Assessment of Nutritional Status

Simon D. Murray, MD: How would you recommend that we assess the elderly for malnutrition? We happen to live here, in an affluent area, but it’s still not uncommon, even here. But in other areas of the country where it may be more common, what are ways that doctors could assess the nutritional status of their elderly patients?

Jane Schwartz, RDN: Well, there are documents. I think it’s Nestle that puts out the Mini Nutritional Assessment. It’s a pretty basic assessment with a simple questionnaire that they can give their patients, or go through with their patients. And it asks very basic questions about mobility, stress, access to food. And so, based on the rating system, if they score a certain amount of points it indicates whether they’re at moderate risk or at-risk, then they can, using those forms, have at least some indication. At least they’re asking what’s going on, or what might be going on in their home environment, and how much they’re eating, as well as what the factors are at home.

Simon D. Murray, MD: Yes.

Jane Schwartz, RDN: I want to mention that many times, patients going into the hospital are assessed for nutrition at that time, but not when they leave the hospital. They’ve often gotten worse nutritionally or immune-wise, or whatever, and they’re getting sent home and they’re in a very precarious state. And they may not have the right food at home, or they may have a condition where they’re not chewing that well, or whatever it may be.

Simon D. Murray, MD: Yes. It’s absurd to think that we can spend $50,000 on a hospitalization and have the person go home and have it undone in a week.

Jane Schwartz, RDN: Yes.

Simon D. Murray, MD: Because the person has no one at home, or no food at home, or they get handed a stack of papers and prescriptions but they don’t really know what any of this stuff means. The proliferation of paperwork given to people when they leave the hospital is unbelievable. So much of it that it just leads to overload, I think.

Jane Schwartz, RDN: Absolutely.

Simon D. Murray, MD: What other things would you recommend doctors do to assess the nutritional status of their patients?

Jane Schwartz, RDN: You can look at basic laboratory work, in terms of iron status, and albumin levels, and things like that. One thing that I find gets overlooked often are [vitamin] B12 levels. The range of B12 is something like 200 to 900 [ng/mL]. But as an elderly person who has low stomach acid and may be on certain medications that are interfering with B12 absorption, like metformin…. One in 20 patients who are on metformin can have B12 issues.

Simon D. Murray, MD: That’s interesting.

Jane Schwartz, RDN: But it’s not going to get flagged unless it’s less than 200. But as you know, there can be many issues of fatigue, dementia, other neurological issues with B12 levels that are 350. And so, they think the B12 is fine, but then they are having all of these compromised situations.

Simon D. Murray, MD: Yes, we sometimes forget about B12, I think. We look at albumin, of course. What other laboratory studies might be recommended?

Jane Schwartz, RDN: Vitamin D levels. There’s a lot of research now about immune status, and heart health, and cancer prevention. So checking vitamin D is good. Another thing that I see that often gets overlooked is magnesium. The problem with magnesium, though, is that only 1% of magnesium is in the blood. So a magnesium level might come back normal, but again, that’s not going to really show whether it’s compromised. It’s going to pull it from the bones and the tissues and the muscles, just to make sure that the serum is within range.

I find that if you do an RBC [red blood cell] magnesium test, that can sometimes be better. But with all of my patients, I always have them consume higher magnesium foods. I want to make sure that they’re getting that, because stress interferes with magnesium absorption. And many other medications, and….

Simon D. Murray, MD: Diuretics.

Jane Schwartz, RDN: Diuretics. And magnesium is involved in like 300 reactions in the body. It affects the bones, the brain, energy levels, digestion. This can get overlooked too.

Simon D. Murray, MD: Yes. I was always taught that magnesium was ubiquitous in the diet, and that magnesium is found in so many foods that it’s really hard to become magnesium deficient, unless you’re an alcoholic or something like that.

Jane Schwartz, RDN: And that’s not true.

Simon D. Murray, MD: But that’s not true.

Jane Schwartz, RDN: Right, because it’s in green leafy vegetables, and nuts and seeds, and whole grains, and things that many of these people may not be getting enough of in their diet.

Transcript edited for clarity.