This is the first Irish study to examine the prevalence of malnutrition in a cohort of older adults presenting to a large urban ED in Ireland, the factors associated with malnutrition and the association of malnutrition with 30 day and 6 month adverse patient outcomes post-discharge from the ED. Over one in three older adults presenting to this Irish ED were at risk of malnutrition or classed as malnourished. These older adults were more likely to be frail and at risk of adverse outcomes, to have experienced a fall in the previous three months, had hospital admissions in the previous six months and reported a poorer functional ability and quality of life. In the short term, malnutrition was associated with a longer stay in the ED but a greater likelihood to be discharged home. At 30-day follow-up, being malnourished was associated with further decline in functional ability, quality of life, greater risk of hospital admissions and a greater likelihood of admission to nursing home facilities. Similar findings were evident at 6 months.
There have been few published studies documenting the prevalence of malnutrition amongst hospitalised older adults in Ireland. An observational multi-site study reported the prevalence of malnutrition as 18% and at risk of malnourishment as 45% among older adults on admission to hospital (27). The higher prevalence of malnutrition on the hospital ward in this study from that observed in the ED setting could be attributed to further decline in nutritional status resulting from the hospital stay (9, 10, 13). This can be related to a number of factors including acute and chronic inflammation, inflexible mealtimes, fasting, insufficient energy and protein content of meals and a lack of recognition of the increasing risk of malnutrition in the hospital setting (9, 26). Among community-dwelling Irish older adults, incidence of malnutrition over two years has been documented to occur at a rate of 10.7% (41). Bardon and colleagues reported that the main predictors of incident malnutrition were being unmarried/divorced/separated, hospitalised in the year previous, and mobility limitations that indicate declining physical function (41). In each study, the authors conclude that the prioritisation of nutritional screening to identify and manage older adults vulnerable to malnutrition in clinical practice should be incorporated into public health policy (26, 27, 41).
Screening for malnutrition is an important step in recognising and identifying risk of or diagnosis of malnourishment (6). However, it is often not completed owing to perceived barriers of screening implementation in hospital settings including time, competence and resources (26, 42). Most of the studies advocating for screening, do so at the ward level, thus potentially missing those who present via ED and are not admitted to the ward (20). We found that over half of the patients discharged from the ED had a risk of malnutrition or were malnourished. Health and social care professionals have both the skills and opportunity to assess older adults and to co-ordinate a care plan to minimise the risk of adverse events after discharge from the ED. The approach to managing nutritional risk needs to be multi-faceted and include the management of co-morbidities, the provision of home and social supports to encourage and facilitate food intake and the implementation of dietary modifications to improve diet quality (43). When energy intake is insufficient to meet the demands of the body, either due to starvation, acute illness, or chronic disease/disability, then malnutrition becomes the driver that leads to further functional decline and an inability to recover from disease and a continuum of nutritional vulnerability (10).
Malnutrition affects quality of life through adverse outcomes, impaired cognitive and affective functioning and physical disability as people age (14). Assessment of quality of life is recognised as a clinically relevant outcome measure when evaluating new treatment strategies in patient populations, particularly older adults (14). We report a decline in quality of life associated with malnutrition at 30-day follow up, however no statistical differences were observed at the6 months follow-up. However, we noted a clinically significant decline in functional ability at 6-months follow up that was associated with being malnourished. Loss of functional independence results in loss of quality of life (44). Low muscle strength, a factor related to undernutrition, can compound the functional decline from chronic disease or conditions related to ageing (45).
Research to date demonstrates that risk of malnutrition is associated with increased morbidity and mortality (25). Therefore, it is crucial to commence nutritional therapy as early as possible. It is imperative to recognise both malnutrition and risk of malnutrition as early as possible during the hospital admission process (6, 25). It has previously been shown that comprehensive, individualised nutritional care combining different measures according to individual needs improves the dietary intake, nutritional status, clinical course and quality of life of older patients with malnutrition or at risk of malnutrition (46). Intervention coordinated by an ED registered dietitian providing nutrition support to older adults identified at nutritional risk at presentation to a hospital setting may lead to improved patient outcomes (20). Consistent with this, interventions designed to improve and sustain optimal nutritional status can also lead to significant improvements in quality of life, for both physical and mental aspects (9, 14).
A more recent and rapidly growing phenomenon is undernourishment concomitant with obesity in older adults (10). Our study was pragmatic in nature and, reflecting the realities of clinical practice in the ED, body weight and height were measured when the equipment was available and it was feasible to remove the patient from the bed. Therefore, only forty-nine participants had measurements of weight and height taken to measure BMI despite the majority indicating an ability to get out of bed/chair. Nonetheless, 13% (n = 4) of those who were classified as overweight/obese based on BMI were at risk of malnutrition. If BMI was relied upon as a sole indicator of nutrition, it would fail to identify nutritional issues in these individuals. This has also been reported in other studies highlighting that older people can be at nutritional risk although they may be overweight or obese (6, 43, 47).
Limitations
A limitation of this study is the lack of clinical information relating to the conditions of sarcopenia and cachexia. Loss of body mass is a common phenotype for these different conditions that can be caused by a combination of reduced food intake, excessive requirements, altered metabolism, sepsis, trauma, ageing and inactivity (11, 48). Cachexia can be defined as a multifactorial syndrome characterized by severe body weight, fat and muscle loss and increased protein catabolism due to underlying disease (6). Therefore, malnutrition in older adults may occur due to a combination of cachexia (disease-related) and malnutrition (inadequate consumption of nutrients) as opposed to malnutrition alone. Sarcopenia is a muscle disease common among older adults that is rooted in adverse muscle changes that accrue across a lifetime. It is assessed by measures of muscle quality and is characterised by low muscle strength as a principal determinant (6, 49). Determining the primary aetiology (starvation, cachexia, and/or sarcopenia) of malnutrition is critical for the implementation of appropriate nutrition support as responsiveness to dietary modifications differ (11). This information is also critical in developing an individualised targeted intervention to address malnutrition with the goal of reducing hospital readmission or institutionalisation in this high risk group.