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BRITISH MEDICAL JOURNAL VOLumE 293 8 NOVEMBER 1986 1189

relative efficacy of two screening procedures, and the curve dietitian uses a questionnaire, but it is usually patients who
provides a rational estimate of the threshold to be used in a are most at risk who are least able to provide the necessary
given setting since one can see the best trade off between information. Doctors may thus have to resort to measuring
sensitivity and specificity. This threshold is then used to the clinical and biochemical consequences of subnutrition,
calculate the predicted prevalence of disorder and positive but these may present difficulties. Old people often exhibit
and negative predictive values. classical signs of nutrient deficiency (angular stomatitis,
It is necessary to use a stratified sampling strategy only if glossitis, or peripheral oedema), but these are usually the
the prevalence of disorder is below 40%, to avoid spending result of intercurrent illness.7 Many old people have
too much time interviewing non-cases. If this is done, low serum vitamin concentrations,189 but these simply
however, it is essential to weight the data back to the original reflect increased physiological and biochemical variation
sample of consecutive subjects; otherwise the estimate of in old age-for example, low riboflavine or calcifediol
specificity will be too low and the estimate of sensitivity will (25-hydroxycholecalciferol) concentrations are not neces-
be too high. sarily associated with clinical abnormalities."0
It is advisable to calculate an ROC curve to check that the Attempts have recently been made to produce order out of
threshold chosen is appropriate: in medical and neurological chaos by standardising anthropometric and biochemical data
inpatients, for example, the threshold may have to be raised in the elderly and resting their reliability in distinguishing
as high as 9/10 on the general health questionnaire-28 to take between normality and subnutrition."1-"1 Easily measured
account of -symptoms and social dysfunction produced by and calculated values such as the triceps skinfold thickness,
medical illness. arm muscle area, and corrected arm muscle area are useful in
DAVID GOLDBERG assessing nutritional state. Serum albumin and prealbumin
Professor ofPsychiatry, concentrations may also help, though in some groups acute
University of Manchester,
Withington Hospital, illness seems to be more important than dietary deficiency in
Manchester M20 8LR reducing these.'3
1 Nabarro J. Unrecognised psychiatric ilness in m patients. BrMedJ 1984;289:635-6. Even if subnutrition can be identified there is uncertainty
2 Goldberg D. The recopition of psychiatric iness by non-psychiatists. Aus N Z J Psyciatty
1984;18:128-34.
as to its effect on the health of old people-for example,
3 Vazquez-Barquero JL. Padierna Acero JA, Pena Martin C, Ochoteco A. The psychiatric vitamin D deficiency may cause a proximal myopathy, but
correlatesofcoronarypathology: validityoftheGHQ-60asascreeinstrument. PsycholMed
1985;15:597-608.
calciferol supplements do not seem to improve mobility in
4 Goldberg D, Blackwell B. Psychiatric illnes in generX practice. BrMedJ7 1970;ii:439-43. most old people with low serum calcifediol concentrations.'4
5 Goldberg D. Manal of e general healh questionnaire. Windsor: NFER, 1978. Folic acid deficiency may cause mental impairment and
6 Bridges K, Goldberg D. Psychiatric illness in patients with neurological disorders. Br Med J
7
1984;288:268-71.
Goldberg D. Estimating the prevalence of a disordet from the results of a screening test. In:
folate concentrations are often low in patients with dementia
Wing JK, Bebington P, Robins L, eds. What isa case? London: (irant McIntyre, 1981:129-36. -yet folate supplements are of little benefit in most of
8 Goldberg D. Identifying psychiatric illness among general medical patients. Br Med J
1985;291:161-2.
them.'5 Nutrient correction may, however, be of consider-
9 WingJK, Mann SA, Leff JT, Nixon JN. The conept of a case in population studies. PsycholMed able value: ascorbic acid accelerates the healing of surgical
10
1978;8:203-19.
Goldberg DP, Cooper AB, Eastwood MR, Kedward BB, Shepherd M. A psychiatri interview
wounds and pressure sores while calciferol is vital for frank
suitable for use in community surveys. Bnrsh ouonalw of Prevensive and Social Medici osteomalacia.'6 17
1970;24:18-26. Clinical and biochemical indices of subnutrition are associ-
11 American Psychiatric Association. Diagnosc and stisticl manual-III-R. Washington: American
Psychiatric Association, 1985. ated with acute illness and an increased mortality,'8 but are
12 Metz CE. Basic priniples ofROC analysis. Seni" NucI Med 1978;8:283-98.
13 Hanley JA, McNeil BJ. The meaning and use of the ares under the ROC curve. Radiology they cause or effect? Stress pushes old people into negative
14
1982;143:29-36.
Mari JJ, Williams P. A comparison of the ralidity of two psychiatric screening questionnaires in
nitrogen balance, while acute infections alter the ratio of
Brzil using ROC analysis. PsycholMed 1985;15:651-9. buffy coat to plasma ascorbic acid.'9
Since only a minority of old people suffer from sub-
nutrition, the first step is to identify those at risk. This is the
task for the primary care team supported wherever possible
by a health visitor or geriatric visitor. Thereafter the dietitian
Subnutrition in the elderly may have a part to play in providing advice and designig and
distributing booklets.2 This is- most easily organised in day
Because of widespread concern about the poor nutritional centres, lunch clubs, and day hospitals.
state of some elderly people several large commrunity studies The time honoured system for supplementing the diet of
were done in the 1960s and 1970s; these showed that most an elderly patient is to organise a meals on wheels service, but
elderly people had an adequate diet.'4 About 1-2% of those are these effective? Individual meals will appreciably improve
surveyed were, however, suffering from serious subnutrition. the diet only if served at least four times a week, and there
This means about 200 000 people in Britain, and doctors are also problems such as loss of nutrient value during
need to know how to identify subnutrition and which groups distribution and ensuring that meals are actually eaten.2'
are most at risk. Meals served at luncheon clubs, day centres, and day
Most at risk are people with severe mental or physical hospitals are more likely to be effective because they are eaten
incapacity. Social isolation is a risk factor only if compounded with others. Relatives should also be given advice from a
by ill health, and, indeed, old women living alone eat rather dietitian or health visitor on specific nutritional problems
better than those living with others.6 Poverty does not appear that arise.
to be a factor, though old people on low incomes may have to The use of nutrient supplements is controversial. There is
choose between feeding and heating themselves. Ignorance little evidence that their routine use is of much value in the
over entitlement to supplementary benefits is often at the elderly, but individuals with specific problems may be
root of this difficulty. helped-for example, patients with biochemical evidence of
Identifying subnutrition is difficult. Accurate information osteomalacia should be given calciferol (as a large single
on dietary intake requires a skilled dietitian and a cooperative parenteral or oral dose once every six months"' fl)* The
subject who is prepared to weigh her intake of foodstuffs over injection of B complex vitamins may be useful in managing
a whole week. There are various shortcuts in which the confuasional states in acute illne;ss or after a proximal fracture
1190 BRITISH MEDICAL JOURNAL VOLUmE 293 8 NOVEMBER 1986

of the femur, circumstances in which thiamine deficiency is India, Jamaica, Fiji, Trinidad and Tobago, and the United
common.23 Protein supplements have also been given down Kingdom-led by the president, Dr N K Tong from
nasogastric tubes to counteract the catabolic effects of trauma Singapore, concentrated their energies on what to do because
in hip fractures.24 Whether this approach may also benefit the all agreed that unless the association could be reinvigorated it
many cachectic and acutely ill elderly patients who present to would fade into history.
geriatric and general medical units remains to be seen. When the BMA led in launching the CMA in the early
1960s the following aims and objectives were agreed: to
W J MACLENNAN promote within the Commonwealth the medical and allied
Professor ofGeriatric Medicine, sciences and to maintain the honour of the profession; to
City Hospital, Edinburgh EH1O 5SB
effect the closest possible links between members; and to
I Departent of Health ancd Social Security. A nuwioon swy of dte ehlerly. London: HMSO, 1972. disseminate news and information of interest.
(Reports on PubLic Health and Medical Subjects No 3.)
2 MacLeod CC, Judge TG, Caird FI. Nutrition of the ederly at home. I. Intakes of energy, Though these general aims have been largely unfulfilled
proteins, carbohydrates and fat. AgeAgeing 1974;3:158-68.
3 MacLeod CC, Judge TG, Caird Fl. Nutrition of the ddery at home. II. Intkes of viutmin. Age
they remain valid today. Only if they can be translated into
Ageing 1974;1:209-26. action, however, will a majority of Commonwealth medical
4 MacLeod CC, Judge TG, Caird Fl. Nutrition of the elderly at home. III. Intak ofminerais. Age
Ageing 1975;4:49-57.
associations join, pay their subscriptions, and contribute to
5 'Lonergan ME, Mibe JS, Maule MM, t al. A dietary survey of older people in Edinburgh. BrJ the CMA's operation. A lifeline was offered by the BMA and
6
Nur 1975;34:417-27.
Department ofHeah and Social Security. Nutio aad health xold age. London: HMSO, 1979. gladly accepted by the meeting: it will provide the secretariat
(Reports on Health and Social Subjects No 16.) for the CMA; it will promote the programme of work
7 MacLennan WJ. Clinic assessment of nutritional status in the elderly. In: Kemm JR, ed.
Viramis de*ienc in the edery. Oxford: Bbckwedl Scientif, 1985: 22-45. approved by the CMA's council; it will encourage national
8 Milne JS, Lonerp n ME, Wiiliaina J, aal Leucocyte ascorbic acid levels and vitamin C intake
in older people. BrMedJ 1971 ;v:83-6.
medical associations to join; and it will seek additional
9 MacLcnnan WJ, Hamilton JC, Timothy JI. 25-Hydroxy-vitamin Dconctaions in old people sources of finance. If, however, within two years the response
10
livingat home.Jornal of Cinical and ExperimalGerontolob 1979;1:201-15.
Burns J, Davidson AV, MAcnnan WJ, Paterson CR. The valeof serum 25-hydroxy-vitamin D
to this initiative is inadequate the BMA will relinquish the
assays in screening eldely patients for vitamin D defiency.Jownal ofCiical and Exprmena secretariat.
Geontolgy 1985;7:213-22. This offer puts considerable responsibility on the
11 Kemm JR, AlBcock J. The distribon of suposed indicators of nutritional status in elderiy
patents. eAgin 1984;13:21-8. BMA. An early target will be to persuade inactive members
12 Morn DB, Newton HMV, Schorah CJ, a al. Abnorl indices of nutrition in the ddery: a such as Nigeria and Kenya to take part and the wealthier
study of diffe t dinical groups. Age Age* 1986;15:65-76.
13 Friedman PJ, Campbel AJ, Caradoc-Daves TH. Hypoallbuninemia in the elderly is due to
disease not malnunrition.Joml of Cliialnd Expeienta Geontlogy 1985;7:191-204.
associations such as the Australians and Canadians to rejoin,
14 Corless D, Dawson E, Fraser F, a al. Do vitamin ulensmprove the physical capabilitiesof as their presence will be essential to boost the CMA's
dderly hospitl patients?AgeAgeig 1985;14:76-84.
15 Shaw DM, MacSweeney DA, Johnso AL, aal. Folate andame metabolites in senil demnentia:
credibility and finances. The BMA's senior officers, who
a combined trial and biochemicl study. PsycholMod 1971;1:166-71. attended the Cyprus meeting, hope that opportunities will
16 Taylor TV, Dymock IW, Torance B. The role of vitmin C in the treatment of pressure sores in arise for personal approaches to these countries' associations.
nurgical patients. BrJ Stag 1974:6:921.
17 Burns J, Patson CR. Single dose vitamin D treatment for oseonaci in the ddedy. BrMedJ More difficult will be those smaller Commonwealth associa-
1985;290:281-2. tions which do not always reply to letters of inquiry.
18 Phillips P. Grip srength, mental performance ad nutiona status as indicators of morta}ity risk
among femal geriatric patients. AgeAgeig 1986;15:53-6.
19 MacLennan WJ, Hmlton JC. The effect of acute tin on kucocyte and phlama ascorbic acid
Communications will be improved, however, as the BMA is
klvels. BrjNutr 197738:217-23. planning to launch a quarterly CMA bulletin.
20 Henderson J. Nutritil advice for the eldrly. In: Cair4 FI, Evans JG, eds. Advanced geiatric
mnedici 3. London; Pitman, 1983: 29-35.
Attracting external funds will likewise be hard. The
21 Exton-Smith AN, Stanton BR. Report of ax s io the ditary of eldery woue lving Commonwealth Foundation withdrew its help some time ago
alone. London: King Edward's Hospital Fund, 1965.
22 Davies M, Mairen EB, Hann TJ, a al. Vitamin D prophylxis in the eldedy: a simple effective
and would doubtless be reluctant to restart unless the CMA
mehdod suitable forlarge popuions. AgeAAge* 1985;14:349-54. could prove it was working effectively. But private philan-
23 Older MWJ, Dickerson JWT. Thiamine and the elddely orthopaedic patient. Age Ageig thropic foundations might be willing to consider help, and
1982,11: 101-7.
24 Bastow MD, Rawlings J, Allison SP. Benefits of supplmetary tube feeding after frtured neck the pharmaceutical industry and private health corporations
of femur: a randoeised controled trial. BrMedJ 1983287: 1589-92.
are other possible sources of funds. To convince them and
Commonwealth doctors of its usefulness, firstly, the CMA
must strengthen its link with the triennial conference of the
Commonwealth health ministers, at which it has observer
Reviving the Commonwealth status. Secondly, the CMA must explore ways of linking with
the World Health Organisation. Thirdly, it should be a
Medical Association source of advice for national medical associations-for
example, on ethics, health care financing, and particular
When the BMA withdrew from the World Medical Associa- national medical difficulties. This year, for instance, the
tion in 19841 it was left with two regular international CMA supported a call from the Pancyprian Medical Associa-
commitments: the Standing Committee of Doctors of the tion to allow patients throughout divided Cyprus access
European Community and the Commonwealth Medical to doctors of their choice. Fourthly, its regular council
Association. The former, of which the BMA has always been meetings should be linked with a self financing international
an active member, is influential on the European medical conference-perhaps with another profession-on subjects
scene. The latter could be an influential body in international of common professional interest-for example, the quality of
medicine. Sadly the CMA is in no shape to do this at present, drugs, alcoholism, and medicolegal dilemmas. Such a con-
as the recent biennial council meeting held in Cyprus ference is planned for London in 1989.
showed. All this is a tall order, but the BMA has the knowledge and
In politics an organisation with only seven participating the experience to relaunch the CMA towards these targets. A
members out of a potential membership of 49 carries little revitalised CMA might help to fill the international medical
dlout. Indeed, it was thanks only to the generosity and efforts role that a lame duck World Medical Association is signally
of the Pancyprian-Medical Association, coupled with the failing to do.
BMA's provision of limited secretarial services for the past GORDON MACPHERSON
two years, that the 1986 meeting took place at all. Not Deputy Editor, BMJ.
surprisingly the delegates presentrepresenting Cyprus, 1 Anocymous. BMA to withdra frm WMA. BrMedJr 1984;288:161-2.