1. Asai, Janelle L. LD, RD, BS


The nutritional status of the geriatric rehabilitation patient can affect progress toward rehabilitation goals. The importance of the referral to the registered dietitian to improve nutritional status is described. Factors affecting the appetite in the geriatric patient are discussed. The anorexia of aging is reviewed. Early signs of protein-calorie malnutrition (PCM) include apathy, low energy, and decline in muscle strength before overt PCM occurs. The role of nutrition in health is discussed. The components of Medical Nutrition Therapy to treat poor nutritional status are reviewed.


THE nutritional status of the geriatric patient can affect progress toward rehabilitation goals. Early signs of protein-calorie malnutrition are nonspecific: fatigue, apathy, and decline in muscle strength. 1 At times, these symptoms are considered related to a disease process or physiologic stress post surgery, but they may be a direct indicator of poor nutritional status that can be corrected. Patients may be too weakened or too disinterested to complete therapy sessions. Patients may be contracting frequent infections causing interruptions in therapy sessions. Consideration for nutritional factors affecting patient outcome is necessary when challenged with slower than expected progress in the geriatric patient. Nutrition intervention should be undertaken and referral to the registered dietitian (RD) will ensure that appropriate recommendations are made.


As people age, they have a decreased margin of homeostatic reserve and a reduced ability to accommodate metabolic challenges, including nutritional stress. 2 The physiologic anorexia of aging puts older persons at high risk for developing protein-calorie malnutrition (PCM) when they develop either psychological or physical disease processes. Health care practitioners, including physical, occupational, and speech therapists, must be on the alert for the need for nutrition intervention.


Low food intake leads to immunodeficiency and subsequent frailty. Any physiological stress including intercurrent illness aggravates both undernutrition and immunodeficiency, creating a disease-to-disease spiral (undernutrition-immunodeficiency) that is difficult to reverse. The release of cytokines during chronic disease may also be an important determinant of frailty. In addition to being anorectic, cytokines also contribute to lipolysis, muscle protein breakdown, and nitrogen loss. 2 Metabolic disorders occur at a later stage of PCM, after the fatigue, apathy, and muscle weakness have set in, generally during an acute illness, leading to overt PCM with abnormal glucose metabolism, recurrent infection, dehydration, impaired wound healing, and calcium bone loss. 1


It is important to diagnose undernutrition in the early stage before more specific symptoms develop: anorexia, weight loss, and infection. 1 In the nursing home setting there are regulations that specify parameters of nutritional status to be met. The minimum data set (MDS) of the Omnibus Budget Reconciliation Act regulations have helped define nutritional risk. These regulations have impacted nutritional status and created the standard of care in nursing facilities. They indicate that a weight loss of 5% in 30 days, 7.5% in 90 days, or 10% in 180 days is significant and any percentages higher than these are considered severe warranting assessment to determine causes. These same guidelines are appropriate for the elderly person residing outside the nursing home.


Despite its high prevalence, however, protein-calorie malnutrition in older persons is rarely recognized and even more rarely treated appropriately. 3 The health care practitioner can help ensure that appropriate referrals are made to the RD. In the case of nursing home facilities, consultant dietitians generally work with facilities and complete nutrition assessments on residents who have been referred due to nutritional risk. In other facilities, there is a registered dietitian on staff to provide nutrition consultation. The RD can make recommendations for a nutritional plan of care to help residents regain lost weight and/or prevent weight loss. In other settings, the nutrition referral is not so routine. In home health care, the home health agency contracts with consultant dietitians on an as-needed basis. Nurses may provide nutrition recommendations instead of the RD. There may be less awareness of nutrition intervention needs, referrals, and/or payment source issues.