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.
136 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 36(1), 131142
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.
Nursing theory and concept development or analysis Analysis of malnutrition in the elderly
2001 Blackwell Science Ltd, Journal of Advanced Nursing, 36(1), 131142 137
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.
138 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 36(1), 131142
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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