A small survey of seniors at a NC emergency department finds that 16% were malnourished and 60% were either malnourished or at risk. Before sounding the alarm bells, however, it's important to put this limited study into perspective.
More than half of "cognitively intact" seniors who went to the emergency department at University of North Carolina Hospital in Chapel Hill last summer were either malnourished or at risk for it.
That's according to a new study published this month in the online issue of Annals of Emergency Medicine. Specifically, the small sample of 138 patients age 65 and older surveyed across eight weeks in June and July 2013 found that 16% were malnourished and 60% were either malnourished or at risk.
Before sounding the alarm bells, however, it's important to put this limited study into perspective.
"Our study is restricted to a single emergency department in the Southeastern United States," cautions study coauthor Timothy Platts-Mills, MD, an assistant professor of emergency physician at UNC School of Medicine. "That said, I don't think ours is off-the-charts high. It is probably fairly representative and I would be surprised if it's much lower than 6% in any ED, which is what we view as the baseline in any community."
Many of these elderly patients do not fit the stereotype of the destitute recluse with no access to care or the cognitive capacity to know better. For example, 95% of the patients in the survey had a primary care provider, 93% lived in a private residence, 96% had some health insurance, 4% were Medicare/Medicaid dual eligible, 64% had both Medicare and secondary insurance, 69% were white, and 35% had a college education.
And while the findings are high, they actually could be higher because the surveyors, using the Mini Nutritional Assessment Short-Form, filtered out patients who were too ill to respond, or who could not communicate, or who were cognitively impaired or who'd already been discharged.
Citing earlier research that estimates that about 6% of seniors in United States are malnourished, and 30% of hospitalized seniors are malnourished, Platt-Mills says the UNC survey finding "sits pretty nicely in between those two."
There was no prevalence of malnutrition based on the patient gender or education level, or between urban and rural dwellers. More than three-quarters (77%) of the 22 malnourished patients said they'd never before been diagnosed with malnutrition or identified as at risk of malnutrition. The prevalence of malnutrition was higher among people with depression (52%), those residing in assisted living (44%)*, those with difficulty eating (38%), those who had difficulty buying groceries (33%).
"We saw pretty strong associations between people saying they had financial difficulty buying food and being malnourished, and difficulty eating due to dental pain and being malnourished," Platt-Mills says. "Being poor by itself does not mean you are critically ill. Unfortunately poverty is fairly common in the United States and older adults are not excluded from that. Some of the things that leads people to being malnourished are endemic in the population."
Cause and Effect?
Are these elderly patients malnourished because they are ill, or are they ill because they are malnourished? Platt-Mills says that's not clear.
"For some of these patients, their acute illness is unrelated to their malnutrition. For others, the malnutrition is causing their illness. For others, the illness is causing their malnutrition. For at least some patients, the malnutrition appears to be due to financial hardship," he says. "So for these patients the malnutrition is not a result on an illness but rather due to environmental factors -- and may be predisposing them to illness."
"We certainly have older patients who will tell us sometimes I have to choose between medications and getting food. That screams for an intervention. That seems like a choice that older adults should not have to make," he says.
Is there anything that clinicians and administrators at community hospitals around the nation can due to measure the extent of patient malnutrition, and develop a care regimen?
"There are a couple of things," Platt-Mills says. "Sometimes emergency physicians and clinicians are wary of making diagnoses if they don't know how to act on them. Before a hospital institutes a policy for screening all older adults for malnutrition it makes sense to consider the resources that are available in the community."
Identifying local resources such as Meals on Wheels and asking if they have the capacity to expand is a nice start, Platt-Mills says. "That makes it easier to start screening people."
"The other thing to keep in mind is that some of these problems are a little more complicated than just getting food to people," Platt-Mills says. "Loneliness, depression, and dental problems are common among older adults. So, simply dropping off a bag of groceries at the door for someone who is lonely or depressed might not solve the problem. They might not be eating because they feel isolated. Eating is often a social behavior. Then, the question is what additional resources are available to help address loneliness and try to help older adults feel more part of a community."
Practically speaking, emergency physicians and other ED staff would be challenged to make that sort of in-depth assessment given all of their more immediately priorities.
"That is often seen as beyond the reach of physicians and certainly emergency physicians don't spend a long time taking up those issues," Platt-Mills says. "But if we are going to take up the question of health for older adults seriously we have to think about how we can partner with community groups to solve those problems as well."
The United States spends billions of dollars on healthcare, particularly for the elderly. Are we being pound wise and penny foolish? What if some fraction of that money was redirected toward social services that could ensure that seniors are fed properly, or that their homes are safe and clean, and that they have contact the outside world?
"A doctor isn't necessarily the person who is going to solve this particular problem so we need to think about the resources that older adults need to maintain their health," Platt-Mills says.
"What about the idea that 16% of our patients might be taking three blood pressure medications but they didn't even have a bowl of cereal for breakfast this morning? There is a lot to be said about policy changes that could better address that."
*(Platt-Mills says he was surprised by the high prevalence of malnutrition or at risk from seniors in assisted living. "That seems insanely high. I think a lot of people have had that same reaction," he says. "Why are they vulnerable at all? I would say the level of care that occurs in assisted living is pretty variable, and so is the oversight.")
John Commins is the news editor for HealthLeaders.