Malnutrition in elderly and senile patients: clinical guidelines

List of Abbreviations

BP – blood pressure

GS – geriatric syndromes

DIC – disseminated intravascular coagulation

FA – fatty acids

GI – gastrointestinal tract

TEN – tube enteral nutrition

IMV – invasive mechanical ventilation

BMI – body mass index

CGA – comprehensive geriatric assessment

TSF – triceps skinfold thickness

ICD – International Classification of Diseases

BW – body weight

AMC – arm muscle circumference

MUAC – mid-upper arm circumference

ARF – acute renal failure

ICU – intensive care unit

PN – parenteral nutrition

PEN – oral enteral nutrition

РКИ – randomized controlled trial

IBW – ideal body weight

FS – frailty syndrome

GFR – glomerular filtration rate

LCE – level of confidence of evidence

LoR – level of conviction of recommendation

ABW – actual body weight

CKD – chronic kidney disease

COPD – chronic obstructive pulmonary disease

HR – heart rate

PEG – percutaneous endoscopic gastrostomy

EFSA – European Food Safety Authority

ESPEN – European Society for Clinical Nutrition and Metabolism

MNA – Mini Nutritional Assessment

MUST – Malnutrition Universal Screening Tool

NRS 2002 – Nutritional Risk Screening 2002

Terms and Definitions

Body mass index is an index used to assess the degree of correspondence between a person's weight and height, and to indirectly evaluate whether weight is insufficient, normal, or excessive. BMI is calculated using the formula: body weight (kg) / height (m)² (kg/m²).

Malnutrition – a state resulting from a dietary pattern in which one or more nutrients are consumed insufficiently or excessively, leading to adverse health effects. Malnutrition implies inadequate (both deficient and excessive) intake of calories, protein, carbohydrates, vitamins, and minerals. In geriatric practice, the term malnutrition is used as a synonym for "protein-energy malnutrition" or undernutrition.

Undernutrition – a pathological condition caused by a mismatch between nutrient intake and expenditure, leading to weight loss and changes in body composition (loss of fat-free mass and active cell mass). This condition results from insufficient intake or impaired digestion/absorption of food, leading to changes in body composition (decrease in lean body mass) and body cell mass, decreased physical and mental functioning, and a worsened prognosis [1].

Parenteral nutrition – a method of delivering nutrients into the body via intravenous infusion.

Nutrition – a physiological act of maintaining human life and health through the intake of food.

Sip feeding – oral consumption of modern artificially formulated liquid nutritional supplements. Can be partial (as a supplement to the main diet) or complete (exclusive consumption of nutritional formulas).

Nutritional state (or status), or nutritional status – a complex of clinical, anthropometric, and laboratory parameters characterizing the condition of human muscle and adipose tissue.

Frailty syndrome – a geriatric syndrome characterized by age-associated decline in physiological reserve and multi-organ function, leading to increased vulnerability of older adults to endo- and exogenous stressors and a high risk of adverse health outcomes, loss of autonomy, and death.

Physical activity – any bodily movement produced by skeletal muscles that requires energy expenditure.

Enteral nutrition – a type of medical or supplementary nutrition using special formulas, in which nutrient absorption (via oral intake, or through a gastric/intestinal tube) occurs physiologically, i.e., through the mucous membrane of the gastrointestinal tract.

Comments on terminology:

In Russian-language literature, there is no universally accepted term for nutritional status. Synonyms used include trophic status, protein-energy status, and nutritional status. For the geriatric syndrome, the term "недостаточность питания" (undernutrition/malnutrition) is used (English: "malnutrition").

ICD-10 features the term "protein-energy malnutrition," which is frequently used in Russian literature as a synonym for undernutrition. Malnutrition is a broader concept than protein-energy malnutrition as it includes macro- and micronutrient deficiencies.

The terms "kwashiorkor," "marasmic kwashiorkor," and "nutritional marasmus" listed under the ICD-10 section "malnutrition" are traditionally not used to characterize the corresponding geriatric syndrome.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Undernutrition is a pathological condition caused by a mismatch between nutrient intake and expenditure, leading to weight loss, altered body composition, decreased physical and mental functioning, and a worsened prognosis. This condition results from insufficient intake or impaired digestion/absorption of food, leading to altered body composition – a decrease in lean body mass and body cell mass [1].

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

Nutrition is a critical factor determining the health status and well-being of older adults. Inadequate nutrition contributes to the progression of many diseases and is considered one of the key links in the multifactorial etiology of sarcopenia and frailty. Older and elderly individuals frequently have a reduced food intake for various reasons, thereby increasing the risk of undernutrition (malnutrition). A strong association has been noted between nutritional disorders and adverse outcomes, particularly in older and elderly patients: increased incidence of infections and stress ulcers, longer hospital stays and higher readmission rates, delayed recovery from acute illness, increased risk of proximal femoral fracture, increased mortality, and decreased quality of life [2,3].

In older and elderly patients, the detection and timely correction of undernutrition play a particularly important role, as malnutrition can lead to the development and/or progression of geriatric syndromes such as frailty, sarcopenia, falls, pressure ulcers, depression, cognitive decline, etc. [1-4].

Fig. 1 Conditions associated with nutritional characteristics [2].

Undernutrition is a multi-etiological pathological condition, the main causes of which are the following factors [1-4]:

Social: poverty, food insecurity, decreased daily activity, social isolation, etc.

Medical: loss of appetite, use of certain medications, prior history of overly restrictive dieting, alterations in taste and olfactory receptors, chewing difficulties, dysphagia, upper extremity dysfunction, limited mobility, acute and chronic diseases/injuries accompanied by inflammatory response and catabolic processes (e.g., malignancy, COPD, congestive heart failure, chronic kidney disease, etc.), pain syndrome, hypermetabolism (pheochromocytoma, hyperthyroidism), etc.

Psychoemotional: depression, cognitive impairment, etc.

One should also bear in mind cases of intentional weight loss or avoidance of certain foods (e.g., cholesterol-lowering dietary restrictions or religious fasting).

1.3 Epidemiology of the Disease or Condition

Undernutrition among older adults, including in developed countries, is very common. According to international studies among community-dwelling older and elderly patients, the prevalence of undernutrition ranges from 5% to 30%. According to Russian studies HRUSTAL, EVCALIPT, and ZABOTA, the frequency of undernutrition in the free-living older population ranges from 0.3% to 9.2% depending on age and region of residence, with 17.3% to 44.3% of older individuals at risk [5].

In elderly care facilities (nursing homes), the prevalence of undernutrition ranges from 16% to 70% depending on the methods used to assess nutritional status and the level of care required. In elderly patients with dementia, depression, and frailty, it can reach 80-90% [5,6].

In intensive care units, 23% to 60% of older and elderly patients suffer from undernutrition, and a high risk of developing it is identified in 22-28% of cases [1-3].

There is a direct association between care dependency and undernutrition [1-3]. The true prevalence of insufficient vitamin and mineral intake in older and elderly individuals is unknown.

1.4 Features of Coding the Disease or Condition

In ICD-10, undernutrition is coded in the following categories:

E43 Unspecified severe protein-energy malnutrition

E44 Moderate and mild protein-energy malnutrition

E46 Unspecified protein-energy malnutrition

1.5 Classification of the disease or condition

Depending on the development mechanism, they are conventionally classified as:

• primary — caused by insufficient nutrient intake;

• secondary — the result of diseases or medications that impair nutrient absorption (Appendix A 3.3)

By severity, moderate and severe malnutrition are distinguished [7]

Table 1. Criteria for assessing the severity of malnutrition

1.6 Clinical presentation of the disease or condition

Symptoms of malnutrition can be general (systemic) or affect specific organs and systems:

• progressive weight loss;

• decreased muscle strength and mass;

• signs of digestive organ atrophy, impaired digestion and absorption processes (maldigestion and malabsorption);

• signs of circulatory hypoxia of organs and tissues;

• signs of immunodeficiency;

• signs of polyhypovitaminosis.

2. Diagnostics, medical indications and contraindications for diagnostic methods

The diagnosis of malnutrition in elderly and senile patients is established based on medical history, physical examination, laboratory tests, and the results of malnutrition screening using recommended tools.

Criteria for the diagnosis of malnutrition:

1) evaluation results using validated screening tools (Table 2) indicate the risk or presence of malnutrition, AND

2) the patient has 1 phenotypic and 1 etiological criterion (Table 3).

Table 2. Validated malnutrition screening tools

Table 3. Phenotypic and etiological criteria for malnutrition

GRC C (LeE 5)

Comments: Each institution providing medical care in the profile of «geriatrics» should have a multidisciplinary team including specialists in nutritional support (a dietitian, a nurse specializing in nutritional therapy). Assessment of nutritional status and implementation of a nutritional support plan in geriatric care institutions and geriatric rehabilitation centers help optimize energy and protein intake levels. The introduction of a screening and treatment protocol for malnutrition in geriatric departments improves the nutritional status of patients, reduces the risk of nosocomial infections and other complications, and helps improve the quality of life of patients with proximal femur fractures, as well as patients with dementia living in nursing homes.

GRC B (LeE 3).

GRC B (LeE 3).

2.1 Complaints and Anamnesis

Appendix A3.1 summarizes the complaints and causes of malnutrition that can be identified during anamnesis collection.

When interviewing the patient, attention should be paid to appetite, impaired sense of smell, touch, preservation of taste sensitivity, presence of difficulties in swallowing, chewing, as well as the presence of signs of depression. It is necessary to interview the patient/relatives/caregivers regarding their ability to eat independently, use cutlery, and clarify the possibility/availability of adequate assistance in purchasing products and cooking.

2.2 Physical Examination

When examining the patient, special attention should be paid to the condition of the oral cavity: preservation of the dentition, condition of the teeth, gums and oral mucosa, presence of dentures and problems with their use.

Anthropometric examination data include:

• measurement of body weight, height, calculation of body mass index (BMI),

• determination of mid-upper arm circumference,

• determination of calf circumference.

During physical examination of a patient with malnutrition, the following signs can be detected:

Body weight: BMI <20 kg/m² if the patient is under 70 years of age, or

BMI <22 kg/m² if the patient is 70 years of age and older.

For individuals of Asian descent: BMI <18.5 kg/m² if the patient is under 70 years of age, or

BMI <20 kg/m² if the patient is 70 years of age and older.

2.3 Laboratory Diagnostics

GRC C (LeE 4).

2.4 Instrumental Diagnostics

Currently, there are no specific instrumental diagnostic methods for establishing a diagnosis of malnutrition. The use of instrumental diagnostic methods is dictated by the clinical necessity to assess etiological factors of malnutrition or for differential diagnosis with other conditions accompanied by a similar clinical picture.

2.5 Other Procedures

The use of other diagnostic methods is dictated by the clinical necessity to assess etiological factors of malnutrition or for differential diagnosis with other conditions accompanied by a similar clinical picture.

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1 General principles of nutritional support for elderly and senile people with malnutrition

Nutritional support for elderly and senile individuals should be part of a multimodal multidisciplinary approach aimed at maintaining an adequate level of food intake, maintaining or increasing body weight, and improving functional status and quality of life. RCTs studying the effects of comprehensive, individually tailored nutritional support interventions in hospitalized elderly people at risk of malnutrition have shown positive effects of individualized interventions on energy and protein intake levels, body weight, reduced incidence of complications, probability of systemic antibacterial drug use, readmissions, and improved functional indicators. In addition, all RCTs revealed an improvement in quality of life in the individualized nutritional support group compared to the standard nutritional support group [23-27].

GRC C (LeE 2)

Comment: The energy requirement of 30 kcal/kg BW is an approximate estimate and a general guide for older adults. This value should be adjusted on an individual basis taking into account various factors such as sex, nutritional status, physical activity, and clinical condition. In addition, the goal of nutritional support, as well as the acceptability and tolerability of nutritional support measures, must be taken into account.

Traditionally, the calculation of daily energy value and protein requirement taking into account physiological body weight and physical activity uses the indicator of ideal/recommended body weight.

For elderly and senile patients, a more individualized approach should be followed.

• If a weight loss or weight gain strategy is chosen, the calculation should be based on the ideal/recommended body weight.

• If a weight maintenance strategy is chosen (the patient's body weight has been stable for a long time, there is no tendency to decrease it, age, existing diseases, level of functional activity, and prognosis are taken into account), the calculation of relevant indicators should be based on the actual body weight.

For elderly and senile patients with normal or excess body weight (BMI <30 kg/m²), energy requirements should be calculated based on actual body weight, since a number of studies have demonstrated better survival rates in patients with a BMI of 27 to 30 kg/m² [34]. In the presence of obesity, elderly and senile patients need a consultation with a dietitian to assess nutritional status, dietary counseling, and, if necessary, draw up an individual weight correction program and individual nutritional recommendations [35].

Liver dysfunction is not considered a contraindication for prescribing specialized nutrition.

GCR A (LEL 2).

Comments: The traditional recommendation for elderly people of any age to consume 0.8 g of protein per kg of body weight per day is currently being discussed in light of accumulated experimental and epidemiological data indicating that older adults may require more protein to optimally preserve lean body mass, vital organ function, and quality of life. According to several expert groups, the daily protein intake for healthy elderly individuals should be at least 1.0 to 1.2 g/kg of body weight. In the presence of acute or chronic diseases accompanied by inflammation (including systemic inflammation in older adults, infections, wounds, pressure ulcers, etc.), the protein requirement may be even higher, reaching 1.2-1.5 g/kg of body weight, and for elderly and senile individuals with serious illnesses, trauma, or malnutrition – up to 2.0 g/kg of body weight per day.

GCR C (LEL 5)

Comments: Norms of physiological requirements for energy and nutrients have been developed for older adults and must be included in their daily diet. Due to the increasing prevalence of gastrointestinal diseases accompanied by reduced nutrient bioavailability (such as in atrophic gastritis and impaired absorption of vitamin B12, calcium, and iron), elderly people have an increased risk of micronutrient deficiency, which should be corrected using dietary supplements and/or medications.

3.2 Enteral nutrition for elderly and senile individuals

Enteral nutrition is the preferred option for nutritional support in patients, as feeding via the gastrointestinal tract is the most physiological method. Enteral nutrition does not require rigorous sterile conditions and does not cause complications associated with parenteral administration procedures. Due to its physiological characteristics, the digestive system itself requires constant intraluminal trophic support.

The main options for enteral nutrition are:

• combined oral nutritional supplements (ONS) with specialized formulas and dietary food;

• ONS only with specialized formulas;

• tube enteral nutrition (TEN): gastric tube (including via stoma), duodenal tube (including via stoma), jejunal tube (including via stoma).

3.2.1 Oral nutritional supplements (ONS)

ONS products have a high calorie and nutrient content and are specifically designed to meet daily nutritional requirements when a normal diet is insufficient.

The variety of ONS products in terms of consistency (liquid, powder, pudding, pre-thickened products), volume, composition (high protein, with dietary fiber), caloric density (from one to three kcal/ml), and taste caters to the needs of different patients. ONS is categorized into high-protein formulas, where protein accounts for >20% of the caloric value, and high-calorie formulas containing >1.5 kcal per ml or g.

GCR B (LEL 2)

Comments: According to research data for community-dwelling older adults who require assistance from social workers and have an increased risk of malnutrition, adding ONS supervised by a clinical dietitian resulted in more intensive weight gain along with a significant reduction in the number of falls. In older adults living in nursing homes, energy intake increased by 30% when snacks were introduced into the diet and by 50% when ONS was used. In malnourished older adults living in nursing homes, the use of ONS led to increased energy and protein intake and improved quality of life compared to a strategy based solely on dietary counseling.

Strategies based on regular dietary recommendations and modifications can be applied over a longer period and are more cost-effective. Therefore, they can be used as a first-line approach in elderly patients with chronic diseases living outside specialized institutions or in nursing homes, resorting to ONS when regular food and food fortification are insufficient to achieve nutritional goals. These differing strategies for supporting adequate food intake should be considered complementary rather than mutually exclusive.

GCR B (LEL 1)

GCR A (LEL 2)

GCR C (LEL 5)

Comments: A systematic review analyzing the efficacy and safety of high-protein ONS (>20% of calories from protein) of any consistency over any period showed that ONS use compared to a traditional diet had diverse effects across various care settings and patient groups, primarily a reduction in the risk of complications and readmissions, and an increase in handgrip strength alongside increased protein and energy intake with a slight decrease in regular food intake and optimization of body weight. High-protein ONS products that provided >400 kcal/day contained an average of 29% protein (20-40%).

GCR A (LEL 1)

Comment: Studies and meta-analyses demonstrate a statistically significant reduction in mortality when ONS is used for at least 35 days compared to shorter periods of use. Malnourished older adults require a higher energy intake to gain weight than younger adults, and the rate of weight and lean mass gain in response to a similar energy intake is lower in older adults. Thus, the nutritional support process must be prolonged to show an effect on nutritional status and other clinical outcomes.

GCR C (LEL 5)

Comments: Adherence to therapy plays an important role in achieving positive outcomes. Clinical studies generally report good adherence rates to oral nutritional supplements (ONS). To maintain adherence to nutritional therapy, the products offered should be tailored to the preferences and needs of patients. Thus, patients with swallowing difficulties should be offered ONS products with a modified consistency. Due to the risk that patients may refuse to consume the same ONS product day after day, treatment adherence must be monitored regularly. Consumption of ONS can be stimulated by providing a variety of choices and alternating options.

GCR B (LEL 2)

Comment: Elderly people often experience gastrointestinal issues, including constipation and diarrhea. The importance of consuming adequate amounts of dietary fiber is emphasized by the fact that it normalizes bowel function, while its intake among elderly and senile patients is typically low.

The adequate daily intake of dietary fiber promoting normal peristalsis in adults of any age is 25 g, which can also be considered a benchmark for elderly and senile individuals. There is no reason to exclude dietary fiber from the diet during enteral nutrition if bowel function is unimpaired. On the contrary, dietary fiber-containing products support normal bowel function during enteral nutrition and are therefore recommended for consumption. Furthermore, patients receiving enteral nutrition should not be deprived of the well-established beneficial metabolic effects of dietary fiber.

Diarrhea may sometimes occur during the intake of ONS formulas. After ruling out acute gastrointestinal diseases, diarrhea may result from improper sip-feeding practices, such as consuming the product too quickly or cold. To reduce the risk of diarrhea, it is recommended to consume the formula at room temperature in small sips over 20-30 minutes. The formula should be stored in a dry place at a temperature of 5-25 °C, avoiding freezing.

3.2.2 Tube enteral nutrition

GCR B (LEL 2)

Comments: The overall efficacy of TEN has been insufficiently studied. Rigorous prospective randomized controlled trials comparing TEN with no TEN are not feasible for ethical reasons. All available data on TEN have been obtained primarily from observational studies. TEN is frequently initiated late in advanced cases marked by substantial weight loss resulting from severe malnutrition, which complicates effective nutritional support. Geriatric patients generally have low survival rates following video-endoscopic gastrostomy. Meta-analysis demonstrated a survival rate of 81% at one month, 56% at six months, and only 38% at one year. However, survival depends heavily on the indications for the intervention and patient characteristics. Several studies have demonstrated some improvement in nutritional status following the initiation of TEN in the elderly. Nevertheless, the effect on functional status, mortality, and quality of life remains unclear.

GCR A (LEL 2)

GCR B (LEL 2)

Comments: Gastrostomy should be considered in individuals with a favorable prognosis and an anticipated long duration of TEN. The four-week period is arbitrary and defined primarily to reduce the number of critically early gastrostomy procedures. If nasogastric tube feeding is well tolerated, it can be extended beyond four weeks. Geriatric patients often poorly tolerate nasogastric tube feeding, and in this age group, the tube is frequently poorly secured, which can lead to displacement. Nevertheless, there is no need to introduce any physical or chemical restrictions in an attempt to prevent tube displacement caused by manipulation or accidental dislodgement. If nasogastric tube displacement occurs despite proper skin fixation, using a nasal bridle can be tried as an alternative.

LOU C (LOCE 1

Comments: Elderly and senile patients with multiple risk factors, such as dementia, urinary tract infection, history of aspiration, diabetes mellitus, hypoalbuminemia, acute-phase illness, hospitalization, pressure ulcers, inability to take food orally, severe nutritional status impairment, low BMI and polymorbidity, have an increased risk of early mortality after PEG, which must be taken into account when making decisions to avoid futile PEG procedures.

For each patient, the risk/benefit ratio must be assessed on an individual basis using the following questions:

1. Can EN improve or maintain the quality of life of this patient?

2. Can EN improve or maintain the functional status of this patient?

3. Can EN increase the life expectancy of this patient?

4. Is the prolongation of life desired by the patient?

5. Do the expected benefits outweigh the risks of tube insertion and EN?

Overall, a low rate of EN complications is reported, but in real-world clinical practice, the complication rate due to nasogastric tube and gastrostomy feeding can be substantial. In this regard, it is recommended to regularly evaluate mortality rates following gastrostomy placement based on data for the specific medical facility or department. If mortality exceeds the figures cited above, it is necessary to review patient selection tactics and technical aspects of the procedure. The condition of patients receiving EN can change very rapidly. Therefore, the indications for and expected benefits of EN must be regularly reassessed. If the ability to take food orally improves significantly, or, conversely, EN no longer provides any benefit, EN should be discontinued. In situations where the effect of EN is difficult to predict, a trial intervention for a specified period with achievable, recordable goals can be recommended. In particular, patients with severe dementia have an unfavorable risk-benefit ratio for EN, and therefore EN is generally not recommended.

LOU C (LOCE 4)

Comments: EN is a procedure aimed at prolonging life. If prolonging life is no longer a desired goal, the patient's quality of life must be assessed individually. This typically applies to palliative care cases. Such patients should be offered their favorite food and drink orally in the amounts they request. This approach is most commonly described by the term "comfort feeding".

GCR C (LEL 5)

Comments: Most patients on tube feeding can consume small amounts of food and fluids orally. In the presence of dysphagia, a specialist must determine the consistency of food and fluids that can be swallowed safely by the patient. For this purpose, specialized modified-consistency enteral nutrition formulas should be used, which are specifically designed for assessing the degree of dysphagia and ensuring safe oral feeding in patients with swallowing disorders. Oral intake of a safe consistency should be encouraged, as it leads to sensation formation and swallowing reflex training, thereby improving quality of life and oropharyngeal clearance. It should be borne in mind that even patients with dysphagia and a restriction on oral intake are forced to swallow more than 500 ml of saliva per day, which in itself is a risk factor for aspiration pneumonia. It is hypothesized that aspiration pneumonia is mainly caused by bacteria from aspirated saliva rather than the saliva itself or the minimal amount of ingested food. Nevertheless, the issue of oral intake safety must be addressed on an individual basis, taking into account the degree of dysphagia, the presence or absence of a protective cough reflex, and cough strength.

LOU C (LOCE 4)

3.2.3 Feeding via percutaneous gastrostomy

LoR C (LEL 4)

3.2.4 Parenteral nutrition

GCR C (LEL 5)

LoR B (LEL 3)

Comments: Refeeding syndrome is associated with a potential risk for malnourished patients with electrolyte disturbances. Possible consequences include volume overload, redistribution of phosphates, potassium, and magnesium, hypophosphatemia, muscle weakness, anemia, and ultimately organ failure and increased mortality risk. Refeeding syndrome can develop with any type of active nutrition: oral, enteral, and parenteral [10]. Sudden cardiac death may occur in 20% of patients. Criteria for refeeding syndrome range from decreased serum concentrations of phosphates or any electrolyte to a combination of electrolyte disturbances and clinical symptoms (e.g., peripheral edema, acute hypervolemia, organ dysfunction). Known risk factors for refeeding syndrome include reduced BMI (BMI <18 kg/m²), significant unintentional weight loss (>10-15% of body weight over the last 3-6 months), last meal several days ago, low plasma concentrations of magnesium, potassium, or phosphates prior to feeding, medications (diuretics, insulins and their analogues, chemotherapy), and a history of drug or alcohol abuse. These risk factors are widespread among hospitalized elderly individuals. For the same patient group, a significant overlap has been established between the risk of malnutrition determined by common screening tools and the risk of refeeding syndrome, suggesting that in elderly individuals with malnutrition or at risk of malnutrition

Special attention should be paid to nutritional therapy in the first 72 h, which generally needs to be initiated early but advanced slowly along with careful monitoring of clinical signs and blood levels of glucose, inorganic phosphorus, total magnesium, potassium, and thiamine. Additional studies are justified in the elderly, especially given the high prevalence of renal dysfunction in this age group.

The risk of refeeding syndrome must be taken into account.

Clinical manifestations of refeeding syndrome:

Cardiovascular system: heart failure (exertional dyspnea, edema), arrhythmia, conduction disorders, ventricular fibrillation, sudden death

Respiratory system: tachypnea, respiratory muscle weakness, mechanical ventilation dependence

Nervous system: weakness, ataxia, tremor, paresthesia, seizures, Wernicke's encephalopathy, delirium, depressed level of consciousness (up to coma), Guillain-Barré syndrome, cerebral edema

Digestive system: nausea, vomiting, early satiety, epigastric fullness and a splashing sound, flatulence, constipation, acute liver failure

Musculoskeletal system: muscle weakness, myalgia, systemic rhabdomyolysis, osteomalacia

Hematopoietic system: thrombocytopenia, disseminated intravascular coagulation (DIC)

Preventive measures for the development of refeeding syndrome include:

• Monitoring of clinical parameters:

  • Pulse assessment.

  • Blood pressure measurement on peripheral arteries.

  • Determination of urine output.

• Laboratory monitoring:

  • Assaying blood ionized magnesium levels.

  • Assaying serum total magnesium levels.

  • Study of blood potassium level.

  • Assaying blood inorganic phosphorus levels.

  • Study of blood urea level.

  • Study of blood creatinine level.

  • Assaying blood glucose levels.

  • Determining blood aspartate aminotransferase activity.

  • Determining blood alanine aminotransferase activity.

  • Assessing acid-base balance and blood gases;

• In case of a high risk of refeeding syndrome, feeding should be started slowly at a caloric intake of 5-10 kcal/kg/day; if tolerated, the caloric intake should be increased gradually over several days to 25-30 kcal/kg/day under the control of blood levels of inorganic phosphorus, total magnesium, and potassium (in patients with normal or reduced BMI, actual body weight should be used for calorie calculation, and ideal body weight in obesity) [10];

• The amount of protein at the start of feeding should be 50% of the calculated requirement (with 1.2-1.5 g/kg body weight/day taken as 100%); 20-30% of total calories should come from protein, 50-60% from carbohydrates, and 15-25% from fats.

3.3 Special categories of patients

3.3.1 Patients with proximal femur fractures

Elderly individuals with proximal femur fractures who have undergone orthopedic surgery are generally at risk of malnutrition due to loss of appetite and immobilization resulting from trauma and surgery. Voluntary oral intake in the postoperative period is often significantly below the required level, and consequently, situations of rapid deterioration of nutritional status, delayed recovery, and rehabilitation are not uncommon.

GCR B (LEL 2)

GRL 2 (LEL C)

Comment: Multicomponent interventions include nutritional support measures, geriatric assessment and subsequent rehabilitation, staff training, a team approach, individual treatment planning, active prevention, and the detection and treatment of postoperative complications during hospitalization. Nutritional support measures include the assessment of nutritional status and food intake, the provision of protein-enriched foods, and supplemental protein shakes.

3.3.2 Patients with delirium or at risk of developing it

GRL A (LEL 1)

3.3.3 Patients with pressure ulcers or at risk of developing them

GRL A (LEL 1)

GRL A (LEL 1)

3.3.4 Patients with dysphagia

LoR B (LEL 3)

Comments: due to difficulties with food and medication intake in patients with dysphagia, it is necessary to provide them with the most convenient food and liquid consistency/texture (cream, yogurt, nectar, etc.) for the correction and prevention of malnutrition.

3.3.5 Patients with renal impairment

GCR C (LEL 5)

3.3.5 Patients with overweight and obesity

GRL B (LEL 2)

Comment: overweight is defined as a BMI of 25 to <30 kg/m², and obesity as a BMI ≥30 kg/m² regardless of age.

Due to changes in body composition and a decrease in height with aging in older adults, the reliability of BMI as an indicator of overweight and obesity is reduced. Moreover, there is growing evidence that the pattern of fat distribution in the body, rather than its amount, plays a more important role in terms of mortality, cardiovascular and metabolic risk, and even functional status. To date, no consensus has been reached regarding the method for assessing health risks associated with obesity in older adults, and the role of BMI, overweight, and obesity remains highly controversial. Older adults with overweight/obesity and malnutrition have a significantly lower risk of death than underweight patients. In patients with overweight/obesity, it is desirable to maintain a stable body weight [1].

In addition, weight loss, whether intentional or not, increases age-related muscle mass loss and, consequently, the risk of sarcopenia, frailty, functional decline, fractures, and malnutrition. After a period of weight-loss dieting, weight regain is frequently observed, predominantly at the expense of fat mass rather than lean tissue mass. Thus, repeated cycles of weight loss and regain, the so-called "weight cycling," can contribute to the development of sarcopenic obesity (reduced muscle mass with excess fat mass). Therefore, and also to prevent progressive weight gain up to obesity, it is desirable for older adults with overweight to maintain a stable body weight. A sound strategy for maintaining stable body weight and preventing obesity consists of combining a balanced, wholesome diet with adequate calorie and protein content and physical activity, preferably even in the form of exercise.

GRL B (LEL 2)

Comment: In older adults, obesity, especially BMI ≥35 kg/m², increases metabolic and cardiovascular risks, as well as the risk of mobility restriction and frailty development, particularly in the presence of pre-existing pronounced muscle mass loss. Current expert recommendations on weight loss in older adults primarily concern cases of obesity combined with comorbidities and associated adverse health effects. In these cases, positive effects of unintentional weight loss, partly combined with exercise, have been reported regarding orthopedic problems, cardiovascular and metabolic risk, insulin sensitivity, chronic inflammation, and functional limitations. On the other hand, due to the potential adverse consequences of weight loss in old age caused by the loss of lean mass, the decision regarding the need for weight loss should always be made on an individual basis. It should be based on a careful assessment of the potential risks and benefits of the intervention in light of functional resources, metabolic risk, comorbidities, patient preferences and priorities, and expected quality-of-life outcomes. If a decision is made against weight loss, the emphasis should be on maintaining a stable body weight and preventing an increase in obesity severity.

GRL B (LEL 2)

Comment: If weight loss is deemed appropriate, this process should be approached with particular care. Interventions effective in young people cannot be extrapolated to older adults with reduced muscle mass and frailty. To prevent muscle mass loss and achieve slow weight loss in older adults, dietary measures should include a balanced diet generally recommended for older adults, combined with as moderate a calorie restriction as possible (daily calorie intake approximately 500 kcal less than the estimated requirement and at least 1000–1200 kcal), aimed at a weight loss of 0.25–1 kg per week (~5–10% of baseline body weight after six weeks or more), while maintaining a protein intake of at least 1 g/kg of body weight per day and preserving muscle mass, along with an adequate micronutrient intake.

GRL B (LEL 2)

Comment: When managing weight loss in elderly individuals, it is important to ensure that the loss of excess fat mass is not accompanied by a loss of muscle mass. To achieve this, dietary interventions should ideally be combined with a carefully designed trainer-supervised exercise program in addition to increasing daily physical activity. Weight loss interventions in older adults with functional impairments and multiple comorbidities should be conducted with extreme caution and under close monitoring.

3.4 Dehydration in elderly and senile patients

Dehydration is associated with a reduction in the body's water (fluid) reserves. Causes include: inadequate fluid intake (low-intake dehydration), excessive fluid loss (bleeding, vomiting, diarrhea, and other conditions leading to hypovolemia), or both factors (combined dehydration). Low-intake dehydration is a state of water deficit that leads to the loss of intracellular and extracellular fluid and an increase in osmolality in both compartments (intracellular and extracellular). Hypovolemia develops due to the excessive loss of fluid and electrolytes (especially sodium and sometimes other elements); initially, extracellular fluid is lost, while blood osmolality remains normal or decreases.

GCR C (LEL 5)

Comment: Individual fluid requirements depend on energy expenditure, water losses, and renal function; therefore, individuals with a higher body weight have a higher fluid requirement. Increased fluid losses due to fever, diarrhea, vomiting, and severe bleeding must also be replenished with additional fluid intake.

GCR C (LEL 5)

Comment: Hydrating beverages include water, sparkling water, flavored water, hot or cold tea, coffee, milk and milk-based drinks, fruit juices, soups, sports drinks or sodas, and smoothies. It is a common belief that maintaining body hydration requires drinking plain water, but this is not the case. Beverages should be chosen taking into account the preferences of elderly people as well as water content and nutritional composition; therefore, in certain circumstances, milk drinks, fruit juices and smoothies, high-calorie and fortified drinks are more preferable. Despite concerns about the dehydrating effects of caffeine and alcohol, evidence suggests that coffee does not cause dehydration, nor do alcoholic beverages with an alcohol content of up to 4%. In terms of hydrating potential, most non-alcoholic beverages such as hot or cold tea, coffee, fruit juice, sparkling water, and soft drinks are very similar to water. Consuming a variety of beverages and those preferred by older adults achieves a hydrating effect and is more enjoyable than drinking plain water alone.

GCR C (LEL 5)

Comment: The causes of low-intake dehydration in elderly individuals are diverse and interrelated. As people age, two primary physiological (and protective) responses to excessively low fluid intake—thirst and primary renal urine concentration—become blunted, and total body water decreases, resulting in a reduced fluid reserve. Many older adults use medications, such as diuretics and laxatives, which increase the body's fluid losses. Frailty syndrome is a risk factor for dehydration. The risk of dehydration increases with the accumulation of other geriatric syndromes: individuals with memory impairments may forget to drink because they do not feel thirsty; older adults often reduce fluid intake due to urinary incontinence (and fear of incontinence) and difficulty using the restroom; as social isolation increases, the habit of drinking beverages socially is lost and, consequently, fluid intake decreases; swallowing disorders and dysphagia are physical limitations to fluid intake. Elderly individuals with low-intake dehydration have less favorable outcomes than patients with proper fluid balance.

GCR C (Leveled Evidence 3)

Comment: Clinical assessment of dehydration is often inaccurate in elderly individuals; therefore, the primary indicator of fluid balance is blood osmolality (osmolarity). When fluid intake is low, blood osmolality (osmolarity) increases. Elevated osmolality (osmolarity) is the main physiological trigger for protective mechanisms (such as thirst and enhanced renal urine concentration). In cases of extracellular fluid loss (hypovolemia) due to diarrhea, vomiting, or renal sodium wasting, blood osmolality (osmolarity) remains within the normal range or decreases. If blood osmolality (osmolarity) measurement is unavailable for low-intake dehydration screening, the following formula is used: blood osmolarity = 1.86 × (Na+ + K+) + 1.15 × glucose + urea + 14 (all in mmol/L), threshold level >295 mmol/L (sensitivity 85%, specificity 59%) [140].

GCR C (Leveled Evidence 3)

GCR C (LEL 5)

GRL B (LEL 2)

Comment: Intravenous infusions are the method of choice for severe dehydration, the need for large volume replacement, or the necessity of maintaining intravenous access for medication or nutritional formula administration. Parenteral hydration therapy should always be considered a medical procedure, and its benefits and risks must be carefully weighed.

GCR C (Leveled Evidence 5)

GCR C (LEL 5)

4. Medical Rehabilitation and Sanatorium-Resort Treatment

The choice of rehabilitation method depends on the underlying pathology causing malnutrition.

5. Prevention and Dispensary Observation

GCR B (LEL 2)

Comments: As one of several strategies to stimulate adequate food intake in malnourished elderly people or those at risk of malnutrition, it is necessary to raise awareness and knowledge levels of formal and informal caregivers on nutritional issues through dietary education. It is preferable that information and training be provided by a nutrition expert (e.g., a clinical nutritionist/dietitian).

GCR A (LEL 2)

Comments: As one of several strategies to support adequate food intake, it is recommended to raise awareness and nutritional knowledge among elderly people with malnutrition or at risk of it through information and education. If caregivers are involved in addressing nutritional issues, for example in patients with cognitive impairment, they should also be included in the training process. It is preferable that information and training be provided by a nutrition expert (e.g., a clinical nutritionist/dietitian).

Level of Evidence A (Grade of Recommendation 2)

GCR B (LEL 2)

Comment: Food fortification (or dietary enrichment) using natural foods (e.g., vegetable oil, cream, butter, eggs) or special food supplements (e.g., maltodextrin, dry protein composite mixture) allows increasing the caloric and protein content of foods and beverages and, consequently, increasing their intake while consuming the same amount of food.

Level of Evidence A (Grade of Recommendation 3)

Comment: Dietary restrictions are one of the potential causes of malnutrition, as they limit food choices and reduce the pleasure of eating, thereby being associated with the risk of restricted food intake. Due to the risk of malnutrition, further studies on the effects of restrictive diets in the elderly are unlikely to be conducted, and standard clinical practice consists in mitigating dietary restrictions for elderly people to reduce the risk of malnutrition and associated losses of fat-free mass and functional capabilities.

Level of Evidence B (Grade of Recommendation 2)

Comment: Many elderly people have a limited ability to eat and drink independently due to functional and cognitive impairments. They may require various types of assistance, ranging from seating at the table and verbal prompts to direct physical help (e.g., bringing food and beverages to the mouth). Providing feeding assistance to elderly people unable to eat independently and living at home can have a positive impact on food intake.

GCR C (LEL 5)

Comment: Environmental factors play an important role in creating a proper atmosphere during meals and include the dining location, furniture and table companions, ambient sounds, smells, temperature and lighting, accessible placement of food on the table, portion sizes, and food appearance. These factors play an important role during meals and can be modified to stimulate adequate food intake in people experiencing eating difficulties. Organizing family-style meals accompanied by soothing music can have a positive effect on food and fluid intake in people with dementia.

Level of Evidence A (Grade of Recommendation 2)

Comment: Eating is a social act, and it has been proven that shared meals stimulate food intake, including in the elderly. Nevertheless, elderly people living alone or in nursing homes often refuse company and conversation during meals. Observational studies have shown that home-dwelling elderly people who ate in company had a significantly higher calorie intake compared to those who ate alone. A higher calorie intake was also observed in hospitalized elderly patients who ate in the dining room compared to those who ate in their rooms. The stimulating effect of shared meals appears to depend on the number of table companions and their relationship: the more people present at the table and the better these people know each other, the more food is consumed. People generally feel more relaxed and comfortable in the company of familiar people. As a consequence, they stay at the table longer and continue eating throughout this time, which contributes to increased food intake. Moreover, a direct behavioral effect is assumed, whereby people adjust their eating behavior to match that of their table companions. This effect is most pronounced in elderly people with cognitive impairments who may avoid meals or forget about them and who can be stimulated to eat by other people.

Level of Evidence A (Grade of Recommendation 2)

Comments: Home-delivered meals, or hot meal delivery, is a good option for elderly people living at home who are unable to shop and cook independently. Using this service allows elderly people to continue living in their own homes while maintaining an adequate level of food intake. The meal delivery service may be particularly useful during the post-discharge period when the patient is still in the recovery phase and has limited activity.

6. Organization of Medical Care

Indications for hospitalization in a medical organization

1) moderate and severe malnutrition;

2) the patient's condition that makes it impossible to provide adequate nutritional and hydration support at home and in an outpatient setting.

Indications for patient discharge from a medical organization

1) improvement of the patient's nutritional status

7. Additional Information

Malnutrition is one of the key geriatric syndromes associated with an unfavorable prognosis regarding the autonomy and life expectancy of elderly and senile individuals. The prevention of malnutrition, identification and correction of its risk factors, and the correction of malnutrition using modern strategies are crucial tasks in implementing a multidisciplinary approach to medical care for elderly and senile patients.

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

Working Group Co-Chairs

Tkacheva O.N. – Corresponding Member of the Russian Academy of Sciences, Doctor of Medical Sciences, Professor, Director of the Russian Gerontology Clinical Research Center, Pirogov Russian National Research Medical University of the Russian Ministry of Health, Head of the Department of Aging Diseases, Pirogov Russian National Research Medical University of the Russian Ministry of Health, President of the Russian Association of Gerontologists and Geriatricians.

Tutelyan V.A. – Academician of the Russian Academy of Sciences, Doctor of Medical Sciences, Professor, Scientific Advisor of the Federal Research Center of Nutrition, Biotechnology and Food Safety, Head of the Department of Food Hygiene and Toxicology at the Institute of Professional Education, I.M. Sechenov First Moscow State Medical University of the Russian Ministry of Health (Sechenov University), Union of Dietitians, Nutritionists and Food Industry Specialists.

Shestopalov A.E. – Doctor of Medical Sciences, Professor, Professor of the Department of Anesthesiology and Emergency Medicine, Russian Medical Academy of Continuous Professional Education (RMACPE), Vice-President of the National Association of Clinical Nutrition and Metabolism.

Working Group Members

Kotovskaya Y.V. – Doctor of Medical Sciences, Professor, Deputy Director for Research at the Russian Gerontology Clinical Research Center, Pirogov Russian National Research Medical University of the Russian Ministry of Health, Member of the Russian Association of Gerontologists and Geriatricians.

Starodubova A.V. – Doctor of Medical Sciences, Associate Professor, Deputy Director for Scientific and Clinical Work at the Federal Research Center of Nutrition, Biotechnology and Food Safety, Professor of the Department of Faculty Therapy, Pirogov Russian National Research Medical University of the Russian Ministry of Health, Professor of the Department of Dietology and Nutrition, RMACPE of the Russian Ministry of Health, Union of Dietitians, Nutritionists and Food Industry Specialists.

Pogozheva A.V. – Doctor of Medical Sciences, Professor, Leading Researcher at the Federal Research Center of Nutrition, Biotechnology and Food Safety, Union of Dietitians, Nutritionists and Food Industry Specialists.

Ostapenko V.S. – Candidate of Medical Sciences, Associate Professor of the Department of Aging Diseases, Faculty of Continuous Professional Education, Pirogov Russian National Research Medical University of the Russian Ministry of Health, Member of the Russian Association of Gerontologists and Geriatricians.

Runikhina N.K. – Doctor of Medical Sciences, Deputy Director for Geriatrics at the Russian Gerontology Clinical Research Center, Pirogov Russian National Research Medical University of the Russian Ministry of Health, Professor of the Department of Aging Diseases, Pirogov Russian National Research Medical University of the Russian Ministry of Health, Member of the Russian Association of Gerontologists and Geriatricians.

Sharashkina N.V. – Candidate of Medical Sciences, Associate Professor of the Department of Aging Diseases, Faculty of Continuous Professional Education, Pirogov Russian National Research Medical University of the Russian Ministry of Health, Member of the Russian Association of Gerontologists and Geriatricians.

Ivannikova E.V. – Candidate of Medical Sciences, Assistant Professor of the Department of Aging Diseases, Faculty of Continuous Professional Education, Pirogov Russian National Research Medical University of the Russian Ministry of Health, Member of the Russian Association of Gerontologists and Geriatricians.

Merkusheva L.I. – Candidate of Medical Sciences, Researcher at the Laboratory of Age-Related Metabolic and Endocrine Disorders, Russian Gerontology Clinical Research Center, Pirogov Russian National Research Medical University of the Russian Ministry of Health, Member of the Russian Association of Gerontologists and Geriatricians.

Balaeva M.M. – Geriatrician, Junior Researcher at the Laboratory of General Geriatrics, Russian Gerontology Clinical Research Center, Pirogov Russian National Research Medical University of the Russian Ministry of Health, Member of the Russian Association of Gerontologists and Geriatricians.

Varaeva Y.R. – Researcher at the Pirogov Russian National Research Medical University of the Russian Ministry of Health, Endocrinologist, Union of Dietitians, Nutritionists and Food Industry Specialists.

Gerasimenko O.N. – Doctor of Medical Sciences, Professor of the Department of Hospital Therapy and Medical Rehabilitation with a Cycle of Clinical Dietology and Nutrition, Novosibirsk State Medical University, Chief Freelance Dietitian of the Novosibirsk Region, Member of the Russian Association of Gerontologists and Geriatricians.

Gorobey A.M. – General Practitioner, Geriatrician, Dietitian at Hospital for War Veterans No. 3, Assistant Professor of the Department of Hospital Therapy and Medical Rehabilitation, Novosibirsk State Medical University, Member of the Russian Association of Gerontologists and Geriatricians.

Livantsova E.N. – Researcher at the Pirogov Russian National Research Medical University of the Russian Ministry of Health, Dietitian, Union of Dietitians, Nutritionists and Food Industry Specialists.

Shpagina L.A. – Doctor of Medical Sciences, Professor, Head of the Department of Hospital Therapy and Medical Rehabilitation, Novosibirsk State Medical University of the Russian Ministry of Health, Chief Physician of City Clinical Hospital No. 2, Honored Doctor of the Russian Federation, Member of the Russian Association of Gerontologists and Geriatricians.

Conflict of interest: all Working Group members have confirmed no financial support / conflicts of interest to disclose.

The draft clinical guidelines were available for public discussion on the Public Discussion Portal for Clinical Guideline Drafts https://portalcr.minzdrav.gov.ru from August 5, 2022, to September 4, 2022.

Appendix A2. Methodology for Developing Clinical Guidelines

The clinical guidelines were developed by expert specialists of the Russian Association of Gerontologists and Geriatricians, the National Association of Clinical Nutrition and Metabolism, and the Union of Dietitians, Nutritionists and Food Industry Specialists.

This version is a revision of the 2020 clinical guidelines "Malnutrition in Elderly and Senile Patients".

The clinical guidelines were based on the following resources and documents:

Cederholm T, Barazzoni R, Austin P, Ballmer P, Biolo G, Bischoff SC, Compher C, Correia I, Higashiguchi T, Holst M, Jensen GL, Malone A, Muscaritoli M, Nyulasi , Pirlich M, Rothenberg E, Schindler K, Schneider SM, de van der Schueren MA, Sieber C, Valentini L, Yu JC, Van Gossum A, Singer P. ESPEN guidelines on definitions and terminology of clinical nutrition. Clin Nutr. 2017 Feb;36(1):49-64.

Volkert D, Beck AM, Cederholm T, Cruz-Jentoft A, Goisser S, Hooper L, Kiesswetter E, Maggio M, Raynaud-Simon A, Sieber CC, Sobotka L, van Asselt D, Wirth R, Bischoff SC. ESPEN guideline on clinical nutrition and hydration in geriatrics. ClinNutr. 2018 18. pii: S0261-5614(18)30210-3.

Cederholm T., Jensen G.L., Correia M.I.T.D., Gonzale M.C., Fukushima R., Higashiguchi T., et al, 2, GLIM Core Leadership Committee, GLIM Working Group. GLIM criteria for the diagnosis of malnutrition - A consensus report from the global clinical nutrition community. Clinical Nutrition 2019; 38 : 1e9.

Sources for recent updates included journal publications in reputable peer-reviewed journals indexed in Russian and international citation databases.

Target audience for these clinical guidelines:

1. Geriatrician in medical organizations providing outpatient and inpatient care;

2. General therapist in medical organizations providing outpatient and inpatient care;

3. General practitioner (family physician);

4. Dietitian;

6. Anesthesiologist-Resuscitator;

7. Clinical Pharmacologist;

8. Gastroenterologist;

9. Endocrinologist.

Level of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)

Scale for assessing levels of evidence (LoE) for prevention, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, therapeutic, and rehabilitative interventions)

Scale for assessing levels of recommendation grades (RG) for prevention, diagnostic, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, diagnostic, therapeutic, and rehabilitative interventions)

Procedure for updating clinical guidelines

Clinical guidelines are updated once every 3 years, taking into account new Russian and international data on the epidemiology of disease forms, diagnostic methods and tactics, pharmacological treatment options, and indications for surgical interventions.

Appendix A3. Reference Materials

Clinical Guidelines CR613 «Geriatric Asthenia»

Methodological Recommendations MR 2.3.1.2432-08

Appendix A3.1 Potential causes of malnutrition and possible interventions

Appendix A3.2 Daily physiological requirements for energy and nutrients in individuals over 60 years of age

[Source: Methodological Recommendations MR 2.3.1.2432-08]

Appendix A3.3 Examples of medications that may lead to drug-induced malnutrition

[Pervertsev AP, Tkacheva ON, Kotovskaya YV, Ostroumova OD. Malnutrition syndrome in elderly patients as a complication of pharmacotherapy: a clinical pharmacologist's perspective. Safety and Risk of Pharmacotherapy. 2019;7(1):23–30. https://doi.org/10.30895/2312-7821-2019-7-1-23-30]

Appendix B. Physician Action Algorithms

Appendix C. Patient Information

Malnutrition significantly worsens the quality of life in elderly individuals, reducing physical activity levels and slowing recovery from illnesses. A wide range of causes of malnutrition in old age has been described. For instance, a quarter of people over 65 lose the ability to perceive one of the four basic tastes (sweet, bitter, salty, sour). Reduced sensitivity to food odors and flavors leads to decreased appetite.

Key factors worsening nutritional status in old age

• Living alone (especially for those who previously lived with family and did not cook for themselves);

• Inability to cook independently or purchase groceries (typically prevalent among men);

• Memory impairment;

• Physical limitations preventing a person from going to the store, cooking, or eating;

• Oral cavity and gastrointestinal disorders. Discomfort or pain during or after meals, changes in appetite;

• Loss of food taste;

• Medicines taken by the individual that may cause side effects such as nausea, decreased appetite, or impaired absorption of certain vitamins or minerals;

• Economic factors (insufficient funds or food not being a priority);

• Reliance on caregivers or other family members (or society) directly responsible for grocery shopping and meal preparation that does not meet the individual's taste preferences;

• Depression, low mood, apathy, loss of interest in life and socializing;

General principles of nutrition in old age

IMPORTANT!

• Prepare meals taking into account the preferences and desires of the elderly person.

• Create a welcoming and friendly atmosphere during meals.

Please note

• If your weight remains stable and normal and you feel well, you can continue with your usual diet, maintaining the same food volume and composition.

• Concomitant long-standing illness may lead to nutritional deficiencies. In such cases, it is necessary to increase food intake and modify its qualitative composition. A lack of adequate nutrition poses a risk of disease progression and complications.

How to suspect the development of malnutrition?

To suspect the development of malnutrition, you need to monitor your weight. Weigh yourself in the morning, on an empty stomach, after using the restroom. It is advisable to weigh yourself at least once every 3 months.

If your body weight has decreased by 5% or more over 6 months, or by 10% over a period exceeding 6 months (for example, for a 70 kg person, a loss of >3.5 kg in 6 months or >7 kg in >6 months), this may indicate the development of malnutrition and requires identifying the causes—be sure to inform your attending physician.

Information on basic food composition and some cooking recommendations

Proteins

• The recommended protein intake in old age is 1.2–1.5 g per kg of body weight per day.

• The optimal ratio of animal to plant proteins is 1:1.

• Among animal proteins, preference should be given to fish and dairy products, and when choosing meat, to lean varieties (beef, veal, rabbit, turkey, horse meat, chicken).

  Meat and meat by-products are rich in purine bases—a source of uric acid formation in the body, which contributes to the development of gout. Purine bases pass into the broth when meat, poultry, or fish are boiled, so it is advisable to consume broths no more than 1-2 times a week. It is recommended to cook soups using secondary broth (boil the meat for 2-3 minutes after boiling, then drain the broth, add fresh water, and cook the soup in it).

• Up to 30% of the daily protein requirement should preferably be provided by dairy and fermented milk products. Fermented milk products are especially beneficial.

• Plant proteins are found in grains, legumes, and soy. Among grains, buckwheat and oatmeal are the most beneficial. The consumption of rice should be limited due to its binding effect.

Fats

• Vegetable oils (flaxseed, olive, sunflower) can be consumed up to 25-30 grams per day (1 tablespoon of olive oil and 1 tablespoon of sunflower oil).

• Avoid the consumption of smoked products and processed meats.

• It is best to cook food without adding fat—boiling, stewing, baking, or steaming is healthier.

Carbohydrates

• Carbohydrate tolerance declines with age, so the diet of older adults should be dominated by so-called "complex" carbohydrates and dietary fiber—a variety of vegetables, berries, fruits, buckwheat and oatmeal porridges, and whole-grain bread. Legumes can increase intestinal fermentation and cause bloating.

• The consumption of so-called "simple" carbohydrates should be limited (sugar, sweets—candies, cakes, pastries).

Vitamins and Minerals

Most vitamins are not synthesized in the body—they are obtained solely from food. The human body is unable to "store" vitamins for future use and therefore must receive them regularly—in a full range and in quantities that meet the daily physiological requirement.

• Citrus fruits, spinach, bell peppers, black currants, onions, and sauerkraut are the richest in vitamin C.

• Vitamin E can be obtained from vegetable oils, flaxseeds, cereals, milk, and soy.

• Sources of B vitamins include fermented milk products, soy, green leafy vegetables, green onions, sprouted wheat, spinach, and nuts; folic acid is found in green plant leaves.

• Vitamin D is synthesized in the body under the influence of ultraviolet sunlight, so daily walks in the fresh air during daylight hours will help prevent the development of its deficiency. However, with age, the body's ability to synthesize vitamin D in the skin decreases, and it must be taken additionally. The dose will be determined by a physician following a blood test for vitamin D levels.

• Calcium is found in dairy products, fish, green vegetables, nuts, sesame seeds, and poppy seeds.

• The main sources of magnesium are cereal and legume products; zinc is found in fish, eggs, cheese, bran, and yeast.

• Iron is abundant in cereal and legume products, mushrooms, dried fruits, apples, nuts, liver, egg yolk, beef, pork, lamb, and black caviar.

Fruits and Vegetables

It is recommended to consume 2-3 servings of fruit and 3-4 servings of vegetables daily. One serving of fruit is one large fruit (apple, pear, orange) or 3-4 small ones (plum, mandarin, strawberry). One serving of vegetables is 1/2 cup of chopped cooked vegetables or one cup of chopped fresh vegetables.

Fluid

It is necessary to drink at least 1.5 L/day. With age, our body loses the ability to perceive thirst, which leads to a decrease in fluid intake and the development of dehydration.

REASONS TO CONSULT A PHYSICIAN

• If you begin to experience difficulty swallowing or frequent tickling in the throat when eating, consult a physician so as not to miss a serious illness.

• If you have decayed teeth, gum pathology, or denture problems, be sure to consult a dentist.

• If you begin to be troubled by constipation despite proper nutrition (consumption of fiber, sufficient fluid) and moderate physical activity, consult a physician—you may need an endoscopic examination of the large intestine.

• If you have lost more than 5 kg over the past 6 months or noticed that your usual clothing has become too large, consult a geriatrician to determine the cause of the weight loss.

  Unintentional weight loss in older age can be a dangerous symptom!

• If you develop signs of depression, lack of desires, or loss of interest in life, consult a psychotherapist or geriatric specialist.

Nutritional Considerations for Patients with Marked Dry Mouth

• Review and discontinuation of medications that exacerbate dry mouth symptoms.

• Ensuring adequate fluid intake; ice can be added to beverages.

• Using sugar-free chewing gum and diabetic hard candies instead of regular sweet ones.

• Drinking during meals.

• Avoiding dry, hard, crumbly foods (cookies, crackers, etc.). Food should be soft (soups, casseroles).

• Eating fruits with a high fluid content (melon, watermelon, grapefruit, etc.).

• Serving dressings and sauces with dishes.

• Breathing predominantly through the nose.

• Avoiding alcohol, caffeine, and caffeine-containing products.

• Prevention of dental caries (oral hygiene, nighttime use of fluoride gel or mouthwashes, regular dental visits).

• Lubricating the lips with lip balm or petroleum jelly.

• Using humidifiers at home.

Feeding Considerations for Swallowing Disorders

• Meals should be taken in a sitting position, with the head slightly tilted forward; if possible, hold your breath at the moment of the swallow and tilt your chin down. This body position should be maintained for 45-60 minutes after eating. If there is weakness of the neck extensor muscles (head drooping forward) and arm weakness, under no circumstances should the head be tilted heavily toward the hand holding the fork. The head should be only slightly tilted forward, and in case of pronounced weakness, fixed with a semi-rigid or rigid cervical collar.

• To bring food to the mouth, you can use forks and spoons with long curved handles or assistance from other people (caregivers or close family members providing care).

• Eat slowly, chewing food thoroughly.

• Do not talk while eating. Start talking only after swallowing all the food that was in the oral cavity.

• Eat frequently (6-7 times a day) in small portions. The size of a single swallowing portion should be no more than 1/2 teaspoon.

• Alternate solid food intake with a small sip of water.

• If the patient experiences a tickling sensation in the throat when swallowing liquids, thicker-consistency liquids should be introduced into the diet (kissels, nectars, plain broth, yogurts). The desired consistency can be achieved by adding thickeners to beverages—gelatin, baby food powders.

• Food should be of a homogeneous, puréed consistency. Foods containing liquid and solid particles (non-puréed soups, grapes, oranges, etc.), as well as sticky and crumbly foods (honey, condensed milk, shortbread pastry items) should not be consumed.

• Use creamy sip feeds.

• It is necessary to concentrate on swallowing without being distracted by the radio or television.

• Thoroughly clean the mouth after eating.

• Food should look appetizing and have an intense aroma. When preparing dishes, it is recommended to use spices and citric acid; they help improve the swallowing reflex.

We have reviewed several useful and easy-to-follow recommendations together. By following them, you can avoid problems associated with nutritional deficiency and remain healthy and happy. Stay active both intellectually and physically, and then you simply won't have time to be ill, bored, or sad.

We wish health to us all!

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Appendix G1. Mini Nutritional Assessment

Russian title: Mini Nutritional Assessment (Short Form)

Original title: Mini Nutritional Assessment, MNA

Source (official developer website, validation publication):

Kaiser MJ, Bauer JM, Ramsch C, Uter W, Guigoz Y, Cederholm T, Thomas DR, Anthony P, Charlton KE, Maggio M, Tsai AC, Grathwohl D, Vellas B, Sieber CC; MNA-International Group. Validation of the Mini Nutritional Assessment short-form (MNA-SF): a practical tool for identification of nutritional status. J Nutr Health Aging. 2009;13(9):782-8

Type: scale

Purpose: Screening for malnutrition in elderly and senile patients

Content (template)

It is necessary to complete the screening part (from item "A" to item "E"), calculate and sum up the obtained points. If the result is less than 12 points, continue filling out the form by adding the subsequent points to the sum of the screening part

Total score: ___________/30

Interpretation of results (full scale from A to T):

>23.5 points – normal nutritional status

17–23.5 points – risk of malnutrition

<17 points – malnutrition

Appendix G2. Malnutrition Universal Screening Tool

Russian title: Malnutrition Universal Screening Tool

Original title: Malnutrition Universal Screening Tool, MUST

Source (official developer website, validation publication): Stratton RJ, Hackston A, Longmore D, et al. (2004) Malnutrition in hospital outpatients and inpatients: prevalence, concurrent validity and ease of use of the ‘malnutrition universal screening tool’ (‘MUST’) for adults. Br J Nutr 92, 799–808

Type: scale

Purpose: Screening for malnutrition in elderly and senile patients

Content (template):

1. Body mass index, kg/m²

>20.0 – 0 points

18.5–20.0 – 1 point

<18.5 – 2 points

2. Unintentional weight loss in the preceding 3–6 months

<5% – 0 points

5–10% – 1 point

>>10% – 2 points

3. Presence of acute illness in the patient and no food intake >5 days / likelihood of no food intake >5 days

2 points

Key (interpretation):

0 points – low risk of malnutrition. Routine care. Rescreening: in hospital – weekly, in nursing home – monthly, for independent living at home – annually for risk groups, e.g., >75 years

1 point – medium risk of malnutrition. Monitoring: hospital, nursing home – monitor food and fluid intake for 3 days, then rescreen (dietary adjustment if necessary). Rescreening: hospital – weekly, nursing home – monthly, at home – every 2–3 months.

≥2 points – high risk of malnutrition. Nutritional support: consultation with a clinical nutritionist, additional protein and nutrient supplementation (sip feeding) as needed, dietary adjustment

Appendix G3. Nutritional Risk Screening

Russian title: Nutritional Risk Screening

Original title: Nutritional Risk Screening 2002, NRS-2002

Source (official developer website, validation publication): Bolayir B, et al. Validation of Nutritional Risk Screening-2002 in a Hospitalized Adult Population. Nutr Clin Pract. 2019. PMID: 29603374

Type: scale

Purpose: screening for malnutrition in elderly and senile patients during hospitalization

Content (template)

Clinical interpretation of disease severity grades

1 point: a patient with a chronic condition is hospitalized due to an exacerbation or complications. The patient is weakened, yet mobile and able to move around (not bedridden continuously). Protein requirement is increased, however, it can be met through regular food intake with the addition of sip feeds or specialized nutrition;

2 points: the patient is on bed rest due to illness, e.g., after abdominal surgery. Protein requirement is significantly increased, however, it can be met through the use of specialized food products and artificial nutrition

3 points: the patient is in the ICU on mechanical ventilation and other critical conditions. Protein requirements are maximally increased and cannot be met with clinical (artificial) nutrition. Protein breakdown and nitrogen loss are significantly increased.

Total score = points for nutritional status impairment severity + points for disease severity

If age is 70 years or older, add 1 point

Key (interpretation)

3 or more points – nutritional risk, a nutritional support plan is developed

Less than 3 points – weekly assessment. If major surgery is planned, a preventive nutritional support plan is discussed