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Undernutrition, or malnutrition, is one of the most significant conditions that adversely affects the health of older adults. It is common among older adults and despite its well-known consequences, often remains undiagnosed (Kaiser, 2010). Malnutrition causes impairment at cellular, physical and psychological levels. It is therefore associated with impaired immune function and wound healing, reduced muscle mass and physical function, cognitive impairment, increased fatigue, frequent falls and longer length of hospital stay, and higher treatment costs (Barker et al., 2011; Phillips et al., 2010; Skates & Anthony, 2012; Stratton et al., 2004). These factors can lead to a downward spiral of poor health, causing decreased independence and quality-of-life, and early

34 mortality. Malnutrition is preceded by a state of nutrition risk, which has also been associated with functional decline, loss of independence, reduced quality- of-life, increased health care costs and hospitalisation (Johansson, 2009; Keller et al., 2004; Kvamme et al., 2011; Skates & Anthony, 2012; Visvanathan, Newbury, & Chapman, 2004; Watson, 2010; Yang et al., 2011).

Ageing increases the risk of poor nutrition because it is associated with many changes that can negatively impact nutrition status. These include physiological changes such as loss of muscle, limited activity and sensory impairment, and socioeconomic changes such as financial or living situation (Skates & Anthony, 2012). These changes, added to the effects of illness and disease, increase the risk of poor nutrition status in older adults. However, malnutrition is not an inevitable part of ageing.

Nutrition risk can arise from three main mechanisms: 1) inadequate dietary intake due to poor appetite, loss of taste and smell, poor dentition, dysphagia, needing assistance with meals, social isolation, lack of access to food, cognitive impairment, or depression; 2) increased requirements associated with infection, post-surgery, wound healing, pressure injuries, hospitalisation, or trauma; and 3) complications of illness such as poor nutrient absorption or excessive nutrient losses, and polypharmacy (Amarantos, Martinez, & Dwyer, 2001; Barker et al., 2011).

2.4.2.1 Nutrition Risk in Hospitalised Older Adults

Malnutrition has been described as the “skeleton in the hospital closet” (p.519) (Barker et al., 2011) because it is often unrecognised and therefore remains untreated. Poor nutrition status in hospitalised older adults is associated with increased complications during admission, and poorer health and quality-of-life post discharge.

Nutrition status is likely to deteriorate while in hospital (Gariballa et al., 1998; Klipstein-Grobusch et al., 1995; Larsson et al., 1990) due to a number of associated factors including catabolism associated with acute illness (Gariballa, 2003); low intake of unappetising or unfamiliar foods, lack of flexibility in hospital catering, interruption or withholding of meals for procedures (Gary &

35 Fleury, 2002; Pennington, 1998); or low appetite due to unpleasant sights and smells (Hickson, 2006). Johansson (2009) found that more hospital stays in the two months prior to the study increased the likelihood of malnutrition.

Malnutrition and its complications are exacerbated by weight loss which is common while in hospital. A Danish cross-sectional study by Rasmussen et al. (2004) found that of the 590 participants, 26 percent lost weight during their hospital stay. Another study found that 75 percent of the 55 patients who were undernourished lost weight during their hospital stay, compared to only 39 percent of those who were normally nourished (McWhirter & Pennington, 1994). Therefore those who already have poor nutrition status may lose the most weight. However, a United States study of 837 patients in sub-acute care found that even patients who had no current nutrition deficits or predicted risk of developing deficits, had significant decreases in markers of malnutrition after three weeks of hospitalisation (Thomas et al., 2002). Weight loss and poor nutrition in hospitalised older adults can lead to complications during admission. Poor nutrition status significantly impacts the speed and efficacy of recovery and rehabilitation in hospital (Moseley, 2001). Malnourished hospitalised older adults usually have longer stays, and develop more complications such as pneumonia, pressure ulcers, poor wound healing, impaired muscle and respiratory function (Edington et al., 2000; Hill, 1992; Pirlich et al., 2006; Sullivan & Walls, 1995; Thomas et al., 2002). Naber (1997) also found that those who were malnourished were more likely to require more medications and have decreased functional capacity when compared to well-nourished patients. Nutrition status during admission therefore significantly affects clinical outcome. Furthermore, a study of 819 hospital patients in Australia found that the incidence of mortality during admission was significantly higher in those who were malnourished (2.7% vs. 1.0%, p=0.04) (Middleton et al., 2001). Poor

nutrition status during admission has many adverse consequences which may continue after discharge.

Malnourished patients have a higher rate of discharge into residential care than those who have normal nutrition status (American Dietetic Association, 2005; Davalos et al., 1996; Neumann, 2005). After hospitalisation, older adults remain

36 nutritionally vulnerable due to reduced reserves and repeated episodes of ill health. A study of 417 older adults in Norway showed that poor nutrition status in the community was more common in those who were recently hospitalised compared to those who were not (31.3% vs 6.6%, p<0.001) (Mowe et al., 1994).

Poorer function and quality-of-life has been found 90 days post discharge (Neumann, 2005), and the incidence of mortality after 12 months is significantly higher in those who are malnourished compared to well-nourished (Middleton et al., 2001; Sullivan, Walls, & Bopp, 1995). Poor nutrition status is therefore associated with complications during hospital admission, and poorer health and quality-of-life post discharge. There are many factors associated with ageing that lead to this poor nutrition status.