Z Gerontol Geriat 40:3–12 (2007)
DOI 10.1007/s00391-007-0430-x
L. Pauly
P. Stehle
D. Volkert
Ernährungssituation
älterer Heimbewohner
" Abstract Malnutrition in insti-
tutionalized elderly is of individ-
ual and public concern since it
negatively affects health outcome
and quality of life and is often
preventable. Over the past years
several studies have examined the
prevalence of malnutrition in in-
stitutionalized elderly and re-
ported greatly diverse results. The
Received: 12 December 2006
Accepted: 2 January 2007
Priv.-Doz. Dr. Dorothee Volkert ())
Pfrimmer Nutricia GmbH
Am Weichselgarten 23
91058 Erlangen, Germany
E-Mail: d.volkert@nutricia.com
Lioba Pauly · Peter Stehle
Dorothee Volkert
Department of Food and
Nutrition Sciences
Nutritional Physiology
University of Bonn
Endenicher Allee 11–13
53115 Bonn, Germany
CONTRIBUTION TO THE MAIN TOPIC
Nutritional situation of elderly
nursing home residents
purpose of the present literature
review is to give an overview of
the current knowledge about the
nutritional situation of institu-
tionalized elderly having specific
regard to the prevalence of pro-
tein-energy malnutrition and nu-
trition-related problems. Based on
a literature search and additional
articles from the files of the
authors, observational studies
with relatively unselected popula-
tions reporting figures for the
prevalence of malnutrition and/or
the prevalence of nutrition-related
problems (e.g. poor appetite,
chewing or swallowing problems,
eating dependency or poor in-
take) and published between 1990
and 2006 were considered. Rele-
vant information was extracted
and compiled. A total of 42 eligi-
ble studies with 41 to 6832 par-
ticipants were found. BMI was the
most frequently used parameter
for nutritional assessment with
mean values mostly between 21
and 24 kg/m2. Eight studies ap-
plied a cut-off value of 20 kg/m2
and reported between 10% and
50% low values. Weight loss was
reported in 7 studies with preva-
lence rates between 5 and 41%,
reduced serum albumin (< 35 g/L)
in 10 studies with prevalence
rates between 0 and 50%. Accord-
ing to the MNA (12 studies) mal-
nutrition was observed in 2 to
38% and a risk of malnutrition in
37 to 62%. Nutritional problems
were reported in 17 studies, again
with great variability between the
studies. In physically and men-
tally capable study populations
malnutrition was relatively unfre-
quent. Prevalence rates were high-
est in studies with great propor-
tions of disabled and severely im-
paired residents.
It can be concluded that mal-
nutrition is generally widespread
in institutionalized elderly. Preva-
lence rates vary according to the
parameters and cut-off values
used for nutritional assessment
and according to the population
under study. Future studies
should carefully characterize their
participants and use standardized
nutritional assessment tools in
order to achieve better compar-
ability of study results as up to
now.
" Key words malnutrition –
undernutrition – nutritional
problems – nursing home –
institutionalized elderly
" Zusammenfassung Ältere
Heimbewohner haben aufgrund
häufiger funktioneller und ge-
sundheitlicher Beeinträchtigungen
ein erhöhtes Risiko für Mangeler-
nährung. Studien über die tat-
sächliche Verbreitung von Man-
gelernährung kamen in den letz-
ten Jahren zu unterschiedlichen
Z Gerontol Geriat 1 2007
4 L. Pauly et al.

Ergebnissen. Ziel der vorliegen-
den Übersichtsarbeit war es da-
her, einen Überblick über die ver-
fügbaren Daten zur Ernährungs-
situation, speziell zur Häufigkeit
von Mangelernährung und von
Ernährungsproblemen, bei älteren
Heimbewohnern zu geben. Mit
Hilfe einer Literaturrecherche mit
definierter Suchstrategie wurden
Beobachtungsstudien mit ge-
mischten Kollektiven älterer
Heimbewohner und Angaben zur
Prävalenz von Mangelernährung
und/oder zur Prävalenz von Er-
nährungsproblemen (z. B. Appe-
titlosigkeit, Kauprobleme,
Schluckbeschwerden) gesucht, die
seit 1990 in englischer Sprache
publiziert worden waren. Zusätz-
lich wurden relevante Arbeiten
aus den Beständen der Autoren
berücksichtigt. 42 Studien mit 41
bis 6832 Teilnehmern wurden
identifiziert. Zur Beschreibung
der Ernährungssituation wurde
am häufigsten der BMI herange-
zogen. In 8 Studien wurde ein
Grenzwert von 20 kg/m2 gewählt
und zwischen 10 und 50% er-
niedrigte Werte festgestellt. Ein
Gewichtsverlust wurde in 7 Stu-
dien mit Häufigkeiten zwischen
5 und 41% beschrieben, ernied-
rigte Albuminkonzentrationen
(< 35 g/L) in 10 Studien mit Häu-
figkeiten zwischen 0 und 50%.
Mittels Mini Nutritional Assess-
ment (MNA; 12 Studien) wurde
Mangelernährung bei 2 bis 38%
und ein Risiko für Mangel-
ernährung bei 37 bis 62% der
Teilnehmer berichtet. Ernäh-
rungsprobleme wurden in 17 Stu-
dien auf sehr unterschiedliche
Weise erfasst, auch hier war eine
große Streubreite auffällig. Bei
funktionell wenig beeinträchtig-
ten Populationen wurde Mangel-
ernährung relativ selten beobach-
tet, dagegen waren Bewohnerkol-
lektive mit großen Anteilen funk-
tionell beeinträchtigter Senioren
vergleichsweise häufig betroffen.
Zusammenfassend lässt sich fest-
halten, dass Mangelernährung bei
älteren Heimbewohnern weit ver-
breitet ist. Die Häufigkeit variiert
je nach Methode und Grenzwert
zur Erfassung von Mangelernäh-
rung und in Abhängigkeit von
der untersuchten Population. Um
in Zukunft besser vergleichbare
Studienergebnisse zu erhalten,
sollten die Teilnehmer weiterer
Studien sorgfältig charakterisiert
und zur Erfassung der Ernäh-
rungssituation einheitliche, stan-
dardisierte Methoden verwendet
werden.
" Schlüsselwörter
Mangelernährung – Unterernäh-
rung – Ernährungsprobleme –
Pflegeheim – Heimbewohner

disabled and highly afflicted with functional impair-

Introduction
Elderly people are at high risk of malnutrition. A
variety of factors including sensory losses, anorexia,
chewing and swallowing problems, chronic and
acute diseases and accompanying multimedication
may compromise dietary intake and lead to nutri-
tional deficiencies and malnutrition. Compared to
well-nourished elderly, those suffering from malnu-
trition have a higher risk of illness, e.g. infections,
falls and fractures or decubitus, and the progression
of age-related chronic diseases as well as the course
of acute diseases may be worsened – resulting in a
loss of quality of life [35, 37].
Whereas the largest part of the elderly population
is living independently and able to manage daily
shopping, cooking and eating by themselves, an in-
creasing number of elderly is in need of help and as-
sistance for these activities of daily life, and thus liv-
ing in institutions. In nursing homes or long-term
care facilities these seniors are relieved of the bur-
den of shopping and cooking. Daily meals with ade-
quate amounts of energy and nutrients are made
available. On the other hand many of the above
mentioned risk factors are highly prevalent in this
population. Institutionalized elderly are more or less
ments and diverse health problems that may com-
promise adequate nutrition – and are thus at high
risk of malnutrition. Nursing staff members often do
not realize nutritional problems and the need for in-
dividualized nutritional care. Malnutrition remains
largely unrecognized [1, 15].
In Germany, presently about 700,000 elderly are
living in institutions and an increase is expected in
the upcoming years due to demographic changes
[53]. In order to allow for a high quality care in in-
stitutions for the elderly, problems and needs of the
residents must be realized and addressed – including
nutritional problems and needs. Presently very little
is known about the nutritional situation of institu-
tionalized elderly in Germany [52, 60]. Over the past
years several studies from other countries have ad-
dressed this topic. However, varying results were
striking.
The purpose of the present literature review is to
give an overview of the current knowledge about the
nutritional situation of institutionalized elderly in
industrialized Western countries having specific re-
gard to the prevalence of protein-energy malnutri-
tion and nutrition-related problems.

Z Gerontol Geriat 1 2007

Nutritional situation of elderly nursing home residents
Methods
This review is based on a qualitative analysis of biblio-
graphic references found in PubMed (National Library
of Medicine and National Institutes of Health, USA). A
defined search strategy with specified keywords for
institutionalized elderly (institution, nursing home,
long term care) in combination with keywords for
the nutritional situation (nutrition, nutritional status,
nutritional assessment, malnutrition, undernutrition,
nutritional problems) was applied. The query was lim-
ited to articles published in English, with abstract and
with participants aged 65 years or older.
This review was restricted to observational studies
in industrialized Western countries with relatively un-
selected populations published not before 1990 and
examining a minimum number of 40 participants.
Studies were selected if figures for the prevalence of
protein-energy malnutrition (PEM) or the prevalence
of nutritional problems were given. Relevant cited ref-
erences in published articles and articles from the in-
ventory of the authors were also used.
From eligible studies information about nutri-
tional status – assessed by body mass index (BMI),
weight loss, anthropometric parameters, serum pro-
tein concentrations, Mini Nutritional Assessment
(MNA) [59], Subjective Global Assessment (SGA)
[19] or otherwise defined protein-energy malnutri-
tion – and nutritional problems (e.g. poor appetite,
chewing or swallowing problems) was extracted and
compiled. Importance was attached to the selection
and characteristics of the study populations.
Results
n Studies and participants
A total of 42 studies fulfilling the above mentioned
inclusion criteria were considered [1, 2, 4, 6–14, 16,
17, 20–26, 28, 29, 31–34, 39, 40, 45–50, 52, 54, 56–58,
60, 61] (Table 1). 28 of these studies were accom-
plished in European countries, mostly Sweden (5
studies) and Spain (5 studies), 12 in the United
States of America and 2 in Canada. 18 studies were
carried out in a single institution, 24 studies re-
cruited their participants in more than one, 9 stud-
ies in more than 10 institutions, 2 in more than 100
[9, 20]. The institutions were referred to as either
nursing home (28), long-term care facility (7), retire-
ment home (4), old people’s home (2) or geriatric
long stay ward (1). In one study so-called service
flats and specific housing forms for demented elderly
were included [49].
5
The number of subjects under examination varied
between 41 [6] and 6832 [9]. 14 studies examined
less than 100 participants, 10 studies between 100
and 200 and in 18 studies more than 200 partici-
pants took part. In 4 surveys – 3 American [1, 9,
20] and 1 Finnish [57] – more than 1000 partici-
pants were included. 5 studies were restricted to
women, in 22 studies more than two thirds were
women, and only 1 study was confined to men [1].
Mean age of the study participants was above 80
years in all but two studies [28, 58]; however, in 12
studies mean age was not reported. With regard to
functional status in some studies great proportions
of mobile, independent, and self-sufficient residents
are remarkable [22, 25, 45, 50, 60]; in others, partici-
pants are predominantly dependent in basic activ-
ities of daily living [7, 20, 23, 28, 34, 40]. In many
studies, no information is given in this regard [1, 2,
4, 6, 11, 13, 25, 33, 39, 46, 47].
In several studies subjects with severe health
problems were excluded. Thus, multiple studies lim-
ited participation to residents without terminal,
acute or severe disease [8, 9, 17, 24, 31, 32, 39, 40,
45, 48, 49, 50, 61]. 5 studies mentioned that subjects
with enteral or parenteral nutrition were excluded
[8, 9, 21, 47, 56]. Frisoni et al. [21] and Sacks et al.
[47] explicitly excluded subjects with decubitus, La-
sheras et al. [32] bedridden or wheelchair-bound,
and Schmid et al. [52] feeding-dependent persons. 5
studies [17, 25, 31, 34, 60] only considered residents
without dementia or severe mental deterioration.
Crogan et al. [17] selected subjects with at least one
risk factor for malnutrition, and Sullivan et al. [56]
recruited only residents with weight loss or poor ap-
petite during the past 3 months. Applying these cri-
teria, either all residents (13 studies), random sam-
ples (5 studies) or newly admitted residents (9 stud-
ies) were considered. In 3 studies volunteers were in-
vited to participate [45, 48, 60], and in 12 studies no
information is given in this regard.
n Nutritional status
BMI was the most frequently used parameter for nu-
tritional assessment (22 studies). Mean values were re-
ported in 12 studies varying in all but two studies
from 21 kg/m2 [2, 7, 8, 56] to 24 kg/m2 [14, 21, 57,
60]. Schmid et al. [52] found a mean BMI of 25 kg/
m2 and an extremely high mean BMI of 28 kg/m2 is
reported by Gamez et al. [22]. In 16 studies the prev-
alence of low BMI values is presented applying differ-
ent cut-off values ranging from 17 to 24 kg/m2 (Table
2). When a BMI of 20 kg/m2 was chosen as the lower
limit of normality (9 studies) prevalence rates between
10% [22, 46] and 50% [40] were found. Beck et al. [8],
Z Gerontol Geriat 1 2007
6 L. Pauly et al.

Table 1 Reviewed studies

Author (year) Country n % women Age Facility

Mean (range)
Abbasi (1993) USA 2811 0 – – 26 NH
Akner (2003) S 54 65 80 ± 10 (51–96) NH
Baldelli (2004) I 352 63 82 ± 8 – NH
Beck (2004) DK 132 77 84 – 4 NH
Beck (2002) DK 180 75 – ≥ 65 5 NH
Beck (2001) DK 41 83 83 – x NH
Blaum (1995) USA 6832 73 – 49% ≥ 85 202 NH
Blaum (1997) USA 186 75 80 ± 6 – LTCF
Bleda (2002) E 67 81 83 – 2 GLSW
Buckler (1994) USA 217 81 – 47% ≥ 85 4 NH
Christensson (1999) S 261 57 – (65–103) RH
Compan (1999) F 423 69 83 ± 10 (57–98) LTCF
Crogan (2003) USA 311 – – ≥ 65 3 NH
Crogan (2006) USA 80 75 81 ± 9 – 2 NH
Fries (1997) USA 2128 – – – 268 NH
Frisoni (1994) I 104 81 82 ± 9 > 60 NH
Gamez (1998) E 93 74 81 ± 8 (60–97) NH
Gants (1997) ISR 205 100 – (56–95) NH
Gerber (2003) CH 78 100 86 ± 8 ≥ 70 11 NH
Griep (2000) B 81 80 83 ± 7 (61–98) RH
Jeske (2006) A 272 84 84 ± 9 – 5 NH
Keller (1993) CAN 200 17 79 – LTCF
Kruizenga (2003) NL 808 – 80 ± 11 – 16 NH
Lamy (1999) CH 120 76 81 ± 8 (65–96) 8 NH
Lasheras (1999) E 161 70 80 ± 6 – 2 NH
Margetts (2003) UK 240 – – ≥ 65 x RH+NH
Mojon (1999) CH 324 70 85 ± 7 ≥ 65 NH
Nelson (1993) USA 100 61 81 ± 1 (65–100) LTCF
Nordenram (2001) S 192 80 84 ± 8 – NH
Ruiz-Lopez (2003) E 89 100 - (72–98) 2 NH
Saava (2002) EST 51 - - (51–97) NH
Sacks (2000) USA 53 79 83 ± 6 ≥ 65 4 LTCF
Sahyoun (1996) USA 176 64 - (60–101) 15 LTCF
Saletti (2000) S 872 69 85 ± 8 - 33 F *
Salva (1999) E 87 79 80 ± 9 - NH
Schmid (2003) D 47 100 85 ± 7 (65–94) NH
Steele (1997) CAN 349 80 87 (71-108) OPH
Sullivan (2004) USA 900 76 86 ± 8 (65–104) 96 NH
Suominen (2005) FIN 214 81 82 – 20 NH
Thomas (1991) USA 50 56 76 ± 13 – LTCF
Volkert (1992) D 50 100 80 ± 4 (75–89) 2 OPH
Wikby (2006) S 127 69 85 ≥ 65 8 RH
F facilities, GLSW geriatric long stay ward, LTCF long-term care facility, NH nursing home, OPH old people’s homes, RH residential home, x number not given
* 33 facilities of 4 different types

Z Gerontol Geriat 1 2007

Nutritional situation of elderly nursing home residents 7

Table 2 Prevalence of low BMI values in nursing home residents Table 3 Prevalence of weight loss in nursing home residents

BMI Author (year) n Facility Prevalence Author (year) n Facility Weight loss Preva-
[kg/m2] (%) lence (%)

< 17 Akner (2003) 54 NH 20 Beck (2002) 24 NH > 5% in 3 months 38

< 18.5 Jeske (2006) 260 5 NH 6 Blaum (1995) 6832 202 NH 5% in 1 month or
< 18.5 Volkert (1992) 50 2 OPH 10 10% in 6 months 10
< 18.5 Beck (2001) 41 x NH 18 Buckler (1994) 217 4 NH > 4.5 kg in 1 month 30
< 18.5 Beck (2002) 180 5 NH 22 Frisoni (1994) 104 NH 0–5 kg in 6 months 38
< 19 Suominen (2005) 2105 20 NH 18 > 5 kg in 6 months 5
< 19.4 Blaum (1995) 6832 202 NH 25 Kruizenga (2003) 808 16 NH 0–5 kg in 6 months 12
> 10% in 6 months 6
< 20 Gamez (1998) 93 NH 10 Nordenram (2001) 192 NH > 5% in 1 month or
< 20 Volkert (1992) 50 2 OPH 12 > 10% in 6 months 41
< 20 Fries (1997) 2128 268 NH 32 or unclear
< 20 Beck (2001) 41 x NH 33
< 20 Beck (2002) 180 NH 33 Sullivan (2004) 900 96 NH ≥ 5% in 1 month 32
< 20 Akner (2003) 54 NH 40 ≥ 10% in 1 month 6

≤ 20 Saava (2002) 51 NH 10 NH nursing home

≤ 20 Saletti (2000) 872 33 F 23
≤ 20 Nordenram (2001) 192 NH 50
< 21 Salva (1999) 87 NH 12
are reported. Whereas Blaum et al. [9] found only
< 21 Sullivan (2004) 900 96 NH 32 10% of almost 7000 American nursing home resi-
< 22 Jeske (2006) 260 5 NH 20
dents with a weight loss of more than 5% in 1
< 22 Crogan (2006) 80 2 NH 23 month or more than 10% in 6 months, another large
< 22 Crogan (2003) 311 3 NH 39 American survey [56] and a small Danish study [7]
≤ 22 Suominen (2005) 2105 20 NH 31 reported 32 and 38% subjects with weight loss using
< 22.5 Blaum (1995) 6832 202 NH 50
similar definitions.
Other anthropometric parameters were only spora-
≤ 23 Saletti (2000) 872 33 F 55
dically used with clear cut-off values to describe the
< 23.1 Blaum (1997) 186 LTCF 25 prevalence of reduced fat stores or muscle mass [10,
< 24 Schmid (2003) 47 NH 46 32, 45]. Lasheras et al. [32] reported 10 to 12% of val-
< 24 Beck (2004) 132 4 NH 69 ues below the 10th percentile of a Swedish reference
≤ 24 Nordenram (2001) 192 NH 78 group for triceps skinfold, arm circumference, arm
muscle circumference and corrected arm muscle area.
NH nursing home, OPH old people’s home, LTCF long-term care facility,
F facilities, x number not given
Blaum et al. [10] found 25% of their residents with an
arm muscle area below 29.5 cm2 and Ruiz-Lopez et al.
[45] noticed 3 to 7% reduced values for triceps skin-
fold, subscapular skinfold and arm circumference.
Nordenram et al. [40] and Schmid et al. [52] used 24 The prevalence of reduced serum albumin concen-
kg/m2 as the cut-off and described 69, 78 and 46%, re- trations is reported in 5 American [1, 12, 17, 39, 48]
spectively, below this value. and 5 European [31, 32, 45, 50, 60] studies, all using
In 3 studies the prevalence of undernutrition was 35 g/L as reference value. Four studies found preva-
estimated by comparing body weight to standard or lence rates of 5% or less [31, 32, 45, 60], 4 studies
ideal body weights [1, 21, 23]. A retrospective survey prevalence rates between 16 and 19% [17, 39, 48,
of the medical records of 2811 residents in 26 Ameri- 50], and one study [12] reported 50% of 217 randomly
can nursing homes [1] revealed 2 – 20% (median 12%) selected residents with low albumin values. In the
of body weights below 80% of the standard in the dif- multicenter study of Abassi [1] prevalence rates from
ferent institutions. Gants et al. [23] in a smaller study 5 to 58% (median 28%) were detected in the 26 insti-
in Israel reported 10% with an actual body weight be- tutions under study. Other serum proteins – prealbu-
low 80% of a standard and 14% between 80 and 100% min, transferrin and/or retinol-binding protein – were
of the standard. Frisoni et al. [21] calculated ideal analyzed in 3 studies [17, 45, 60]. Using different cut-
body weight by a specific formula and found 42% of offs the prevalence of low values varied from 0 to 33%.
104 residents of an Italian nursing home having actual In 13 studies the MNA was used for nutritional
body weights below these ideal values. assessment (Fig. 1). The prevalence of malnutrition
Weight loss was reported in 7 studies (Table 3). ranged from 2% [25] to 38% [4] with 4 studies find-
Using different definitions for a significant weight ing less than 10% affected participants [25, 31, 45,
loss, prevalence rates between 5% [21] and 41% [40] 50]. A risk of malnutrition was detected in 37% [11,

Z Gerontol Geriat 1 2007

8 L. Pauly et al.
Fig. 1 Prevalence of malnutrition according to Mini
Nutritional Assessent (MNA) in nursing home residents
(MN malnutrition)
25] up to 62% [45]. In 8 studies at least half of the
residents were judged to be at risk. In the study of
Baldelli et al. [4] more than 90% were either at risk
or malnourished. In contrast, in the study of Saava
et al. [46] this was the case for only 28%.
Sacks et al. [47] determined malnutrition by sub-
jective global assessment (SGA) and classified 53%
of 53 consecutive admissions to 4 long-term care fa-
cilities in the USA as moderately and 17% as se-
verely malnourished. Volkert et al. [60] and Schmid
et al. [52] characterised 13 and 8% respectively as
undernourished by an unstandardized subjective
clinical judgement.
In 8 studies a nutritional index including several
parameters was used for the assessment of malnutri-
tion. Thus, Christensson et al. [13] defined malnutri-
tion as 2 or more of 5 nutritional variables being
subnormal, including one anthropometric and one
biochemical measurement, and found 33% malnour-
ished elderly on admission to a Swedish residential
home. Using the same index Wikby et al. [61] re-
ported nearly the same prevalence (32%) in another
survey in Swedish residential homes.
Nordenram et al. [40], also in Sweden, calculated
a nutrition score as the sum of points for 7 vari-
ables. The score ranged from 0 (good) to 7 (worst),
2 points were denoted as “at risk for PEM” and ≥ 3
points as “evident PEM”. For both categories the
authors found a prevalence of 25%. Nelson et al.
[39] and Thomas et al. [58] stated malnutrition if at
least 4 out of 7 nutritional parameters were below a
standard value and found 39 and 54% of elderly ad-
mitted to American long-term care facilities, respec-
tively, to be malnourished. Keller et al. [28] also con-
sidered 7 different parameters and classified 18% as
severely and 28% as mild to moderately undernour-
Z Gerontol Geriat 1 2007
ished. Mojon et al. [34] combined BMI (< 21 kg/m2)
and serum albumin (< 33 g/L) to estimate malnutri-
tion and reported 52% with at least one of the two
nutritional markers below the selected cut-off. Final-
ly Margetts et al. [33], considering different BMI and
weight loss categories, detected 13% at high and 8%
at medium risk of malnutrition.
n Nutritional problems
Nutritional problems, namely poor appetite, chewing
problems, swallowing problems, problems cutting
food, eating dependency and poor dietary intake, were
reported in 17 studies with great variability between
the studies (Table 4). In several studies more than half
of the participants were affected [31, 52, 54, 56].
Discussion
During the last 15 years a considerable number of
studies have examined the nutritional situation of
institutionalized elderly and reported prevalence fig-
ures for malnutrition and nutritional problems.
Using different methods and parameters a wide
range of prevalence rates were observed.
Malnutrition in the elderly is often associated
with functional impairment, disability and impaired
health. Thus, among non-institutionalized, indepen-
dently living elderly the prevalence of malnutrition
is generally low [18, 33]. In contrast, geriatric pa-
tients in acute care settings are affected to a great
extent. In a recent German multicenter study, for ex-
ample 56% of 306 geriatric patients were moderately
or severely malnourished according to SGA [43]. In
Nutritional situation of elderly nursing home residents 9

Table 4 Prevalence of nutritional problems in nursing home residents

Author (year) n Facility Poor Chewing Swallowing Poor Poblems Feeding

appetite problems problems intake cutting assistance
food (totally eating
dependent)
Akner (2003) 54 NH 22% - 19% - - 48% (20%)
Beck (2002) 180 5 NH - - - - - (14%)
Blaum (1995) 6832 202 NH - 22% - 21% - (28%)
Blaum (1997) 186 LTCF 7% 11% 7% 26% - -
Christensson (1999) 261 RH 35% 21% * 18% - 41%
Frisoni (1994) 104 NH - - - - - (35%)
Keller (1993) 200 LTCF 38% - 19% - - 41% (25%)
Lamy (1998) 120 8 NH - 52%** - - - -
Nordenram (2001) 192 NH - 23% 15% 14% - -
Sahyoun (1996) 176 15 LTCF - 57% - - - -
Saletti (2000) 872 33 F - - - - - 39% (14%)
Schmid (2003) 47 NH 51% 26% 15% - 45% 0%
Steele (1997) 349 OPH - - 68% 46% - 49% (18%)
Sullivan (2004) 900 96 NH 66% - - - - 43% (18%)
Suominen (2005) 2114 20 NH - - 20% - - -
Volkert (1992) 50 OPH 14% 20% 10% - 16% -
Wikby (2006) 127 8 RH - - - - - 36%
NH nursing home, LTCF long-term care facility, OPH old people’s home, RH residential home, F facilities; * chewing and swallowing problems, ** not able to chew
raw carrots

other studies with acutely ill geriatric patients even
higher prevalence rates are reported [27, 38]. Since
nursing home residents are more or less disabled
and generally living in an institution because of
their need of help or care, high prevalence rates of
malnutrition could be expected as well in this group
of elderly. This speculation was confirmed in many
of the studies reviewed here that reported malnutri-
tion in more than 40% [2, 9, 12, 21, 28, 34, 40, 47,
49, 58]. In other studies, however, prevalence rates
were merely around 10% or below [22, 25, 31, 45,
46, 50, 60]. Abassi et al. [1] reported a broad range
of malnutrition, expressed as reduced body weight
and albumin levels, within one study that was ac-
complished in 26 different nursing homes and ob-
served great differences between these homes. The
authors ascribe this to the great heterogeneity of the
elderly population even within the group of gener-
ally compromised seniors living in institutions. In
fact, studies considered in the present review also
differed with respect to their populations. In general,
mixed groups of residents were surveyed; neverthe-
less different degrees of dependence, need of help
and care were noticable. Whereas in some studies
functional impairment and dependency prevail [7,
20, 23, 28, 34, 40], others report great proportions of
mobile, independent or self-sufficient residents [22,
25, 45, 50, 60]. These differences in functional status
are at least partly reflected in the different preva-
lence rates of malnutrition. This is in accordance
with several studies reporting an increasing preva-
lence of malnutrition with decreasing functional
abilities within their institutionalized study popula-
tions [24, 26, 44, 49, 57].
Differences in study populations can partly be ex-
plained by the variation in kind and number of in-
stitutions, number of participants and recruitment
procedures (Table 1). Whereas a number of studies
reported specific inclusion or exclusion criteria
others included all residents. Regrettably in many
studies, selection criteria and characteristics of the
institutions as well as of the participants are only
poorly or not described at all. Consequently signifi-
cance and comparability of study results is ham-
pered.
In the present review, the terms used for the dif-
ferent types of facilities – nursing home, residential
home, old people’s home or long-term care facility –
did not allow any conclusion concerning functional
or nutritional status of the residents. For example,
Bleda et al. [11] in geriatric long-stay wards reported
similar prevalence rates of malnutrition and risk of
malnutrition assessed by MNA as Wikby et al. [61]
in residential homes. In old people’s homes, Volkert
et al. [60] found a rather low prevalence of malnutri-
tion and nutritional problems, whereas Steele et al.

Z Gerontol Geriat 1 2007

10
[54] reported high prevalence rates of nutritional
problems like dysphagia, need of feeding assistance
and poor intake.
For the assessment of malnutrition, generally, a
variety of different methods is available [41, 42]. In
the studies reviewed here, anthropometric, biochem-
ical and clinical methods were applied with body
mass index, weight loss, albumin and MNA as the
most frequently used parameters or tools.
Although the reliability of the BMI is questioned
in the elderly because of difficulties measuring body
height and weight, this index is widely used and re-
garded as an important parameter for nutritional as-
sessment also in the elderly [5, 41]. There is no gen-
eral agreement about the limits of normality and,
accordingly, a broad range of different cut-off values
is in use, resulting in often incomparable results (Ta-
ble 2). When prevalence rates below 20 kg/m2 are re-
garded in relation to the functional abilities of the
populations under study, the association between
functional and nutritional status is obvious, as just
discussed.
Weight loss is regarded as one of the most mean-
ingful parameters for the assessment of malnutrition
[3, 5, 36]. Surprisingly only 7 studies reported recent
weight loss in their populations and, unfortunately,
different criteria concerning the extent of the weight
loss were used (Table 3).
Interestingly, serum albumin was analyzed in many
studies despite its limited value as nutritional param-
eter and strong interaction with health status [30, 55].
Even though in many studies subjects with terminal,
severe and acute diseases were excluded, and nursing
home residents usually are not acutely ill, more than
half of the studies reported more than 15% of resi-
dents with reduced albumin concentrations.
Other serum proteins as well as anthropometric
results were only exceptionally reported in the re-
viewed studies using different cut-offs for normality.
Since accepted reference values are lacking for the
elderly, these parameters are of limited value for nu-
tritional assessment in this population group [41].
In 8 studies nutritional indices were used report-
ing prevalence rates between 21% [33] and 54%
[58]. The approach of considering several parame-
ters from different areas simultaneously seems to be
reasonable at first glance; however, the variety of dif-
ferent indices in use impedes comparison of study
results and diminishes their significance.
In recent years the MNA as special kind of nutri-
tional index is increasingly used to detect malnutri-
tion or the risk of malnutrition in the elderly. The
method is especially designed for the elderly, vali-
dated and rather popular [59]. As it covers several
functional aspects, namely mobility, eating-depen-
dency and cognition, it is not surprising that the
Z Gerontol Geriat 1 2007
L. Pauly et al.
prevalence of malnutrition and the risk of malnutri-
tion is low in studies with great proportions of self-
sufficient, capable subjects and high in more depen-
dent study groups.
Nutritional problems like poor appetite, chewing
or swallowing problems, problems cutting food or
eating dependency were reported in a considerable
number of studies, however, in an unsystematic
manner. Mostly the problems were assessed by ques-
tionnaire and clear definitions are not given. Conse-
quently comparison and interpretation of the results
is difficult. It can be recorded that nutritional prob-
lems are widespread in institutionalized elderly. In
some studies a relation between nutritional status
and nutritional problems was evident [28, 49, 60].
In order to facilitate comparison of study results in
the future, the use of standardized nutritional assess-
ment techniques is strongly suggested. Recently a lim-
ited list of items that should be used in nutritional in-
tervention studies in the elderly was proposed by an
expert group [51]. This list can easily be applied also
in observational studies. Further discussion about this
topic is suggested in order to identify valid and reli-
able tools and the best proceeding. In future studies
also recruitment procedures and characteristics of
the participants should be clearly described. Study
populations should be well characterized with respect
to physical, mental and general health status, also
using uniform parameters.
If reliable information about the prevalence of
malnutrition and nutritional problems is available,
in a next step the need for intervention might be es-
timated. In many cases malnutrition is treatable or
even preventable. If recognized early, appropriate nu-
tritional care can prevent further weight loss and
avoid worsening of nutritional status. Currently, in
daily routine nutritional concerns are often ne-
glected. In Germany, awareness of nutritional prob-
lems in institutions is generally increasing; however,
in most of the facilities nutritional screening, assess-
ment and treatment procedures are not established,
and consequently systematic and effective nutritional
care is not provided. As soon as possible strategies
for effective nutritional interventions should be im-
plemented in long-term care institutions for the el-
derly in order to prevent and treat malnutrition and
thus ensure high quality care.
Conclusions
• Prevalence rates for malnutrition in institutiona-
lized elderly vary according to the definition of
malnutrition, method used for nutritional assess-
ment and population under study.
Nutritional situation of elderly nursing home residents 11

• Independent of the method used, it can be con-
cluded that malnutrition is widespread in institu-
tionalized elderly and increasing in prevalence with
increasing functional impairment and disability.
• Routine nutritional screening and assessment is
mandatory for early identification of residents at
risk.
• Strategies for effective nutritional interventions
should be implemented in long-term care institu-
tions for the elderly in order to prevent and treat
malnutrition and thus insure high quality care.
• Future studies should carefully characterize their
participants and use standardized parameters for
nutritional assessment in order to achieve better
comparability of study results.
" Conflict of interest There is no conflict of interest. The corre-
sponding author assures that there is no association with a com-
pany whose product is named in the article or a company that
markets a competitive product. The presentation of the topic is
impartial and the representation of the contents are product neu-
tral.

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