Malnutrition in the institutionalized elderly: the effects on wound healing.

Under-nutrition and protein-energy malnutrition are seen at alarmingly high rates in institutionalized elderly and in patients admitted to hospitals. A combination of immobility and loss of lean body mass - which comprises muscle and skin - and immune system challenges increases the risk of pressure ulcers by 74%. The development of pressure ulcers in the hospital affects 10% of admissions, with the elderly at the highest risk. Common causes of malnutrition in the elderly involve: decreased appetite, dependency on help for eating, impaired cognition and/or communication, poor positioning, frequent acute illnesses with gastrointestinal losses, medications that decrease appetite or increase nutrient losses, polypharmacy, decreased thirst response, decreased ability to concentrate urine, intentional fluid restriction because of fear of incontinence or choking if dysphagic, psychosocial factors such as isolation and depression, monotony of diet, and higher nutrient density requirements along with the demands of age, illness, and disease on the body. All have been found to delay healing and increase the risk of pressure ulcer development. In addition, what is ingested should contain nutrients to support health and healing. The financial impact of malnutrition is high and the consequences for patient morbidity and mortality are severe. Practical suggestions to improve the nutritional status of long-term care residents include liberalizing previous diet restrictions where safe and appropriate, addressing impairments to dentition and swallowing, addressing physical and/or cognitive deficits, encouraging family and friends to provide favorite foods, auditing/addressing specific food under-consumption, and providing prudent nutrient supplementation. Clinicians must be aware of the numerous factors in play with regard to nutrition and its impact on not only general well-being but also on wound care. Nutritional intervention in pressure ulcer management is truly "healing from the inside out."