); * p<0.05; ***
p<0.001.
Nutrition support
Seventeen patients (8.3 %) received nutrition support,
mostly in the form of oral supplements (3.9 %), followed by
enteral (2.9 %) and parenteral nutrition (1.5 %). Irrespective of
the method used for nutritional assessment, malnourished
patients received significantly more often nutrition support than
non-malnourished patients (p<0.05; Figure 2). The mean BMI
390
of those receiving nutrition support was 21.7 3.7 kg/m vs.
25.4 4.3 kg/m in the others (p<0.001). Only 3 of the patients
receiving nutrition support were judged to be malnourished by
their physician. Nine had a BMI below 22 kg/m, 10 were
malnourished according to the MNA, and 11 severely
malnourished according to the SGA. Thirteen were severely
and 3 moderately ill.
Discussion
The present study clearly documents a wide discrepancy
between the actual presence of malnutrition and nutrition-
related problems and the identification by physicians and
nurses, and a low percentage of patients receiving nutrition
support in the geriatric department of a German community
hospital. Thus, we could show that the diagnosis of
malnutrition is often missing and nutritional problems ignored
in daily clinical routine also in geriatric patients, as described
earlier for the general hospital population (5-13). Obviously,
doctors and nurses fail to recognise malnutrition and nutrition-
related problems also in great proportions of geriatric patients
and only rarely use nutrition support despite the fact that this
particular patient group is well known to be at especially high
risk of malnutrition and better nutritional awareness might have
been expected.
The patients under study are typical for the geriatric
population with a mean age over 80 years, multiple diseases
and widespread physical and mental impairments (Table 1), and
thus clearly differ from the general hospital population. As
expected, malnutrition, risk of malnutrition and nutrition-
related problems were highly prevalent. About 25 to 30 % of
the patients were malnourished according to BMI, SGA and
MNA, as reported earlier in other geriatric patient groups (1, 2,
20-22). Different methods were used for the assessment of
malnutrition because they focus on different aspects of
nutritional status, and still no gold standard is available. Broad
agreement between these methods was observed. In contrast
only several patients were identified as malnourished by the
physicians (Figure 1). Those recognized as malnourished by the
physicians, however, mostly were correctly identified, as
indicated by great agreement with the other methods.
Physicians in this hospital department routinely assess
malnutrition by a subjective clinical judgement. This method
has the advantage of being quick and feasible and can be
performed without any measurement or equipment.
Accordingly, a clinical judgement of nutritional status was
performed by the physicians in nearly all patients (91 %).
Weight change and poor appetite were assessed by the doctors
to a much lower extent with missing information in 42 and
32 %, respectively. In the patients asked, interestingly, the
prevalence of these problems was comparable to that reported
by the researcher. However, due to not asking, these problems
were not realised in about one half and one third of the patients
affected (Table 2). Similarly, weight and height were only
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JNHA: GERIATRIC SCIENCE
partly available and in no single case BMI was calculated.
All nutrition-related problems which were recorded by the
nurses revealed markedly higher prevalence rates in the
research interview (Table 2). It is well known that these
problems are widespread among geriatric patients (23, 24), and
the prevalences found in the research interview do not seem to
be overestimated. In contrast, it is more likely that nurses did
not ask for the problems, resulting in lower prevalence rates
with the consequence of missing treatment, since problems can
only be addressed if noticed.
Among the nutrition-related problems considered here,
difficulties in cutting food were observed most often both in
absolute figures and also compared to the prevalence found in
the research interview. Chewing and swallowing problems
were realised in considerable low proportions of documented
cases: 4 % and 10 %, respectively, compared to 32 % and 24 %
detected in the research interview (Table 2). Since both of these
problems may severely impair adequate nutrition and reduce
food intake and both are amenable to effective interventions, it
would be desirable to assess these problems on a regular basis.
Interestingly, none of the patients was asked for problems with
food supply at home. Comprehensive nutritional care, however,
includes not only adequate interventions in the hospital setting
but also has to ensure adequate nutrition after discharge at
home, e.g. by meals on wheels or social services.
In the light of poor assessment and documentation of
malnutrition, it is not surprising that only a small number of
patients received nutrition support. Although nutrition support
is more often given to malnourished patients than to not
malnourished ones (Figure 2), it has to be pointed out that only
one quarter of the patients identified as malnourished by the
attending physician received nutrition support conversely
meaning that 75 % of those judged to be malnourished by the
physicians did not get nutrition support. Despite the fact that
those patients receiving nutrition support were mostly
malnourished and moderately or severely ill, it is difficult to
judge from the present information, if nutrition support was
used adequately. Beside the use of nutrition support, future
studies should assess its appropriateness and benefits for the
patients. It was beyond the scope of the present study to clarify
these questions. Thus, nutrition support might have been used
correctly in the present study, but is clearly underutilised, and
the full potential to treat malnutrition is not tapped, as already
described in surgical patients (5).
Why do physicians fail to recognise and treat malnutrition
and nutritional problems and what can be done to improve this
situation? In the present study, unfortunately, the reasons for
that have not been asked because such a big discrepancy
between the actual presence of malnutrition and nutrition-
related problems and the identification by physicians and
nurses, and the low percentage of patients receiving nutrition
support were not expected at the beginning of the study. In
several studies regarding the general hospital population, the
following reasons have been identified: lack of time, lack of
391
interest, low priority given to nutritional information, lack of
knowledge, of routine procedures and of defined
responsibilities (7, 25-27). We have no reason to believe that
for HCPs caring for elderly patients other reasons are relevant.
Obviously, also in the elderly nutritional information is
considered unimportant.
Based on the fact that malnutrition in the elderly can
effectively be treated and nutrition-related problems potentially
be eliminated by appropriate interventions (3,4), there is a high
potential as well as an urgent need for quality improvement of
nutritional care in geriatric institutions. This will not only go
along with improved nutritional status and outcome, and thus
potential individual benefit for the affected patient, but also
with economic benefits both for the institution and the health
care system (28).
In order to reach this goal and improve the quality of
nutritional care, malnutrition screening tools and nutritional
guidelines have been developed (29, 30). A discrepancy,
however, between these standards and clinical practice has been
reported (9, 31). On the other hand, it has been shown that
interventions like education of health care professionals, simple
screening sheets and the elaboration and implementation of an
action plan can indeed improve nutritional care and effectively
correct the problem (25, 26). Routine screening, assessment and
documentation of malnutrition and nutrition-related problems
in patients newly admitted to hospitals is the first step to draw
the attention to the potentially, malnourished patient and a
prerequisite for any nutritional intervention. In addition
practical guidelines and standard protocols for nutrition support
should be implemented in geriatric hospital wards in order to
facilitate adequate treatment. As a prerequisite, nutrition should
be included in basic education and further training of health
care professionals.
In conclusion, this study suggests, that as reported earlier
for the general hospital population also in geriatric patients
the awareness of malnutrition and nutrition-related problems is
generally low. Despite high prevalence rates among geriatric
patients, malnutrition and nutrition-related problems are rarely
recognised and treated. Thus, there is a clear need and high
potential for improvement of nutritional care. Physicians and
nursing staff should be made more sensible towards these
problems as a basis for effective treatment and even better
prevention of malnutrition. Routine screening and practical
guidelines for adequate interventions and nutrition support
should urgently be implemented in geriatric hospital wards in
order to improve nutritional care.
Acknowledgements: The study was partly supported by a grant of Fresenius Kabi (Bad
Homburg, Germany). The sponsor was neither involved in study design, collection,
analysis and interpretation of data, nor in writing of the manuscript or in the decision to
submit the manuscript for publication. DV, CCS and PS were responsible for designing of
the study and drafted the manuscript. CS carried out all measurements and assessments,
performed the data analysis and helped to draft the manuscript. HG participated in
formulating the study design and coordination. All authors read and approved the final
mauscript.
Disclosure of interest: There is no conflict of interest.
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Conference presentation: Parts of the paper were presented at the congress Ernhrung
2007 in Innsbruck, Austria, June 2007.
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