Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1694573193016.pdf (Australia)
Malnutrition in older Australians Older Australians in residential care and in the community represent a heterogeneous population with respect to nutrition, i.e.

some are well nourished, some are overweight or obese, some are malnourished.
Malnutrition is defined as two or more of the following characteristics: insufficient energy intake, weight loss, loss of muscle mass, loss of subcutaneous fat, localized or generalized fluid accumulation or diminished functional status.1 People with malnutrition experience greater morbidity and mortality than people who are well nourished.

There are a variety of tools available to screen and assess malnutrition in different care settings.
These have been reviewed and summarised on NEMO on the Queensland Health webpages.

While there is no single marker for malnutrition, unplanned weight loss is a key indicator of malnutrition.

It is possible to be overweight or obese and to be malnourished where there has been unintended weight loss.

Studies show also that there is an increased risk for older people with a BMI <23.0 kgm2.

Body weight should be monitored regularly and action taken in individuals where unplanned weight loss has occurred.
There may be many contributors to malnutrition and for this reason approaches to identifying, treating and preventing malnutrition need involve various stakeholders i.e.

include consumers, carers, dietitians, nurses, care workers, food service managers, food service staff etc.

Trends in weight changes for older people in care are a flag to inform organisation efforts to ensure people are adequately nourished and hydrated.

An organisation would aim to minimise prevalence of unplanned weight loss.
Public reports of prevalence can be accompanied by indicators of what steps organisations take to prevent and to manage malnutrition.

A distinction might also be made between malnutrition acquired in that organisation, as distinct to prior to entering care of the organisation or while in the care of another facility e.g.

hospital.

1.
hospital.

1.

White JV, Guenter P, Jensen G, Malone A, Schofield M. Consensus statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition).

JPEN 2012; 36: 275-83 Annette Byron, Senior Policy Officer, Dietitians Association of Australia.

June 2017 Thanks to Prof Karen Walton for contributing a number of references.
Effectiveness of the Aged Care Quality Assessment and accreditation framework for protecting residents from abuse andpoor practices, and ensuring proper clinical and medical care standards are maintained and practisedSubmission 10 - Attachment 1 Summary table showing prevalence of malnutrition in Australian studies While the focus in this document is residential care and community settings, the prevalence of malnutrition in Australian hospitals is also of concern.
Most hospital programs aim to screen and assess patients soon after admission, which reflects nutritional status prior to admission to hospital.

This is not to say however that a great deal more needs to be done to address malnutrition in hospital, whether it is pre-existing or not.

The table below is a summary of Australian studies in malnutrition.
Year of publication 2016 Age of subjects >75 yrs Number subjects 72 Author Hamirudin et al Hamirudin et al 2016 Walton et al 2015 Winter et al 2013 2013 Ulltang 2013 Charlton et al 2013 Manning et al 2012 Malnutrition prevalence 1.4% malnourished 27.8% at risk 61.8% at risk or malnourished 5% malnourished 38% at risk Assessment Tool MNA-SF MNA MNA 79 42 225 1 malnourished person MNA-SF Practice setting State/Territory General Practice DVA MoW customers General Practice NSW NSW NSW VIC 16% At Risk 153 774 23 17% malnourished 34% malnourished 55% at risk 35% malnourished 52% at risk SGA MNA MNA Hospital – MAPU Older Rehabilitation Inpatients Hospital QLD NSW NSW Mean: 85+5.8 yrs Mean: 81.9 (±9.4) yrs >75 yrs Mean: 81.3 + 4.3 yrs Mean age 62 Mean: 83.2+8.9 yrs Effectiveness of the Aged Care Quality Assessment and accreditation framework for protecting residents from abuse andpoor practices, and ensuring proper clinical and medical care standards are maintained and practisedSubmission 10 - Attachment 1 PG- SGA hospital Charlton et al 2012 Kellett 2013 Kellett 2013 Kellett 2012 Gout 2012 Ackerie 2012 Sheard 2012 Agarwal 2010 Rist 2009 Vivanti 2009 Gaskill 2008 Adams et al 2008 Leggo 2008 Brownie et al 2007 Mean: 80.6+27.7 yrs 59.5 +/- 19.9 yrs Mean 70 (35 -92) 64 +/- 18 yrs 82 (65– 100) yrs Median 74 yrs (65–82) Mean: 81.9 yrs 76.5 +/- 7.2 yrs 65-98 yrs 2076 51.5% malnourished or at risk MNA 57 101 189 275 352 97 3122 235 126 350 100 1145 1263 26% moderately malnourished 7% severely malnourished 20% moderately malnourished 2% severely malnourished 47% moderately malnourished 6% severely malnourished 16% % moderately malnourished 6.5% severely malnourished 19.5% moderately malnourished – Public 18.5% moderately malnourished - Private 5% severely malnourished – Public 6% severely malnourished - Private 16% moderately malnourished 0% severely malnourished 24% moderately malnourished 6% severely malnourished 8.1% malnourished 34.5% at risk of malnutrition 14.3% moderately malnourished 1% severely malnourished 43.1%
 moderately malnourished 6.4/5 severely malnourished 30% malnourished 61% at risk 5 – 11% malnourished 36% high risk 23% moderate risk SGA SGA SGA SGA PG-SGA SGA MNA SGA SGA MNA PG - SGA ANSI Older Rehabilitation Inpatients RACF RACF Hospital Hospital – public and private NSW ACT ACT ACT VIC QLD Hospital QLD Community VIC metro QLD QLD QLD Hospital – Emergency department RACF Hospital HACC eligible clients Community setting Effectiveness of the Aged Care Quality Assessment and accreditation framework for protecting residents from abuse andpoor practices, and ensuring proper clinical and medical care standards are maintained and practisedSubmission 10 - Attachment 1 2007 Thomas et al Walton et al 2007 Banks 2007 Mean: 79.9 yrs Mean: 79.2+11.9 66.5/ 65.0 yrs 64 30 774 1434 hospital 78.9 78.7 yrs 381 458 RACF 53% moderately malnourished 9.4% severely malnourished 37% malnourished 40% at risk Hospital 27.8% moderately malnourished, 7.0% severely malnourished (2002), 26.1%% moderately malnourished, 5.3% severely malnourished (2003) RACF 41.6% mod malnourished, 8.4% severely malnourished (2002), 35.0% moderately malnourished, 14.2% severely malnourished (2003) malnourished PG_SGA Hospital MNA SGA Rehabilitation Hospitals Hospital NSW QLD – metro, regional and remote RACF 34% moderately malnourished 8% severely malnourished (at baseline) 42.3% malnourished SGA SGA Community NSW Acute Hospital NSW Collins et al 2005 Lazarus et al Martineau et al Neumann et al Visvanathan et al 2005 2005 2005 2004 Visvanathan 2003 Mean: 80.1 +8.1 Mean: 66.8 yrs Mean: 72 yrs Mean: 81 yrs Mean: 76.5-79.8 yrs 67 – 99 yrs 50 324 73 133 65 16.4% moderately malnourished 2.7% severely malnourished 6% malnourished 47% at risk 35.4-43.1% 250 baseline Baseline 38.4% not well nourished 4.8% malnourished Patterson et al 2002 70-75 yrs 12,939 30% high risk 23% moderate risk PG-SGA MNA MNA MNA ANSI Acute Stroke Unit Rehabilitation Hospital Rehabilitation Hospital Domiciliary care clients Community setting SA
 SA metro Effectiveness of the Aged Care Quality Assessment and accreditation framework for protecting residents from abuse andpoor practices, and ensuring proper clinical and medical care standards are maintained and practisedSubmission 10 - Attachment 1 Middleton et al Beck et al 2001 2001 Median: 66 yrs Mean not available 819 36% malnourished 5749 7-14% malnourished in acute setting 49% malnourished in rehabilitation setting Burge & Gazibarich 1999 >65 yrs 92 Mean: 75.2 +5.8 yrs -High risk: 27% (score of 6 or more) -Moderate risk: 30% (score of 4-5) -Low risk: 43% (score of 0-3) -Most common nutrition risk factors: polypharmacy (47%), eating alone most of the time (45%) and dietary modification due to illness (35%).
SGA MNA Australian Nutrition Screening Initiative (ANSI) Acute Hospital NSW NSW NSW Regional Acute and Rehabilitation Hospitals Community living (Senior citizen’s centres) Cobiac & Syrette 1996 >70 yrs 1098 30% high risk 20.6% moderate risk ANSI Community setting Effectiveness of the Aged Care Quality Assessment and accreditation framework for protecting residents from abuse andpoor practices, and ensuring proper clinical and medical care standards are maintained and practisedSubmission 10 - Attachment 1 References for summary table 1.
Ackerie A, Carroll E, McCray S, Hill J, Leveritt M. Malnutrition does not discriminate.

Nutr Diet 2012; 69: (Suppl.

1): 146 2.

Adams NE, Bowie AJ, Simmance N, Murray M & Crowe TC.

Recognition by medical and nursing professionals of malnutrition and risk of malnutrition in elderly hospitalised patients.

Nutrition & Dietetics 2008; 65:144-150.

3.


Agarwal E, Ferguson M, Banks M, Batterham M, Bauer J, Capra S, Isenring E. Nutrition care practices in hospital wards: Results from the Nutrition Care Day Survey 2010.

Clin Nutr 2012; 31: 995 – 1001 4.

Banks M, Ash S, Bauer J, Gaskill D. Prevalence of malnutrition in adults in Queensland public hospitals and residential aged care facilities.

Nutr Diet 2007; 64: 172-178 5.

Beck E, Patch C, Milosavljevic M, Mason S, White C, Carrie M & Lambert K (2001a).
Implementation of malnutrition screening and assessment by dietitians: malnutrition exists in acute and rehabilitation settings.

Australian Journal of Nutrition and Dietetics;58(2):92-97.

6.

BROWNIE, S., MYERS, S. P. & STEVENS, J.

2007.

The value of the Australian nutrition screening initiative for older Australians - Results from a national survey.

Journal of Nutrition, Health and Aging, 11, 20-25.

7.

BURGE, K. & GAZIBARICH, B.

1999.


Nutritional risk among a sample of community-living elderly attending senior citizens' centres.

Australian Journal of Nutrition & Dietetics, 56, 137- 143.

8.

Cobiac, L. & Syrette, J.

A.

1995.

What is the Nutritional Status of Older Australians?

Proceedings of the Nutrition Society of Australia, 19, 139.

9.

Charlton, K. E., Batterham, M. J., Bowden, S., Ghosh, A., Caldwell, K., Barone, L., Mason, M., Potter, J., Meyer, B.
& Milosavljevic, M. 2013, 'A high prevalence of malnutrition in acute geriatric patients predicts adverse clinical outcomes and mortality within 12 months', e - SPEN Journal, vol.

8, no.

3, pp.

e120-e125.

10.

Charlton K, Nichols C, Bowden S, Milosavljevic M, Lambert K, Barone L, Mason M, Batterham M. 2012.

Poor nutritional status of older subacute patients predicts clinical outcomes and mortality at 18 months of follow-up.

European Journal of Clinical Nutrition, 66, 1224-1228.

11.
11.

Collins CE, Kershaw J, Brockington S. Effect of nutritional supplements on wound healing in home-nursed elderly: A randomized trial.

Nutrition 2005; 21: 147 – 155.

12.

Gaskill D, Black LJ, Isenring EA, Hassall S, Sanders F. Bauer JD.

Malnutrition prevalence and nutrition issues in residential aged care facilities.

Australasia J Ageing 2008; 27: 189 – 94 13.

Gout BS, Barker LA, Crowe TC.

Malnutrition identification, diagnosis and dietetic referrals: Are we doing a good enough job?
Nutr Diet 2009; 66: 206-211 14.

Hamirudin A, Walton K, Charlton K, Carrie A, Tapsell L, Milosavljevic M, Pang G & Potter J (2016).

Feasibility of Home-Based Dietetic Intervention to Improve the Nutritional Status of Older Adults Post Hospital Discharge.

Nutrition & Dietetics; DOI: 10.1111/1747-0080.12305 15.

Hamirudin A, Charlton K & Walton K (2016).

Outcomes Related To Nutrition Screening In Community Living Older Adults: A Systematic Literature Review.
Archives of Gerontology and Geriatrics; 62:9-25.

16.

Kellett J, Itsiopoulos C, Kyle G, Luff N. Prevalence of malnutrition amongst adult inpatients at a tertiary teaching hospital in the ACT region.

Nutr Diet 2013; 70 (Suppl.

1): 26 - 47 17.

Kellett J, Kyle G, Itsiopoulos C, Bacon R, Chapple L. A snapshot of malnutrition prevalence in five residential aged care facilities in the ACT region.

Nutr Diet 2013; 70 (Suppl.


1): 4 - 25 Effectiveness of the Aged Care Quality Assessment and accreditation framework for protecting residents from abuse andpoor practices, and ensuring proper clinical and medical care standards are maintained and practisedSubmission 10 - Attachment 1 18.

Kellett J, Bacon R, Simpson A, Richards C. Malnutrition prevalence in aged care residences.

Nutr Diet 2012; 69 (Suppl.

1): 72 - 164 19. lazarus, C. & Hamlyn, J.

2005.


Prevalence and documentation of malnutrition in hospitals: A case study in a large private hospital setting.

Nutrition & Dietetics, 62, 41-47.

20.

Leggo M, Banks M, Isenring E, Stewart L, Tweeddale M. A quality improvement nutrition screening and intervention program available to Home and Community Care eligible clients.

Nutr Diet 2008; 65: 162 -167 21.

Manning F et al.


Additional feeding assistance improves the energy and protein intakes of hospitalised elderly patients.

A health services evaluation.

Appetite 2012; 59: 471-477 22.

Martineau J, Bauer JD, Isenring E & Cohen S (2005).

Malnutrition determined by the patient- generated subjective global assessment is associated with poor outcomes in acute stroke patients.

Clinical Nutrition;24(6):1073-1077.

23.


Middleton MH, Nazarenko G, Nivison-Smith I, Smerdely P (2001).

Prevalence of malnutrition and 12-month incidence of mortality in two Sydney teaching hospitals.

Internal Medicine Journal; 31:455-461.

24.

Neumann SA, Miller MD, Daniels L & Crotty M (2005).

Nutritional status and clinical outcomes of older patients in rehabilitation.

Journal of Human Nutrition and Dietetics; 18:129-136.

25.

Patterson, A., Young, A., Powers, J., Brown, W. & Byles, J.

2002.
2002.

Relationships between nutrition screening checklists and the health and well-being of older Australian women.

Public Health Nutrition, 5, 65.

26.

Rist G, Miles G, Karimi L. The presence of malnutrition in community-living older adults receiving home nursing services.

Nutr Diet 2012; 69: 46 - 50 27.

Sheard J, Ash S, Silburn P, Kerr G. Prevalence of malnutrition in community-dwelling adults with Parkinson’s Disease.

Nutr Diet 2012; 69 (Supple 1): 72 - 164 28.


Thomas JM, Isenring E & Kellett E (2007).

Nutritional status and length of stay in patients admitted to an Acute Assessment Unit.

Journal of Human Nutrition and Dietetics; 20:320- 328.

29.

Ulltang M, Vivanti A, Murray E. Malnutrition prevalence in a medical assessment and planning unit and its association with hospital readmission.

Aust Health Review 2013; 636 - 641 30.

Visvanathan R, Penhall R & Chapman I (2004).


Nutritional screening of older people in a sub- acute care facility in Australia and its relation to discharge outcomes.

Age and Ageing;33(3):26-265.

31.

Visvanathan R, Macintosh C, Callary M, Penhall R, Horowitz M, Chapman I.

The nutritional status of 250 older Australian recipients of domicilary care services and its association with outcomes at 12 months.

J Am Geriatr Soc 2003; 51: 1007 – 11 32.


Vivanti A, McDonald CK, Palmer MA, Sinnott M. Malnutrition associated with increased risk of frail mechanical falls among older people presenting to an emergency department.

Emergency Medicine Australasia 2009: 21: 386 – 394 33.

Walton KL, Williams P, Tapsell LC & Batterham M (2007).

Rehabilitation inpatients are not meeting their energy and protein needs.

e-SPEN the European e-Journal of Clinical Nutrition and Metabolism; 2 (6): e120 - e126.

34.
34.

Walton K, Charlton KE, Manning F, McMahon A, Galea S & Evans K (2015).

The nutritional status and dietary intakes of Meals on Wheels (MOW) clients.

Appetite; 95: 528-532.

Effectiveness of the Aged Care Quality Assessment and accreditation framework for protecting residents from abuse andpoor practices, and ensuring proper clinical and medical care standards are maintained and practisedSubmission 10 - Attachment 1 35.

Winter, J., Flanagan, D., McNaughton, S. A.

& Nowson, C. 2013.
& Nowson, C. 2013.

Nutrition screening of older people in a community general practice, using the MNA-SF.

Journal of Nutrition, Health and Aging, 17, 322-325.

Additional references 1.

Barker LA, Gout BS, Crowe T. Hospital malnutrition: Prevalence, identification and impact on patients and the healthcare system.

Int J Environ Res Public Health 2011; 8: 514 - 527 2.

Charlton K. Nutrition screening: Time to address the skeletons in the bedroom closet as well as those in hospitals.
Nutr Diet 2010; 67:209 – 212 3.

De van der Schueren M, Elia M, Gramlich L, Johnson MP, Lim SL, Philipson T, Jaferi A, Prado CM.

clinical and economic outcomes of nutrition interventions across the continuum of care.

Ann N Y Ad Sc 2014; 1321: 20 - 40 4.

Demeny D, Jukic K, Dawson B, O’Leary F. Current practices of dietitians in the assessment and management of malnutrition in elderly patients.

Nutr Diet 2015; 72: 254 – 260.

5.


Ferguson M, Banks M, Bauer J, Isenring E, Vivanti A, Capra S. Nutrition screening practices in 6.

Australian healthcare facilities: A decade later.

Nutr Diet 2010; 67: 213 – 218 Isenring EA, Banks M, Ferguson M, Bauer JD.

Beyond malnutrition screening: Appropriate methods to guide nutrition care for aged care residents.

J Acad Nutr Diet 2012; 112: 376 – 381.

7.


Kendig H, Browning C, Pedlow R, Wells Y and Thomas S. Health, social and lifestyle factors in entry to residential aged care: an Australian longitudinal analysis.

Age and Ageing 2010; 39: 342–349 8.

May M. Importance of nutrition intervention in geriatric patients waiting for residential care.

Nutrition & Dietetics 2007; 64 (Supp.

1): S25 9.


Miller M, Crotty M, Whitehead C, Daniels L, Finucane P. Nutritional assessment and intervention in patients admitted with a femoral neck fracture: a chronical of missed opportunities.

Nutr Diet 2001; 58: 86 - 91 10.

Orpin P, Boyer K, King A.

Study report: Assessment of nutrition risk in Home and Community Care Clients.

May 2014.

11.

Phillips, MB, Foley AL, Barnard R, Isenring EA, Miller MD.
Nutritional screening in community-dwelling older adults: a systematic literature review.

Asia Pac J Clin Nutr 2010; 19 : 440 – 449.

12.

Spence A, McRorie T, Pearce L, Crowe T. Nutrition risk of elderly patients with dementia attending a memory loss clinic.

Nutr Diet 2007; 64 (Suppl.

1): S40 13.

Walton K. Improving opportunities for food service and dietetics practice in hospitals and residential aged care facilities.

Nutr Diet 2012; 69: 222 - 225 14.

White JV et al.


Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the identification and documentation of adult malnutrition (undernutrition).

J Acad Nutr Diet 2012; 112: 730 - 738 15.

Winter J, MacInnis RJ, Wattanapenpaiboon, Nowson CA.

BMI and all-cause mortality in older adults: a meta-analysis.
Am J Clin Nutr 2014; doi:10.3945/ajcn.113.068122 Effectiveness of the Aged Care Quality Assessment and accreditation framework for protecting residents from abuse andpoor practices, and ensuring proper clinical and medical care standards are maintained and practisedSubmission 10 - Attachment 1