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The patient, almost 80, appeared happy and healthy, sitting with his wife, who always accompanied him for his periodic check-ups. He’d lost a few pounds since his last visit, which didn’t seem remarkable, until the clinician took a look at the notes from the last few consults. The patient had been registering a similar weight loss at the last several visits, which now added up to 15 lb.
The doctor—T.S. Dharmarajan, MD, clinical director of the division of geriatrics at the Wakefield Campus of Albert Einstein College of Medicine’s Montefiore Hospital in the Bronx—was perplexed. He asked the patient, who had previously been just above ideal weight, whether he was concerned. Not only was he concerned about the weight loss, but he also reported that he just did not have a good appetite.
Dharmarajan went to work. The patient was not depressed and did not have many of the common risk factors for malnutrition in the elderly, such as lack of access to transportation or food, a recent loss, or a solitary existence. Dharmarajan conducted a battery of tests, including chest radiography and abdominal CT. He contemplated upper endoscopy, but first decided to thoroughly review the man’s medications.
He noted that the patient was taking ramipril, an angiotensin-converting enzyme inhibitor known to create taste disturbances. Dharmarajan proposed stopping the drug for a few months. It worked: The patient’s appetite returned, and he quickly gained a few pounds. Ramipril wasn’t ever proven to be the cause, but that didn’t matter. “I saw a happier patient,” Dharmarajan said.
Who Is At Risk?
The story is not unusual. Six percent to 30% of seniors living in the community are malnourished, and up to half may be at risk, according to West Health, a San Diego-based nonprofit that advances research and policy to improve the lives of seniors.
A 2017 report by Meals on Wheels America (funded by the AARP Foundation and Caesars Foundation) found that more than 10 million older Americans (16%) face hunger each year, driven largely by food insecurity—the inability to access enough food for an active, healthy life.
At its simplest, malnutrition is defined as “any disorder of nutrition, including overnutrition and undernutrition,” according to the Academy of Nutrition and Dietetics (AND).
A 2012 consensus statement from the AND and the American Society for Parenteral and Enteral Nutrition proposed that adults be considered malnourished if they have any two of the following conditions:
A small study published in the Journal of the Academy of Nutrition and Dietetics in 2016 validated the proposed measures, and urged their adoption. But the authors cautioned that a larger study was required to gather further evidence of their validity.
Malnutrition as a diagnosis is complex, and its causes are multiple: financial, social, physical, emotional, and mental.
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