Malnourishment among elders undetected in ER
Doctors and nurses in the hospital emergency department where Dr. Timothy Platts-Mills works were so focused on attending to the medical problems that spark ER visits, they often missed an important health issue that had been hiding in plain sight.
Many of their older patients were apparently malnourished.
When Platts-Mills and his colleagues took a closer look, they found that more than half of the ER patients age 65 and older that they studied were either malnourished or close to it.
The routine questions nurses ask all patients coming into the ER typically include one question about nutrition, and yet malnourishment was still overlooked, according to Platts-Mills’s research, which was recently published in the Annals of Emergency Medicine.
“One of the things alarming to us is, we were asking about malnutrition in the emergency room and yet none of the patients we identified [as malnourished in our study] were picked up” in the routine screening, said Platts-Mills, an assistant professor of emergency medicine at the University of North Carolina at Chapel Hill.
Patients identified as malnourished in Platts-Mills’s study were those who scored low on a test widely used by researchers, a test that considers a patient’s height and weight, weight loss, and food intake in the previous three months, and whether the patient has suffered any recent acute diseases or psychological stress.
Platts-Mills found that malnutrition was more common among older patients with symptoms of depression, also those reporting difficulty buying groceries, and those who said they had trouble eating because of denture problems, pain, or difficulty swallowing. The researchers noted that Medicare, the federal health insurance program for millions of adults over age 65, does not cover routine dental care, an issue that may contribute to some of the poor oral health they detected.
Other studies have pinpointed malnutrition as a significant problem among older adults in community and hospital settings, with rates ranging from 6 percent in the community to as high as 39 percent among hospitalized elders. But the North Carolina research is believed to be among the first to detect it among seniors coming to the emergency room.
With older adults heading to the ER more often than younger patients, the setting could be used for screening medical problems that typically are under diagnosed among seniors who do not receive routine medical care, the researchers suggested.
“Emergency physicians are increasingly an important source of medical care for older adults,” Platts-Mills said. “The onus is on us to try to identify some of these unmet needs and malnutrition is one of them.”
His study was small — it involved just 138 patients — but the findings are resonating with other emergency room physicians, social workers, and specialists who treat older adults, and who said instances of malnutrition would likely be similar in other emergency rooms.
“If patients are malnourished, they are more at risk for infections, and their ability to maintain their health is much more challenged, said Dr. Shan Woo Liu, an emergency room physician at Massachusetts General Hospital who was intrigued by Platts-Mills’s findings.
Liu, who is also an assistant professor at Harvard Medical School, said patients are not specifically asked about nutrition when they enter the emergency room at Mass General.
“In an ideal world, there would be so much more we could do in our emergency department for our elderly,” said Liu, who also researches traumatic health problems among older adults.
“I know the challenge of working in a busy emergency department and not having the support or time to do all of these screening tests,” she said. “There needs to be, overall, better geriatric emergency care.”
Eleanor Ballentine, a 90-year-old Jamaica Plain resident, is well-acquainted with hospitals and the challenges in getting out to grocery shop. Ballentine lost much of her sight five years ago because of macular degeneration, a common eye condition that can cause vision loss in older adults.
She has also in recent years lost what once was a robust appetite. Then in June she got an infection, was hospitalized, and struggled to eat and regain a lot of lost weight as she recuperated over the summer at home.
“You look at food and go, ‘ugh,’ ” Ballentine said.
What stands between Ballentine and malnutrition are regular visits from her nephew, who brings groceries, in addition to the daily meals delivered by Meals on Wheels, a home-delivered meals program.
“This is 2 dollars a day for one meal and it’s worth every penny,” Ballentine said. “And they make the most wonderful lasagna.”
Ballentine’s meals are delivered by Ethos, a Boston nonprofit organization that provides home-based and other services to more than 2,500 seniors and disabled residents.
Dale Mitchell, Ethos executive director, said Massachusetts has done an admirable job ensuring that Meals on Wheels programs are sufficiently funded so there are no waiting lists as there are in other parts of the country. But he said Massachusetts falls far short in helping home-bound seniors combat depression.
“As mobility is impaired, connections to the outside world are restricted, and that has psychological consequences,” Mitchell said.
“Depression is a growing phenomenon among home-bound elders, and yet there are few to zero options for these people to address the problems, and that will have nutritional consequences,” he said.
Ethos just received a state grant, Mitchell said, to develop a program aimed at helping home-bound seniors with depression.
But sometimes having meals and other services delivered to home-bound older adults can be tricky, said Dr. Sarah McGee, an assistant professor of medicine at the University of Massachusetts Medical School, who specializes in treating older patients.
“Let’s say they don’t want someone to come into their home,” and decline Meals on Wheels, McGee said.
“When someone starts to lose weight, one of the first things we do is review what they have been eating,” McGee said. “It’s always an eye-opener to see what people are eating and not eating.”
She said she has found that some medications can sometimes play havoc with older patients’ appetites because they can leave an unpleasant taste, or cause chronic dry mouth.
McGee and others agree that malnutrition among elders is a serious problem. But the best way to detect it and intervene is still an open question.
Elizabeth Dugan, an associate professor of gerontology at University of Massachusetts Boston, used to train medical students and is not convinced a busy emergency room is the best place to pinpoint poor nutrition. She would aim for focusing more on the issue in primary care settings.
But either way, she said, “the prevalence is alarming enough, that it needs to be addressed.”