Mohammed T. Abou-Saleh

750 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYLow body weight is associated with an increased mortality ofelderly people living at home 21 and admitted to hospital 22 . Poornutrition increases the risk of falls and hip fractures 23 and isassociated with excess winter deaths 24 , the development ofpressure sores 25 and infections 26 .Undernutrition may arise from quantitative and qualitativedietary inadequacy, leading to mixed nutrient deficiency. If oldpeople meet their energy requirements by taking a good mixeddiet their needs for nutrients will be met. Some elderly people leadsuch sedentary lives that their energy requirement is very low 27and they become at risk of taking inadequate protein, mineralsand vitamins. As life becomes more sedentary and energy intakedeclines, then diet needs to become more nutrient-dense. Asplundet al. 28 found that 30% of 91 patients, with a variety of diagnoses,admitted to psychogeriatric inpatient care were undernourished.A high prevalence of thiamine deficiency has been reported,especially among the housebound, solitary and confused 29 butalso among admissions to psychiatric units 30 . Alcoholism iscommonly associated with deficiencies in thiamine but alsoriboflavine, pyridoxine, vitamin B 12 and folic acid. Subnormallevels of vitamin C, thiamine and pyridoxine were found byMacLennan et al. 31 in long-stay elderly patients who were alsoprotein-deficient. Inadequate intake of vitamin C has been shownfor 75% of elderly men and over 80% of women, not alwaysreflected by leucocyte ascorbate levels or laboratory parameters31,32 . Vitamin D levels have been shown to be very low inlong-stay elderly populations 33 , almost certainly secondary toinadequate exposure to sunlight 34 . Evidence of multiple vitamindeficiencies has been reported in elderly day hospital attendersand residents of local authority residential homes 8 .Vitamin deficiency is rarely sought in clinical practice, whenonly B 12 and folate estimations tend to be performed with anyregularity. Yet any deficiency, particularly involving the B group,can present with apathy, anorexia, weight loss, mood changes,acute and chronic confusional states and occasionally hallucinationsand paranoia 35 . Depression and alcoholism seem to be thecharacteristic disorders associated with vitamin B and folatedeficiencies, while organic psychosyndromes are typical of B 12deficiency 30 . Thiamine deficiency can produce a wide variety ofmental disturbance and ascorbic acid deficiency is usually linkedwith apathy and depression. Irritability, aggressive behaviour andpersonality change were reported in healthy volunteers undergoingthiamine restriction 36 . Vitamins and minerals are intimatelyinvolved in cell metabolism, neurotransmitter synthesis and cellmembrane stability. Mineral and electrolyte deficiencies, includingiron, calcium, potassium and magnesium, are also commonfindings among elderly populations 3 , with obvious implicationsfor health.TREATMENTThe immediate significance of single deficiency states is confinedto few specific circumstances, e.g. thiamine and the Wernicke–Korsakoff syndrome, B 12 and folate with certain dementias andpseudodepressive states. In most instances, the import ofnutritional status is less obvious and the effects of deficiencyprobably more subtle. Although nutritional supplementation isunlikely to be curative in these situations, there are few studies ofthe effects of nutritional intervention in elderly populations withmental disorder and more information is needed before drawingfirm conclusions. While the real significance of nutritionalmanipulation is awaited, a pragmatic position recommendingdietary supplementation and adjustment with efforts to preventundernutrition is advised.In many circumstances, treating an underlying mental disorderor physical illness effectively will restore appetite and drive,thereby correcting deficiency by the resumption of a normal diet.The admission of a confused elderly person to hospital or caremay provide the opportunity to re-establish a normal eatingpattern. In specific deficiency disorders the prescription ofnecessary supplements will be an essential part of treatment.The possibility that nutrient supplementation may enhance theresponse to conventional psychotropic medication 37 is an interestingpossibility that requires further exploration.The correction of deficiency does not necessarily involveprescribed medication but may be possible by simple measures,such as supplementing the diet with fruit juices to provide morevitamin C. Low levels of vitamin D are found in up to 40% of theelderly living at home or in hospital. Diet is an inadequate sourceof vitamin D, which depends on exposure to ultraviolet light forits formation. A greater exposure to natural sunlight is the mostimportant preventive measure, but because the elderly are atspecial risk it is recommended they receive vitamin D supplementationto achieve a daily intake of 10 mg 38 .The overwhelming priority in the management of undernutritionamong the elderly population is prevention. A majorimpetus must ultimately come from a change in public policy thatimproves the elderly person’s social, material and financialposition in society and ensures the efficient provision of servicesto those in need.The market-led approach to nutrition that operates in manyfood-rich countries has been found to increase the disparitybetween the nutrition and health of the rich and poor 39 . Theprovision of domiciliary care services is inequitably distributed,often inefficiently organized and frequently determined by demandrather than need 40 . Consequently, invaluable services, like mealson-wheelsand home helps (often the only people to provide foodto isolated mentally ill old people), may not reach those most atrisk. Little attention or imagination has been given to the mealsservice, potentially an important resource, which suffers from acomplex, multi-agency organization, inflexibility in deliveringmeals of a type or at a time to suit individuals and often arrivingcold. Only half the recipients find the meals at least moderatelysatisfactory 41 while 15% never eat them and 15% eat only halfthose delivered 42 . There is little evidence that they are targeted atthose most at risk of undernutrition and some evidence that themeals, themselves, are nutritionally inadequate 40 . This has ledsome to suggest that the service acts only as a symbol of concernfor elderly people 43 .Often the supervision of meal times is as important as the mealitself. Confused elderly people may eat voraciously in thecompany of their family yet put meals aside when left to eatalone. Altering the timing of home help or family visits orattendance at a day centre or luncheon club may be theintervention required.The prevention of undernutrition may be possible by simplemeasures, e.g. providing meals in a form that is appealing andeasily edible. Kennedy and Henderson 8 demonstrated theimportance of noting the food returned after meals by the elderlyin residential care. Fruit, vegetables and meat were often leftbecause they were difficult to chew. For seriously impairedindividuals, maximizing food intake during the times of day whencognitive abilities are at their peak can improve dietary intake 44 .The time allowed for meals is normally less in institutions than athome 45 , meal times are inflexible and little consideration is givento personal choice. Some patients will take food from familymembers and not care staff, or only from certain members of staff.Obviously adequate staffing levels will affect success when largenumbers of disabled or resistive patients are eating together.The recent practice in UK hospitals of extending menus toinclude less traditional dishes may be appreciated by the young,but experience suggests many elderly people are happier with localdishes and attempting radical alterations of lifelong dietary habits