Geriatric MedicineTier 1Disease (DEADMAN)

Malnutrition and weight loss

Description

Unintentional weight loss +/- reduced intake in older adults
- Distinct from age-related anorexia (mild, physiological) - pathological if functional decline results
Malnutrition - deficit of energy/protein/micronutrients affecting function
Frailty and sarcopenia overlap heavily but are not synonymous
- Sarcopenia = muscle mass + strength loss; malnutrition = broader nutrient deficit; frailty = multisystem reduced reserve

Malnutrition: ~10% community-dwelling >65, up to 30-50% hospitalised/residential aged care
Under-recognised - often attributed to "normal ageing"
Strong predictor of mortality, LOS, readmission, pressure injury

Reduced intake

Anorexia of ageing - dec ghrelin sensitivity, early satiety, dec smell/taste
Dysphagia - stroke, Parkinson's, dementia, oesophageal pathology
Dental/oral - poor dentition, ill-fitting dentures, xerostomia (polypharmacy)
Depression, cognitive impairment (forgets to eat)
Social - isolation, poverty, inability to shop/cook, meal access
Drugs - opioids, digoxin, metformin, SSRIs (nausea/anorexia)

Increased requirement/loss

Impaired absorption

Screening

Workup

Weight trend, BMI, mid-arm circumference, grip strength
Bloods: FBE, UEC, LFT, albumin (low specificity - inflammatory marker not pure nutrition marker), CRP, TFTs, B12/folate/iron studies, calcium, glucose, coeliac serology
Swallow assessment if dysphagia suspected
Cancer screen guided by history/exam, not routine blind screen in all
Medication review, dental review, mood screen (GDS), cognition screen
Social history - who shops/cooks, finances, isolation

By mechanism

Correct reversible cause - dental review, swallow therapy, treat depression, deprescribe offending drugs, treat underlying disease
Dysphagia - texture-modified diet, SLP input, avoid inappropriate strict restriction that worsens intake
Social - Meals on Wheels, community supports, carer involvement

Nutritional support

Food-first approach - fortify meals, small frequent feeds, favourite foods, address the eating environment
Oral nutritional supplements if food-first inadequate
Dietitian referral for individualised plan
Enteral feeding (NGT/PEG) - only after MDT discussion incl. goals of care
- Evidence does not show survival/aspiration-pneumonia benefit in advanced dementia - focus on comfort feeding instead

Avoid

Unnecessary therapeutic diet restrictions (low salt/diabetic/low cholesterol) in frail underweight patients - often does more harm than good

Independent predictor of mortality, hospitalisation, functional decline, institutionalisation
Weight loss in advanced dementia often represents disease trajectory rather than reversible cause
- Aggressive nutritional intervention here may not alter outcome - shift to comfort-focused goals

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