Wednesday 22 April 2015

More elderly suffer from malnutrition

Nearly half of old people admitted to hospital were eating poorly, a local study found
By Joyce Teo, The Straits Times, 16 Apr 2015

When retiree Ang Liang Huat, 73, was admitted to hospital in 2012 for a hip fracture, he weighed just 29kg.

"He was very skinny and weak, but had no idea he was malnourished," said Dr Lim Su Lin, the chief dietitian at National University Hospital (NUH).

"He had poor social support. Sometimes, his wife cooked for him and sometimes, she didn't."

Mr Ang, who is blind, also has no dentures. He would typically have one small bowl of porridge with some minced meat prepared by his wife for his three main meals.

His calorie intake was about 900 calories a day, far below his daily requirement of 1,500 calories.

He is one of a growing number of elderly people being picked up by hospitals because they have become malnourished through ignorance, neglect or poverty.

Hospitals such as NUH and Tan Tock Seng (TTSH) detect malnutrition, or poor nutrition, in elderly patients admitted for other health problems.

Most hospitals here now carry out nutritional screening for older people who require admission, as malnutrition in the elderly is a problem, said

Dr Sitoh Yih Yiow, a private geriatrician at Age-Link Specialist Clinic for Older Persons.

The numbers are rising, probably because malnutrition in the elderly or those aged 65 and above has been largely undiagnosed up until recently, said Dr Lim.

According to her, the ignorance of changing nutritional needs with ageing is the major reason why people do not realise it when an elderly person is becoming malnourished.


In 2006, NUH conducted the first major local study on this problem and found that nearly half of elderly people admitted to the hospital were malnourished, said Dr Lim.

"When the results were published in a scientific journal in 2012, many doctors were surprised as they did not expect the prevalence of malnutrition in a developed country to be so high.

"What was more worrying was that the elderly who were malnourished had a fivefold increase in risk of death after one year," she added.

At TTSH, every one in four patients referred to dietitians today are malnourished, said Dr Lim Yen Peng, its principal dietitian and head of the nutrition & dietetics department.

In the elderly, it is one in three.

TTSH estimates about 30 per cent of the elderly general population are at risk of being malnourished.

Among health-care providers, there is increasing awareness of the problem, said Dr Sitoh. "But the public remains largely unaware of it."

Said NUH's Dr Lim: "Given the ageing population here, there is a growing concern that the malnutrition rate among the elderly is going to rise."

That is why TTSH partnered with SPRING Singapore last month to draft a set of guidelines on nutrition and food service for older adults.

When ready, these guidelines will provide useful parameters for care facilities and organisations that provide food for older adults who have inadequate nutrition or require special diets.


Malnutrition sets in when someone does not eat enough or when he does not have a balanced diet.

A malnourished elderly person usually does not consume enough calories. Most are deficient in protein, calcium, iron, zinc and vitamins B6, B12, D, E and folate, said NUH's Dr Lim.

While often overlooked, malnutrition is a serious health concern among the elderly.

They will take longer than a younger patient to recover from it, and they are at risk of a range of adverse outcomes as a result of that malnutrition, such as infections, organ dysfunction and impaired healing, which may lead to longer hospital stays, re-admissions and higher health-care costs, she said.

"People often overlook the fact that we are exposed to bacteria from everywhere all the time, as our body has a natural defence mechanism and antibodies to fight infections," she pointed out.

But these defence mechanisms are largely made of proteins, so a malnourished person who lacks protein and other nutrients is very susceptible to infections, she said.

Malnutrition also delays recovery, wound healing and rehabilitation, and raises the risk of medical complications, said Associate Professor Reshma Merchant, a geriatrician and head of general medicine at NUH.

A malnourished patient has a poorer quality of life, and is more vulnerable to falls and fractures as he is weaker.

Also, the vitamin deficiencies can affect muscles, bones, memory and nerves, leading to numbness, she said.


The elderly are particularly prone to malnutrition due to the physical changes that result from ageing, as well as psycho-social problems.

Ageing affects one's sense of smell and taste, which can make eating a lot less pleasurable.

Some elderly people are unwilling to spend money on nutritious food, while others have mobility issues that make cooking difficult.

Ill-fitting or a lack of dentures can affect chewing and biting. As a result, many older adults stop eating meat and rely on just porridge, though new dentures may be a relatively simple fix, said Prof Merchant.

Older adults can also have multiple health problems and be on many types of medication, which can blunt their appetite and taste buds, she said.

Certain conditions, such as Alzheimer's and Parkinson's diseases, also lead to a reduced sense of smell, which can ultimately reduce appetite and cause malnutrition, she said.

Said TTSH's Dr Lim: "The presence of depression, loneliness, lack of social support, financial issues and low nutrition knowledge can further compound the risks."

As their ability to eat and enjoy food shrinks, old people may simply put up with it, not knowing there are measures they can take to make eating less onerous. For instance, some are unaware they have swallowing problems. Instead, they reduce their food intake for fear of choking, said Dr Sitoh.

Others with swallowing difficulties may omit key sources of protein and nutrients in their diet as they do not know how to modify the texture of the food, said NUH's Dr Lim.

Others may not realise their choices can lead to malnutrition.

"Many could have been unwell for long periods, so they might have been eating just plain porridge during that time," she said. "But one bowl is equivalent to just half a bowl of rice and when they eat porridge, they don't add oil."

Adding just a teaspoon of sesame oil can make a bowl of porridge more nutritious.


A bowl of noodles or porridge was what housewife Hooi Lai Keen, 76, often had for dinner on her own.

When she was admitted to TTSH for a lung infection last November, she was found to be malnourished.

It took her son, Mr Chua Bor Erng, 38, by surprise as his mother has always been skinny.

Since then, he has taken steps to help her. "She used to have meals alone but now, as my wife and I are staying with her and a helper is assisting with the cooking, we can better control what she eats."

One big mistake people often make is to assume that a loss of appetite and weight is part of ageing, said NUH's Dr Lim.

Some people also believe that every symptom needs to be treated, so the more the medication, the better, said Prof Merchant.

They do not realise that taking many drugs can affect a person's appetite and lead to weight loss, she said.


To detect any signs of unplanned weight loss, monitor the weight of an older adult regularly, such as every month, advised TTSH's Dr Lim.

Keep track of what and how much he is eating. Given that weight loss typically happens after about a month of reduced food intake, do not wait till a person has lost weight before doing something.

In fact, it is critical for the patient and his family to recognise that there is a problem. Only then can steps be taken to boost his food intake.

Some ways to do this include giving the loved one ice cream if he is not diabetic, adding sesame oil to porridge and offering snacks such as red bean soup and curry puffs, she suggested.

At this stage, boosting calories, rather than eating healthily, is the main goal, she said.

It is even more important to prevent malnutrition in those who are sick.

"Early intervention by a dietitian is important, especially for patients with medical conditions that are susceptible to malnutrition," said NUH's Dr Lim. This would include people with cancer and congestive heart failure, as well as those who have had surgery.

Caregivers in care facilities and nursing homes must also be trained on how to conduct nutrition screening and to manage or prevent the problem.

At NUH, patients are asked to visit the dietitian once a month for the first four months, followed by once every three months.

For Mr Ang, that level of care has helped him put on weight. He now weighs 37kg and NUH's Dr Lim aims to push it up slightly higher.

He now eats a more varied diet, including curry chicken from the economy rice stall on weekends.

"I was very thin. Now, I have more strength," he said.



An elderly person should not be losing weight as he ages, unless he is overweight.

The first sign of malnutrition could be a loss of appetite, followed by reduced food intake, to the point that he is not eating enough to meet nutrition requirements, said National University Hospital (NUH) chief dietitian Lim Su Lin. This leads to weight loss, followed by a loss of muscle and the ability to function normally, she said.

Watch out for weight loss amounting to 5 per cent to 10 per cent of one's body weight over a period of six months, said Associate Professor Reshma Merchant, geriatrician and NUH's head of general medicine.

Some other signs to watch out for include lethargy, tiredness, a change in behaviour and general body weakness, she said.

Tips on how to boost appetite of the elderly

Although ageing can lead to decreased sense of smell or taste, early satiety and disinterest in food, these can be addressed with a few simple methods. National University Hospital (NUH) chief dietitian Lim Su Lin and Tan Tock Seng Hospital principal dietitian Lim Yen Peng show you how.


1. Enhance the flavour of the dishes by adding herbs and spices, for example, garlic, onions, ginger, pepper, turmeric, lemon grass, curry leaves, wolfberries, red dates, chilli, basil and rosemary.

2. Prepare food with a variety of colours. For example, cook broccoli with mushrooms and carrots.

3. Pay attention to food presentation.

4. Understand food preferences and provide food that your loved one prefers.


1. These can be three small main meals a day, with three snacks in between. The minimum is three meals a day, with two or three snacks in between.

As older adults tend to have smaller appetites, it is important to maintain frequent meals and snacks to ensure adequate intake. The Health Promotion Board recommends that older adults eat at least four to six servings of rice or alternatives, three servings of meat or alternatives, two servings of fruit and two servings of vegetables daily.

2. Fluids should be consumed between meals instead of during meals, as fluids can limit the quantity of food intake.

3. Provide nutritious snacks such as steamed buns, sandwiches, poh piah, or green or red bean soup. If an elderly person is unable to eat adequately, nutritional supplements may help.


1. To make every mouthful count, prepare food with a higher energy and protein content by adding good oils such as sesame, olive or canola oil, and protein-rich food, such as eggs, milk, beans, nuts, seeds, tofu and meat. Protein-rich food help to reduce muscle loss and functional capacity.

2. Include vegetables and fruit in the diet. These types of food are rich in vitamins, antioxidants and fibre and help in the maintenance of a person's well-being and health.

Maintain a balanced diet, with a variety of food from all the food groups in adequate portions.

3. Zinc deficiency can cause a loss of taste and smell. Include zinc-rich food, such as nuts, well-cooked oysters, pumpkin, nuts and whole grain food.

4. Try not to use canned food.


1. Moisten the food with adequate gravy and sauces to ease chewing and swallowing.

2. If an elderly person has dentition problems, modifying the texture of food can help. Some examples are minced meat, boneless fish and chopped or soft vegetables.

3. Those with swallowing problems may benefit from a finely minced diet.


1. Involve your elderly relative in food preparation as this may help to stoke an interest in food.

2. Provide assistance in cooking as the loss of taste and smell can cause one to become frustrated with cooking. Take cooked food to your elderly parents' home, have it delivered or hire a domestic helper to do the cooking.


1. Eat together as a family. Eating in a social environment can help to improve an older adult's appetite. A study that investigated the effect of eating together for elderly patients in an acute medicine ward found that those who ate together had a higher caloric intake than those who ate alone, said NUH's Dr Lim.

2. Elderly people may also eat better with encouragement and help from family members when they are all having a meal together.


1. Maintain good oral hygiene as poor oral health can cause the loss of taste and smell.

2. Encourage the elderly person to stay active as this can boost their appetite.

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