IM25.22 | Geriatric Nutritional Disorders — Summary & Reflection

KEY TAKEAWAYS

Nutritional disorders in the elderly are prevalent, underdiagnosed, and carry serious complications across every organ system. The key points are:

Presentations:
- PEM — weight loss, sarcopaenia, poor wound healing, hypoalbuminaemia, recurrent infections
- Sarcopaenia — low grip strength (<27/16 kg), slow gait (<0.8 m/s), reduced muscle mass; EWGSOP2 criteria
- Vitamin D deficiency — proximal myopathy, bone pain, osteomalacia; serum 25-OH-D <20 ng/mL
- Vitamin B12 deficiency — macrocytic anaemia, SCD of cord (posterior + lateral columns), reversible dementia; metformin and PPIs are risk factors
- Scurvy — perifollicular haemorrhages, gingival bleeding, poor wound healing; treat with vitamin C 500–1000 mg/day
- Refeeding syndrome — hypophosphataemia on initiating nutrition in severely malnourished: give thiamine first, start low (10 kcal/kg/day)

Assessment:
- MNA-SF (6 items): 12–14 normal, 8–11 at risk, 0–7 malnourished; gold standard for geriatric nutritional screening
- Anthropometry: BMI, MAC, calf circumference, handgrip strength, skin-fold thickness
- Biochemistry: albumin (prognostic, not specific), prealbumin (more sensitive to recent change), CRP (interpret albumin in context), micronutrient levels

Management:
- Step 1: address cause (polypharmacy review, dysphagia management, depression treatment, food security)
- Step 2: dietary fortification → ONS (1.2–1.5 g protein/kg/day, 25–35 kcal/kg/day) → enteral nutrition (NGT/PEG) → parenteral nutrition (last resort)
- Step 3: specific micronutrient replacement (vitamin D 800–2000 IU/day; IM hydroxocobalamin for B12; oral iron or IV if malabsorbed; thiamine IV before glucose)
- Refeeding precautions for BMI <16 or prolonged starvation
- Resistance exercise synergistic with protein supplementation for sarcopaenia

REFLECT

Return to Meenakshi from the opening hook — BMI 17.2, albumin 2.6, losing weight, eating inadequately because arthritis prevents cooking. The orthopaedic surgeon is asking whether to proceed with surgery. You now have the clinical, assessment, and management tools to answer. Consider: what is her MNA-SF score likely to be? What complications is she at risk of if she undergoes surgery in her current nutritional state? What nutritional rehabilitation plan would you recommend before her knee replacement, and for how long? What is the role of the speech therapist, dietitian, and social worker in her care? Beyond Meenakshi, reflect on a systemic question: if 30–50% of hospitalised elderly patients in India are malnourished, and malnutrition triples complication rates, what would a hospital-wide nutritional screening programme need to look like? What would need to change in training, staffing, and clinical culture to make nutritional assessment as routine as blood pressure measurement? The answers require not just clinical knowledge but a vision of what excellent geriatric care looks like — which is precisely what this module has tried to build.