08 Chen 2001 a Concept Analysis of Malnutrition in the Elderly

NURSING THEORY AND CONCEPT DEVELOPMENT OR ANALYSIS

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 Womens Health Specialty, Yale University School of

Nursing, New Haven, Connecticut, USA

Submitted for publication 27 December 2000

Accepted for publication 27 June 2001

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

50% of hospitalized elderly patients are malnourished

(Nutrition Screening Initiative 1993). Slightly lower preval-

ence 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,

2001 Blackwell Science Ltd 131

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: [email protected]

C H E NC H E N CC.C .C .-H- H., S C H I L L I N GS C H I L L I N G LL.SS . && L Y D E RL Y D E R CC.H . ( 20 01 )H . ( 20 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 significantly to morbidity and mortality in

the elderly. Unfortunately, the concept of malnutrition in the elderly is poorly

defined. The purpose of this paper is to clarify the meaning of malnutrition in the

elderly and to develop the theoretical underpinnings, thereby facilitating commu-

nication regarding the phenomenon and enhancing research efforts.

Scope, sources used. Critical review of literature is the approach used to system-

atically 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 identified. Key wards used for

searching included malnutrition, geriatric nutrition, nutritional status, nutrition

assessment, elderly, ageing, and weight loss.

Conclusions. The definition of malnutrition in the elderly is defined as following:

faulty or inadequate nutritional status; undernourishment characterized by insuf-

ficient 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

Thomas 1999). The variance in this figure 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 defining malnutrition. Table 1 presents

the prevalence studies of malnutrition in the elderly and the

criteria used for defining 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 significant implication world-

wide. 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 malnutri-

tion in the elderly and to develop the theoretical proposi-

tions, thereby facilitating communication regarding the

phenomenon and enhancing research efforts. It was intended

that attributes of malnutrition in the elderly, and its ante-

cedents 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 definition

The review of literature reveals that the definitions of

malnutrition can differ among institutions, disciplines, and

cultures. Keller (1993) notes that malnutrition is an overall

term, encompassing: (1) undernutrition resulting from insuf-

ficient food intake, (2) overnutrition caused by excessive food

intake, (3) specific nutrient deficiencies and (4) imbalance

because of disproportionate intake. The terms malnutrition

and undernutrition, however, tend to be used interchange-

ablely in the literature. Although there are health conse-

quences 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 define

malnutrition in the elderly. The first definition characterizes

malnutrition as any insufficient dietary intake among essen-

tial nutrients. Presumably, an inadequate dietary pattern will

result in malnutrition. With this approach, the researchers

operationally defined malnutrition as dietary intake below

the recommended dietary allowance (RDA) (Walker &

Beauchene 1991, Posner et al. 1994) or the elderly persons

calculated maintenance energy requirements (Sullivan et al.

1999).

The second approach refers to malnutrition as protein-

energy undernutrition (PEU) (or protein-caloric malnutrition,

PCM). Protein-energy undernutrition is the progressive loss

of both lean body mass and adipose tissue resulting from

insufficient 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 (hypoalbu-

minemia), 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 skin-

fold 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 confirmed

by an albumin level less than 3530 g/dL (Morley & Sliver

1994). Kwashiorkor is often precipitated by an acute infec-

tion 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 defining 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 anthropo-

metrics. Some researchers defining 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 defining malnutrition in the elderly.

This makes the diagnosis of malnutrition in the elderly

extremely difficult. The so-called gold standards have

ultimately had an element of fools gold mixed in (Morley

et al. 1998). Malnutrition is a continuum. It becomes clear

C.C.-H. Chen et al.

132 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 36(1), 131142

Table 1 Prevalence studies of malnutrition in the elderly

Reference Setting n Diagnosis criteria Prevalence (%)

Bistrian et al. (1976) Acute Hospital, USA 251 Weight for height

Table 1 (Continued)

Reference Setting n Diagnosis criteria Prevalence (%)

Miller et al. (1996) Inner City Older Black,

USA

400 NSI alike tool 48 High risk

Ritchie et al. (1997) Home-Bound Elders, USA 49 (86% AA) BMI

that a major difficulty in defining malnutrition hinges on

whether it is the process associated with poor dietary intake

or the state an elderly person reaches after being malnour-

ished (Roy 1994). In other words, do you measure risk or

status?

Critical attributes

Attributes are defining characteristics or salient features that

assist in identifying the occurrence of a concept. After

reviewing the literature, five critical attributes emerge, inclu-

ding insufficient dietary intake, muscle wasting, weight loss,

poor appetite, and downward trajectory.

Insufficient dietary intake

Malnutrition is characterized by an insufficient 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 utiliza-

tion of external losses is excessive (Rudman 1987). Some

researchers operationally define 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).

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 bodys 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

identified.

Weight loss

Weight loss per unit of time is believed to be a major

indicator of malnutrition in the elderly (Barrocas et al. 1995).

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 definition

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 invol-

untary, is positively associated with increased mortality

(Wallace et al. 1995). In addition, the ICD9 definition 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).

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 difficult to

correct in the elderly than in younger adults (Fiatarone et al.

1994).

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 identification 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 identified as antecedents

of malnutrition in the elderly.

Nursing theory and concept development or analysis Analysis of malnutrition in the elderly

2001 Blackwell Science Ltd, Journal of Advanced Nursing, 36(1), 131142 135

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

definite effects on nutritional status that become particularly

significant 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 difficult 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, nonsignificant relation-

ships 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 flow, atrophy of mucus membranes and

loss of taste buds (Cooper et al. 1959, Massler 1986).

However, recent investigations indicate there are no such

significant 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 difficulties, poor denti-

tion, ill-fitting dentures, dry mouth, or other symptom that

makes eating uncomfortable are at risk for developing

malnutrition (Saunders 1997). Missing teeth can have

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, medi-

cation, 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 difficult or impossible and resulting in

malnutrition.

Olfaction contributes to nutritional status and food enjoy-

ment by mediating the perception of food odours through the

nostrils (orthonasal route) and food favours through the oral

cavity (retronasal route) (Schiffman 1997). Retronasal olfac-

tory 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 fitting 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 reflect 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 measur-

able 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

C.C.-H. Chen et al.


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 difficult or impossible.

The elderly may decrease social interaction because of the

visual and hearing losses and this may further decrease their

chances of sufficient nutrition intake.

Loss of roles function

Social and environmental losses may also affect nutritional

status in the elderly. The losses in role function accom-

panying retirement and the death or departure of family,

friends, and confidantes is frequently overlooked. Addition-

ally, 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 well-

being of the elderly (Newbern & Krowchuk 1994).

Dependency

When the supports the elderly have relied upon are lost or

diminished in their old age, the elderly may have difficulty in

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 significantly correlated to their

nutritional status (Miller et al. 1996). When the elderly

experience difficult 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

difficulties with one or more activities of daily living (bathing,

dressing, toileting, continence, feeding, mobility). Twenty-

eight percent have difficulty with one or more instrumental

activities of daily activities (shopping, preparing meals,

taking medication, handling finances, etc.). Deficits 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 findings are inconsis-

tent.

Loneliness

Humans are innately social animals. Loneliness is linked to

negative affects, including boredom, restlessness, and unhap-

piness, 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, financial worries, and

malnutrition (Hansson et al. 1990). Walker and Beauchene

(1991) found that loneliness was related to dietary inadequa-

cies 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 under-

stood, a growing body of literature has suggested direct links

between social support and physiological functioning.



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 Beauchenes 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 grie-

ving-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.

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 suscep-

tibility 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 testified 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 benefit 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 conse-

quence of polypharmacy is the risk of nutritional deficiencies

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

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 finding 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 place-

ments, escalate societal costs significantly (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).

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 malnutri-

tion. Cellular immunity, production of specific 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 institution-

alization, 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 under-

standing of healthy development and successful ageing

(Dwyer 1991). The World Health Organizations definition

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).

C.C.-H. Chen et al.


Definition of malnutrition in the elderly

The following definition of malnutrition in the elderly is

derived from the attributes identified in this critical literature

review.

Malnutrition in the elderly: Faulty or inadequate nutri-

tional status; undernourishment characterized by insufficient

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.

Conclusion

It is a sad reflection 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

influence 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 interven-

tion 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 findings 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 prepar-

ation.

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08 Chen 2001 a Concept Analysis of Malnutrition in the Elderly