Abstract
A nutritionally vulnerable older adult has a reduced physical reserve that limits the ability to mount a vigorous recovery in the face of an acute health threat or stressor. Often, this vulnerability contributes to more medical complications, longer hospital stays, and increased likelihood of nursing home admission. We have characterized in this review the etiology of nutritional vulnerability across the continuum of the community, hospital, and long-term care settings. Frail older adults may become less vulnerable with strong, consistent, and individualized nutritional care. Interventions for the vulnerable older adult must take their nutritional needs into account to optimize resiliency in the face of the acute and/or chronic health challenges they will surely face in their life course.
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Bernstein M, Munoz N. Position of the Academy of Nutrition and Dietetics: food and nutrition for older adults: promoting health and wellness. J Acad Nutr Diet. 2012;112(8):1255–77. This position paper outlines distinct nutritional needs of community-dwelling older adults and how to address them.
Agarwal E, Miller M, Yaxley A, Isenring E. Malnutrition in the elderly: a narrative review. Maturitas. 2013;76(4):296–302.
Soenen S, Chapman IM. Body weight, anorexia, and undernutrition in older people. J Am Med Dir Assoc. 2013;14(9):642–8.
Gielen E, Verschueren S, O'Neill TW, Pye SR, O'Connell MD, Lee DM, et al. Musculoskeletal frailty: a geriatric syndrome at the core of fracture occurrence in older age. Calcif Tissue Int. 2012;91(3):161–77.
Fried LP, Ferrucci L, Darer J, Williamson JD, Anderson G. Untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care. J Gerontol A Biol Sci Med Sci. 2004;59(3):255–63.
Shamliyan T, Talley KM, Ramakrishnan R, Kane RL. Association of frailty with survival: a systematic literature review. Ageing Res Rev. 2013;12(2):719–36.
Brewer DP, Catlett CS, Porter KN, Lee JS, Hausman DB, Reddy S, et al. Physical limitations contribute to food insecurity and the food insecurity-obesity paradox in older adults at senior centers in Georgia. J Nutr Elder. 2010;29(2):150–69.
Penn DM, Fischer JG, Sun Lee J, Hausman DB, Johnson MA. High BMI and waist circumference are associated with a high prevalence of comorbidities in older Americans Act programs in Georgia senior centers. J Nutr Health Aging. 2009;13(9):827–32.
Porter KN, Johnson MA. Obesity is more strongly associated with inappropriate eating behaviors than with mental health in older adults receiving congregate meals. J Nutr Gerontol Geriatr. 2011;30(4):403–15.
Johnson MA, Fischer JG, Park S. Vitamin D deficiency and insufficiency in the Georgia Older Americans Nutrition Program. J Nutr Elder. 2008;27(1–2):29–46.
Quigley KK, Hermann JR, Warde WD. Factors associated with Oklahoma Older Americans Act Nutrition Program participants’ ability to shop, cook, and feed themselves. J Nutr Elder. 2005;25(2):69–82.
Porter Starr K, Fischer JG, Johnson MA. Eating behaviors, mental health, and food intake are associated with obesity in older congregate meal participants. J Nutr Gerontol Geriatr. 2014;33(4):340–56.
Lee JS, Fischer JG, Johnson MA. Food insecurity, food and nutrition programs, and aging: experiences from Georgia. J Nutr Elder. 2010;29(2):116–49.
Mathus-Vliegen EM. Obesity and the elderly. J Clin Gastroenterol. 2012;46(7):533–44.
Porter Starr KN, McDonald SR, Bales CW. Obesity and physical frailty in older adults: a scoping review of lifestyle intervention trials. J Am Med Dir Assoc. 2014. A recent scoping review of lifestyle interventions targeted towards obese, frail older adults.
Walker AE. Multiple chronic diseases and quality of life: patterns emerging from a large national sample. Aust Chron Illn. 2007;3(3):202–18.
Seals DR, Melov S. Translational geroscience: emphasizing function to achieve optimal longevity. Aging (Albany NY). 2014;6(9):718–30.
Kennedy BK, Berger SL, Brunet A, Campisi J, Cuervo AM, Epel ES, et al. Geroscience: linking aging to chronic disease. Cell. 2014;159(4):709–13.
Ward BW, Schiller JS. Prevalence of multiple chronic conditions among US adults: estimates from the National Health Interview Survey, 2010. Prev Chron Dis. 2013;10:E65.
Parekh AK, Goodman RA, Gordon C, Koh HK. Managing multiple chronic conditions: a strategic framework for improving health outcomes and quality of life. Public Health Rep. 2011;126(4):460–71.
Luppa M, Sikorski C, Luck T, Ehreke L, Konnopka A, Wiese B, et al. Age- and gender-specific prevalence of depression in latest-life—systematic review and meta-analysis. J Affect Disord. 2012;136(3):212–21.
Djernes JK. Prevalence and predictors of depression in populations of elderly: a review. Acta Psychiatr Scand. 2006;113(5):372–87.
Cabrera MAS, Mesas AE, Garcia ARL, de Andrade SM. Malnutrition and depression among community-dwelling elderly people. J Am Med Direct Assoc. 2007;8(9):582–4.
Williams JA, Sink KM, Tooze JA, Atkinson HH, Cauley JA, Yaffe K, et al. Low 25-hydroxyvitamin D concentrations predict incident depression in well-functioning older adults: the health, aging, and body composition study. J Gerontol A Biol Sci Med Sci. 2014.
Gougeon L. Nutritional predictors of depression in a cohort of community-dwelling elderly Canadians: NuAge cohort. Appl Physiol Nutr Metab. 2014;39(12):1412.
Skarupski KA, Tangney C, Li H, Ouyang B, Evans DA, Morris MC. Longitudinal association of vitamin B-6, folate, and vitamin B-12 with depressive symptoms among older adults over time. Am J Clin Nutr. 2010;92(2):330–5.
Swardfager W, Herrmann N, Mazereeuw G, Goldberger K, Harimoto T, Lanctôt KL. Zinc in depression: a meta-analysis. Biol Psychiatry. 2013;74(12):872–8.
Taylor WD. Depression in the elderly. N Engl J Med. 2014;371(13):1228–36.
Coyle CE, Dugan E. Social isolation, loneliness and health among older adults. J Aging Health. 2012;24(8):1346–63.
Dickens AP, Richards SH, Greaves CJ, Campbell JL. Interventions targeting social isolation in older people: a systematic review. BMC Public Health. 2011;11:647.
Steptoe A, Shankar A, Demakakos P, Wardle J. Social isolation, loneliness, and all-cause mortality in older men and women. Proc Natl Acad Sci U S A. 2013;110(15):5797–801.
Romero-Ortuno R, Casey AM, Cunningham CU, Squires S, Prendergast D, Kenny RA, et al. Psychosocial and functional correlates of nutrition among community-dwelling older adults in Ireland. J Nutr Health Aging. 2011;15(7):527–31.
Hughes G, Bennett KM, Hetherington MM. Old and alone: barriers to healthy eating in older men living on their own. Appetite. 2004;43(3):269–76.
Holwerda TJ, Beekman AT, Deeg DJ, Stek ML, van Tilburg TG, Visser PJ, et al. Increased risk of mortality associated with social isolation in older men: only when feeling lonely? Results from the Amsterdam Study of the Elderly (AMSTEL). Psychol Med. 2012;42(4):843–53.
Bickel G, Nord M, Prince C, Hamilton W, Cook J. Guide to measuring household food security revised. In: U.S. Department of Agriculture FaNS, ed. Alexandria, VA; 2000.
Coleman-Jensen A, Nord M, Singh A. Household food security in the United States in 2012, ERR-155. U.S. Department of Agriculture, Food and Nutrition Service, Economic Research Service 2013.
Ziliak J, Gundersen C. The state of senior hunger in America 2012: an annual report. National Foundation to End Senior Hunger; 2014.
Cook JT, Frank DA. Food security, poverty, and human development in the United States. Ann N Y Acad Sci. 2008;1136:193–209.
Buys DR, Locher JL. Food insecurity and hunger among older adults. In: Bales C, Locher J, Saltzman E, editors. Handbook of clinical nutrition and aging. 3rd ed. New York: Springer Science + Business Media; 2014. p. 147–59. This chapter provides a succint discussion of food inscruity and hunger in the aging population and how to address it.
Alley DE, Soldo BJ, Pagán JA, McCabe J, de Blois M, Field SH, et al. Material resources and population health: disadvantages in health care, housing, and food among adults over 50 years of age. Am J Public Health. 2009;99 Suppl 3:S693–701.
Seligman HK, Laraia BA, Kushel MB. Food insecurity is associated with chronic disease among low-income NHANES participants. J Nutr. 2010;140(2):304–10.
Lee JS, Gundersen C, Cook J, Laraia B, Johnson MA. Food insecurity and health across the lifespan. Adv Nutr Int Rev J. 2012;3(5):744–5.
Holben DH, Pheley AM. Diabetes risk and obesity in food-insecure households in rural Appalachian Ohio. Prev Chron Dis. 2006;3(3):A82.
Klesges LM, Pahor M, Shorr RI, Wan JY, Williamson JD, Guralnik JM. Financial difficulty in acquiring food among elderly disabled women: results from the Women’s Health and Aging Study. Am J Public Health. 2001;91(1):68–75.
Dinour LM, Bergen D, Yeh MC. The food insecurity-obesity paradox: a review of the literature and the role food stamps may play. J Am Diet Assoc. 2007;107(11):1952–61.
Kim K, Frongillo EA. Participation in food assistance programs modifies the relation of food insecurity with weight and depression in elders. J Nutr. 2007;137(4):1005–10.
Stuff JE, Casey PH, Szeto KL, Gossett JM, Robbins JM, Simpson PM, et al. Household food insecurity is associated with adult health status. J Nutr. 2004;134(9):2330–5.
Gao X, Scott T, Falcon LM, Wilde PE, Tucker KL. Food insecurity and cognitive function in Puerto Rican adults. Am J Clin Nutr. 2009;89(4):1197–203.
Lee MR, Berthelot ER. Community covariates of malnutrition-based mortality among older adults. Ann Epidemiol. 2010;20(5):371–9.
Jensen GL. Inflammation as the key interface of the medical and nutrition universes: a provocative examination of the future of clinical nutrition and medicine. JPEN J Parenter Enteral Nutr. 2006;30(5):453–63.
Tappenden KA, Quatrara B, Parkhurst ML, Malone AM, Fanjiang G, Ziegler TR. Critical role of nutrition in improving quality of care: an interdisciplinary call to action to address adult hospital malnutrition. J Acad Nutr Diet. 2013;113(9):1219–37. This article highlights the immediate need for identifying and addressing malnutrition in the hospital setting.
White JV, Guenter P, Jensen G, Malone A, Schofield M. Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). J Acad Nutr Diet. 2012;112(5):730–8.
Corkins MR, Guenter P, DiMaria-Ghalili RA, Jensen GL, Malone A, Miller S, et al. Malnutrition diagnoses in hospitalized patients: United States, 2010. JPEN J Parenter Enteral Nutr. 2014;38(2):186–95.
US Bureau. U.S. Census Bureau: State and County QuickFacts. 2014; http://quickfacts.census.gov/qfd/states/00000.html. Accessed 12 Dec 2014.
Weiss AJ, Elixhauser A. Overview of hospital stays in the United States, 2012. HCUP Statistical Brief #180. Rockville, MD: Agency for Healthcare Research and Quality; 2014.
Col N, Fanale JE, Kronholm P. The role of medication noncompliance and adverse drug reactions in hospitalizations of the elderly. Arch Intern Med. 1990;150(4):841–5.
Creditor MC. Hazards of hospitalization of the elderly. Ann Intern Med. 1993;118(3):219–23.
Fernandez HM, Callahan KE, Likourezos A, Leipzig RM. House staff member awareness of older inpatients’ risks for hazards of hospitalization. Arch Intern Med. 2008;168(4):390–6.
Kaiser MJ, Bauer JM, Ramsch C, Uter W, Guigoz Y, Cederholm T, et al. Frequency of malnutrition in older adults: a multinational perspective using the mini nutritional assessment. J Am Geriatr Soc. 2010;58(9):1734–8.
Mowe M, Bøhmer T, Kindt E. Reduced nutritional status in an elderly population (>70 y) is probable before disease and possibly contributes to the development of disease. Am J Clin Nutr. 1994;59(2):317–24.
Cerri AP, Bellelli G, Mazzone A, Pittella F, Landi F, Zambon A, et al. Sarcopenia and malnutrition in acutely ill hospitalized elderly: Prevalence and outcomes. Clin Nutr. 2014.
Heersink JT, Brown CJ, Dimaria-Ghalili RA, Locher JL. Undernutrition in hospitalized older adults: patterns and correlates, outcomes, and opportunities for intervention with a focus on processes of care. J Nutr Elder. 2010;29(1):4–41.
Buie VC, Owings MF, DeFrances CJ, Golosinskiy A. National hospital discharge survey: 2006 annual summary. Vital Health Stat. 2010;13(168):1–79.
Inoue M, Kinoshita K, Sano F, Kobayashi M, Yasuda S, Sowa T, et al. Perioperative nutritional support with immune-enhancing diet for surgical closure of open thoracic window. Kyobu Geka. 2012;65(7):559–62.
Martindale RG, McClave SA, Taylor B, Lawson CM. Perioperative nutrition: what is the current landscape? J Parenter Enter Nutr. 2013;37(5 suppl):5S–20S. This article provides a detailed and compendious description of preoperative nutritional strategies to improve recovery and reduce adverse outcomes.
Greene KA, Wilde AH, Stulberg BN. Preoperative nutritional status of total joint patients: relationship to postoperative wound complications. J Arthroplasty. 1991;6(4):321–5.
Guo JJ, Yang H, Qian H, Huang L, Guo Z, Tang T. The effects of different nutritional measurements on delayed wound healing after hip fracture in the elderly. J Surg Res. 2010;159(1):503–8.
Foster MR, Heppenstall RB, Friedenberg ZB, Hozack WJ. A prospective assessment of nutritional status and complications in patients with fractures of the hip. J Orthop Trauma. 1990;4(1):49–57.
Cerri AP, Bellelli G, Mazzone A, Pittella F, Landi F, Zambon A, et al. Sarcopenia and malnutrition in acutely ill hospitalized elderly: prevalence and outcomes. Clin Nutr. 2014.
Patel V, Romano M, Corkins MR, DiMaria-Ghalili RA, Earthman C, Malone A, et al. Nutrition screening and assessment in hospitalized patients a survey of current practice in the United States. Nutr Clin Pract. 2014;29(4):483–90.
Graham CL, Ivey SL, Neuhauser L. From hospital to home: assessing the transitional care needs of vulnerable seniors. Gerontologist. 2009;49(1):23–33.
Boling PA. Managing posthospital care transitions for older adults: challenges and opportunities. JAMA. 2014;312(13):1303–4.
Krumholz HM. Post-hospital syndrome–an acquired, transient condition of generalized risk. N Engl J Med. 2013;368(2):100–2.
Locher JL, Wellman NS. “Never the twain shall meet:” dual systems exacerbate malnutrition in older adults recently discharged from hospitals. J Nutr Gerontol Geriatr. 2011;30(1):24–8.
Sahyoun NR, Akobundu U, Coray K, Netterville L. Challenges in the delivery of nutrition services to hospital discharged older adults: the community connections demonstration project. J Nutr Elder. 2009;28(2):127–42.
Sahyoun NR, Anyanwu UO, Sharkey JR, Netterville L. Recently hospital-discharged older adults are vulnerable and may be underserved by the Older Americans Act Nutrition Program. J Nutr Elder. 2010;29(2):227–40.
Kayser-Jones J. Malnutrition, dehydration, and starvation in the midst of plenty: the political impact of qualitative inquiry. Qual Health Res. 2002;12(10):1391–405.
Bell CL, Tamura BK, Masaki KH, Amella EJ. Prevalence and measures of nutritional compromise among nursing home patients: weight loss, low body mass index, malnutrition, and feeding dependency, a systematic review of the literature. J Am Med Dir Assoc. 2013;14(2):94–100.
Pauly L, Stehle P, Volkert D. Nutritional situation of elderly nursing home residents. Z Gerontol Geriatr. 2007;40(1):3–12.
Serrano-Urrea R, Garcia-Meseguer MJ. Malnutrition in an elderly population without cognitive impairment living in nursing homes in Spain: study of prevalence using the Mini Nutritional Assessment test. Gerontology. 2013;59(6):490–8.
Sloane PD, Ivey J, Helton M, Barrick AL, Cerna A. Nutritional issues in long-term care. J Am Med Dir Assoc. 2008;9(7):476–85.
Bell CL, Lee AS, Tamura BK. Malnutrition in the nursing home. Curr Opin Clin Nutr Metab Care. 2015;18(1):17–23.
Cowan DT, Roberts JD, Fitzpatrick JM, While AE, Baldwin J. Nutritional status of older people in long term care settings: current status and future directions. Int J Nurs Stud. 2004;41(3):225–37.
Tamura BK, Bell CL, Masaki KH, Amella EJ. Factors associated with weight loss, low BMI, and malnutrition among nursing home patients: a systematic review of the literature. J Am Med Dir Assoc. 2013;14(9):649–55. A thorough and recent systematic review of studies of malnutrition and weight loss in nursing homes.
Messinger-Rapport BJ, Gammack JK, Little MO, Morley JE. Clinical update on nursing home medicine: 2014. J Am Med Dir Assoc. 2014;15(11):786–801.
Powell LS, Felix HC, Bradway C, Miller E, Heivly A, Fleshner I. Additional research on the cost of caring for obese nursing home residents is critical to maintaining adequate resources in the long-term care industry. J Am Med Dir Assoc. 2010;11(3):222.
Felix HC. Personal care assistance needs of obese elders entering nursing homes. J Am Med Dir Assoc. 2008;9(5):319–26.
Buys DR, Roth DL, Ritchie CS, Sawyer P, Allman RM, Funkhouser EM, et al. Nutritional risk and body mass index predict hospitalization, nursing home admissions, and mortality in community-dwelling older adults: results from the UAB Study of Aging with 8.5 years of follow-up. J Gerontol A Biol Sci Med Sci. 2014;69(9):1146–53.
Aselage M, Amella EJ, Rose SB, Bales CW. Dementia-related mealtime difficulties: assessment and management in the long-term care setting. In: Bales CW, Locher JL, Saltzman ES, editors. Handbook of Clinical Nutrition and Aging. 3rd ed. Springer 2014. This chapter provides a detailed and comprehensive discussion of dementia-related feeding difficultites and their management, including different approaches to careful hand feeding.
Heuberger RA. Artificial nutrition and hydration at the end of life. J Nutr Elder. 2010;29(4):347–85.
Galanos AN, Neff EC, Heuberger RA. What is “optimal nourishment” for older adults at the end of life? A conversation. Interview by Connie W. Bales. J Nutr Elder. 2010;29(4):386–92.
Fischberg D, Bull J, Casarett D, Hanson LC, Klein SM, Rotella J, et al. Five things physicians and patients should question in hospice and palliative medicine. J Pain Symptom Manage. 2013;45(3):595–605.
Hanson LC, Carey TS, Caprio AJ, Lee TJ, Ersek M, Garrett J, et al. Improving decision-making for feeding options in advanced dementia: a randomized, controlled trial. J Am Geriatr Soc. 2011;59(11):2009–16.
Candy B, Sampson EL, Jones L. Enteral tube feeding in older people with advanced dementia: findings from a Cochrane systematic review. Int J Palliat Nurs. 2009;15(8):396–404.
Teno JM, Mitchell SL, Kuo SK, Gozalo PL, Rhodes RL, Lima JC, et al. Decision-making and outcomes of feeding tube insertion: a five-state study. J Am Geriatr Soc. 2011;59(5):881–6.
Committee AGSECaCPaMoC. American Geriatrics Society feeding tubes in advanced dementia position statement. J Am Geriatr Soc. 2014;62(8):1590–3.
Yukawa M, Seel RC. Nutrition at the end of life. In: Bales CW, Locher JL, Saltzman E, editors. Handbook of clinical nutrition and aging. 3rd ed. New York: Springer Science + Business Media; 2014. p. 303–12.
Del Rio MI, Shand B, Bonati P, Palma A, Maldonado A, Taboada P, et al. Hydration and nutrition at the end of life: a systematic review of emotional impact, perceptions, and decision-making among patients, family, and health care staff. Psychooncology. 2012;21(9):913–21.
Yang Y, Brown CJ, Burgio KL, Kilgore ML, Ritchie CS, Roth DL, et al. Undernutrition at baseline and health services utilization and mortality over a 1-year period in older adults receiving Medicare home health services. J Am Med Dir Assoc. 2011;12(4):287–94.
Acknowledgments
The authors acknowledge the support of the National Institutes of Health via training grant support for KPS (AG0000029) and the Duke Claude D. Pepper Older Americans Independence Center (1P30-AG028716). The authors also acknowledge having participated in the following studies:
•National Pork Board: A High-Protein Weight Loss Treatment for Sarcopenic Obesity, November 1, 2013 to October 30, 2015; Connie W. Bales, PhD, RD, Principal Investigator; Shelley R. McDonald DO, PhD, Coinvestigator.
•AMDA Foundation/Pfizer Quality Improvement Award: Development of an Educational Program to Improve the Skills of CNAs to Recognize, Report and Respond to BPSD; Shelley R. McDonald DO, PhD, Principal Investigator, March 1, 2013 to June 1, 2015.
•National Cattlemen’s Beef Association: Does Enhanced Protein Intake Preserve Function and Lean Muscle Mass during Weight Reduction in Frail, Obese Older Adults? (MEASUR-UP); Connie W. Bales, PhD, RD, Principal Investigator; Shelley R. McDonald, DO, PhD, Coinvestigator, February 1, 2012 to September 30, 2014.
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Kathryn N. Porter Starr, Shelley R. McDonald, and Connie W. Bales declare that they have no conflicts of interest.
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Starr, K.N.P., McDonald, S.R. & Bales, C.W. Nutritional Vulnerability in Older Adults: A Continuum of Concerns. Curr Nutr Rep 4, 176–184 (2015). https://doi.org/10.1007/s13668-015-0118-6
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DOI: https://doi.org/10.1007/s13668-015-0118-6