Quality Indicators for the Care of Undernutrition in Vulnerable Elders

As a population, older adults are more likely than younger individuals to be afflicted with a variety of age-related diseases and functional impairments that may interfere with the maintenance of good nutritional status. This is particularly true of vulnerable elders (VEs). This population is also at greater risk of drug-induced nutritional deficiencies because of the number of prescription drugs they take. The term malnutrition can encompass a wide range of deficiencies (e.g., protein-energy, vitamins, fiber, water) and excesses (e.g., obesity, hypervitaminosis) that may or may not be clearly associated with adverse health outcomes. However, undernutrition has emerged as a priority area in caring for older persons. For example, an expert panel ranked undernutrition as the third leading condition in hospital and home care sites and the fourth leading condition in office practice and nursing home sites for which quality improvement efforts would enhance the functional health of older persons. Undernutrition in older persons is a particularly complex issue, because three populations must be considered: community dwelling, hospitalized, and institutionalized (nursing home). Although the overlap among these three populations is considerable, the burden of acute and chronic disease differs in the three groups. As a result, their nutritional requirements vary. This article will address quality indicators (QIs) for undernutrition only for community-dwelling and hospitalized VEs. The prevalence of energy undernutrition in VEs varies depending upon the definition used. In community-dwelling individuals in the United States, if energy undernutrition is defined as having a body weight of less than 45.4 kg (100 lbs), slightly more than 3% of those aged 60 and older may be affected. Similarly, low body mass index (BMI) is uncommon in community-dwelling older persons. Based on data from the 1999 to 2002 National Health and Nutrition Examination Survey, the prevalence of BMI levels less than 18.5 in persons aged 70 and older was 2.4%. If undernutrition is defined according to caloric or nutrient intake, 37% to 40% of older community-dwelling men and women (=65) report energy intakes less than two-thirds of the recommended dietary allowance (RDA). Although other surveys have suggested that 30% of community-dwelling older persons have energy intakes below the RDA, the same surveys indicate that protein intake has generally been above the RDA. The prevalence of undernutrition is considerably higher in hospitalized patients, ranging from 55% to 61% in different populations using different definitions. Developing QIs for undernutrition in older persons is problematic, because there is no universally accepted clinical definition of undernutrition and because the research conducted on malnutrition in older persons, although voluminous, has not systemically focused on concerns of quality of care. As a result, there are substantial knowledge gaps in the literature, and many of the proposed QIs in this article are not supported by randomized clinical trials. When clinical trials have been available, many have studied patients who met narrow entry criteria. Moreover, most of the trials do not meet the highest quality of methodological rigor (e.g., concealed randomization and complete follow-up). Thus, even the clinical trial evidence cannot be regarded as conclusive when evaluating the proposed QIs in this monograph. METHODS: A total of 116 articles were considered in this review: nine identified through a Web search and 107 through reference mining. RESULTS: Of the 16 potential QIs, the expert panel process judged nine to be valid; seven were rejected. The literature summaries that support each of the indicators judged to be valid in the expert panel process are described.