The Australian: Kellie Bisset

Many older Australians are malnourished, and experts suspect some may even be starving to death. Kellie Bisset reports

THE elderly man was 76, severely depressed, and hadn't eaten for two weeks.

Some mouldy pumpkin languished at the bottom of the fridge.

Dehydrated and incontinent, he could barely stand, and when he did, he struggled to keep his pants from falling off.

Getting to the shops from his first floor unit was impossible, and had medical concerns not brought Dr Peter Lipski to his door, he probably would have died there - alone, sad and starving.

As a staff specialist in geriatric medicine at Gosford Hospital, on the NSW Central Coast, Lipski has plenty of stories like this about the malnourished elderly.

"I have horror videos of people who are literally starving because their depression was not treated and malnutrition not identified," he says.

"Malnutrition has massive health implications."

About a third of elderly living at home, and up to two-thirds of older people hospitalised for acute illness are undernourished. In residential aged care facilities up to 60 per cent of residents are affected.

It seems inconceivable that such a simple thing as food can be so hard to get right in this era of advanced medicine. And many hospitals are doing the right thing - including Gosford, and Melbourne's Heidelberg Repatriation Hospital, where dietician Alan McCubbin is on hand to make sure food is suitable.

But experts say that doesn't happen across the board, and malnutrition is a huge problem in Australia that goes unrecognised in as many as 80 per cent of cases. Associate Professor Michael Woodward, director of aged and residential care services at Austin Health in Melbourne, says while you won't see malnutrition listed by doctors on death certificates, it is often a significant cause of death for older people. "At the moment we have older people who are dying of under-nutrition in nursing homes: it happens routinely," he says.

Melbourne dietician Ann Cassar agrees. She has seen skeletal little old ladies who have lost weight rapidly in nursing homes, yet no alarm bells have sounded with staff.

"I have seen cases where a dietician is not called until a person gets to 28kg - and they are pretty much on death's door.

"Some nursing homes don't see it as a problem for an old lady to weigh 40kg after a few months, even if they've always weighed 60kg. They are easier to lift when they're thinner."

Experts like Lipski say that while malnutrition is a huge problem today, it will explode in magnitude as our population ages.

"We are going to see a 500 per cent increase in the number of older patients presenting to accident and emergency in the next 15 years - we have not seen anything yet," he warns.

The flow-on health effects of malnutrition are many. Wound healing is impaired, there are higher rates of reinfection, and patients fall over more often and suffer more bone fractures.

Many of these problems land old people in hospital, where, if malnourished, they will need to stay longer, costing the system more money. One US study showed that for every dollar spent on better nutritional services in hospital, nearly $US5 is saved (Healthcare Financial Management, August 1997).

But Lipski and Cassar say the quality and quantity of food is often the first thing hospitals and nursing homes scrimp on when they need to save dollars.

"Menus look great on paper, but when you see some of the portion sizes they are meagre - they would not feed a child," Cassar says.

"There is a big movement in Europe to have the food and catering in hospitals taken away from housekeeping (departments) and brought under medical so doctors have control over the food. That would be great."

Geriatricians say there can be many causes of malnutrition, and it's important those working in aged care understand these if we are going to get anywhere near a solution. Elderly people might have poor vision, dental problems, and impaired taste and smell.

They could have swallowing difficulties following a stroke.

Dementia, depression, and Parkinson's disease might have left them cognitively impaired and they could be socially isolated, housebound or poor. All of these things affect people's ability to choose and eat appropriate food, but they are often overlooked by the system. Many medical conditions common in older people such as dementia, chronic lung disease, infection, pneumonia and heart failure mean their protein requirements are vastly increased.

If they don't get the extra protein they need, they can develop protein energy under-nutrition, where muscle mass is burnt up and they become progressively weaker, thinner and often confused. Then there's the huge issue of drug toxicity.

Lipski, who says he spends most of his time taking elderly patients off drugs, says one audit at Gosford Hospital showed 50 per cent of all patients over 75 were directly admitted due to adverse drug reactions.

Part of the problem, he says, is that medicine has historically operated as a "single-organ paradigm" where patients are treated in bits rather than as a whole person.

The result is often one patient seeing six different doctors who each prescribe their own pharmacopoeia.

This can amount to a toxic cocktail, according to Professor Allan McLean, director of the National Ageing Research Institute.

Older people are routinely given average drug doses, despite the fact that most drug trials are conducted in heavier, healthier, and younger adults, he says.

But as the body ages, the ability of our liver to clear out toxins is reduced.

Add to the mix five or more different medications, many of which can suppress appetite, and you have not only the potential for at least 120 different drug interactions, but an impaired ability to excrete the excess doses.

Last year, McLean described malnutrition in the elderly as "a national shame" and he stands by that statement.

He says we need less bureaucracy and more action in aged care if any progress is to be made on the problem.

"We know what the problems are, and in many cases we know what the solutions are - [but] we have a bureaucratic industry that generates lots of policies, there is an announcement and everybody sits around and waits for something to happen and what happens? Often nothing, or worse, something inadequate."

The Senate Community Affairs References Committee held an inquiry into aged care last year. It recommended the federal Government review accreditation standards for residential aged care and also "address the health and personal care needs of residents, especially nutrition and oral and dental care".

It also urged greater funding for Home and Community Care (HACC) services, so better levels of care could be provided to the elderly still living at home.

While there has been much recent publicity and some action on the issue of assaults in nursing homes, it's unclear what, if anything, has been done in response to the Senate Inquiry recommendations on nutrition.

The federal Department of Health and Ageing did not respond to Weekend Health's questions on this issue.

In its submission to the Senate Inquiry, the Dieticians Association of Australia said better routine funding of dietician services in aged care facilities would help address the problem. It also urged better accreditation standards for nutrition, which Cassar says are vaguely worded and open to interpretation. The Senate committee report noted that existing standards "merely require that residents receive 'adequate nourishment and hydration' ".

But just as important, according to the experts, is education: -

• of nursing home staff about the nutritional requirements of older people;
• of hospital staff, who frequently remove untouched trays of food without realising old patients might need help to eat their meal;
• of community carers who shop for their elderly clients, but buy all the wrong things;

and of the elderly themselves, many of whom don't realise the link between food and feeling good, or understand how to make cheap, nutritionally adequate food choices.

One thing Allan McLean would do to address this "national shame" would be to reintroduce the nationally funded public dental service. He'd also require those responsible for feeding the elderly to design menus they actually wanted to eat.

Lipski couldn't agree more on that one. He also advocates high-energy snacks like Kit-Kats, meat pies and Mars Bars between meals to stimulate appetite.

"There comes a time when we have to abolish this low-fat nonsense. I still see 90-year-olds who are malnourished and on cholesterol lowering drugs. It is ridiculous."

Apart from regular screening for malnutrition in the elderly, Lipski also backs simple interventions like fortified milk or fruit drinks, which he says can make a huge difference.

"I would put food services in the pharmacy - at the same level as drugs," he says. "We don't need high-tech machines or to put people on tube feeding; we need to do simple, holistic things."