According the consensus report published in 2007 (1), the French High Health Authority (HAS) selected the following definitions :

• Thinness is a clinical conditiions characterised by a weight inferior to a common average value, even if this condition is not considered as pathological. It can be a constitutional condition.
• Malnutrition means that the food intakes are not balanced, and refers to undernourishment due to deficiencies as well as over-eating by excess.
• Undernutrition is a physiological term that means « lack of assimilation », phenomenon that implies that the principles that constitute the live organs split from the latter and become residues.

According to the French Health Authorities, protein-energy malnutrition in people over 70 years is defined by four criteria (2,3):

1) weight loss > 10% in 6 months or > 5% in 1 month, or

2) diminution of body mass, particularly muscular mass, with a body mass index (BMI: weight (kg)/size² (m²)) < 21, or

3) albuminemia < 35 g/l, or

4) Mini Nutritional Assessment® <17 (MNA®, Nestlé).

BMI interpretation for elderly: <21: risk of malnutrition; <17: malnutrition.

MNA® interpretation: >24: no malnutrition, 23.5 to 17.5: risk of malnutrition; <17: malnutrition.

Malnutrition: asthenia, apathy, anorexia and weight loss

Protein-energy malnutrition has four cardinal symptoms: asthenia, apathy, anorexia and loss of weight. Asthenia means difficulties to realize previous daily activities. Apathy means lack of interest for daily living activities and social relationships. Anorexia means poor appetite. The loss of weight means an already important malnutrition with a modification of the physical composition, immuno-deficiency and subsequent frailty. Medical symptoms include a diminution of muscle mass and strength, calcium bone loss and bone fragility, recurrent infections, as well as disorders of glyco-regulation, hydration and healing. Any illness episode worsens both malnutrition and immunodeficiency, creating a disease-to-disease spiral that is difficult to reverse. Malnutrition is easier to treat than to prevent (4,5).

Risk factors for malnutrition

Malnutrition is linked to poly-pathologies, to pain, to psychological distress and sometimes to insufficient nutritional care (3). Malnutrition worsens with: the deterioration of the cognitive functions, the poverty, the social isolation and the taking of more than 3 or 4 drugs a day. At the oral level, the risk increases with taste and smell alterations, and oral problems such as oral pain, bad breath (halithosis), untreated caries, dental mobility (periodontitis), loss of teeth and unfitting dentures (6-8). In institution, the risk also increases with the changes of the environment, schedules of meal, food habits and with the lack of help at meal time (2,6,9,10)^.

Protein and energy needs for the elderly

For the elderly, the minimal needs in proteins are 0.8 g of proteins / kg / day (11,12).The sick elderly require at least 1 g of proteins / kg / day and approximately 30 kcal / kg / day, according to their physical activity (13). In case of malnutrition of the elderly, the French Health Authorities recommend 1.2 to 1.5 g of proteins / kg / and 30 to 40 kcal / kg / day (2). For bedridden patients or people with reduced mobility, the contribution of 20 kcal / kg / day can be sufficient (14).

Nutritional assistance for malnourished elderly

The nutritional assistance has "to be increased according to the gravity of the failure. The absolute priority is to privilege if possible the oral route with the help of dietitians, at first by optimizing and by adapting the spontaneous oral food, then by establishing an oral complementation (oral nutritional supplements: ONS) before envisaging artificial nutrition ". For that purpose, the doctors can prescribe ONSs, enriched in proteins and/or in energy (2).

To prevent or fight against malnutrition of the elderly, the French High Authority of Health (HAS) recommends to increase the number of meals and snacks during the day, to avoid a night-fast of more than 12 hours, to favor food enriched in proteins and/or in energy adapted to the preferences of the patients (15) and to help during the meals the patients who need it (2).

Protibis cookies: a solide Oral Nutritional Supplement (ONS)

High protein and high energy Protibis cookies are an ONS which helps to answer these needs, while favoring patients’ autonomy including Alzheimer patients. Eight small cookies a day (48 g) allow to bring under a small volume 10.7 g of proteins and 225 kcal. This dose is easy to distribute during the day. Protibis cookies are recommended to fight against malnutrition within the framework of an enriched food, if needed as a supplement to the other ONSs in the form of drinks or of creams. The objective is to diversify the offer of ONSs to avoid the dullness. It is a French protein-rich galettes.

References

1. Agence nationale d’accréditation et d’évaluation en santé (ANAES). Evaluation diagnostique de la dénutrition protéino-énergétique des adultes hospitalisés. Service des recommandations professionnelles. Septembre 2003.

2. Haute Autorité de Santé (HAS). Recommandations professionnelles. Stratégie de prise en charge en cas de dénutrition protéino-énergétique chez la personne âgée. Avril 2007.

3. Haute Autorité de Santé (HAS). Ministère de la santé et des solidarités. Deuxième programme national nutrition santé 2006-2010. Actions et mesures. Septembre 2006.

4. Sidobre B, Ferry M, Huguenot R. Guide pratique de l’alimentation Editions Hervas, 1997.

5. Raynaud-Simon A, Lesourd B. Dénutrition du sujet âgé. Conséquences cliniques. Presse Méd 2000 ;29 :2183-2190.

6. Donini LM, Dominguez LJ, Barbagallo EM, Sarina C, Castellaneta E, Cucinotta D et al. Senile anorexia in different geriatric settings in Italy. J Nutr Health Aging 2011;15:775-81.

7. Suzuki K, Nomura T, Sakurai M, Sugikara N, Yamanaki S, Mastuskubo T. Relationship between number of present teeth and nutritional intake in institutionalized elderly. Bull Tokyo Dent Coll 2005;46:135-43

8. Madinier I, Starita-Geribaldi M, Berthier F, Pesci-Bardon C, Brocker P. Detection of mild hyposalivation in the elderly based on the chewing time of specifically-designed disc-tests: diagnostic accuracy. J Am Geriatr Soc 2009;57:691-6.

9. Morley JE. Anorexia and weight loss in older persons. J Gerontol A Biol Sci Med Med Sci 2003;58,131-7.

10. Bartali B, Salvini S, Turrini A, Lauretani F, Rosso CR, Corsi AM et al. Age and disability affect dietary intake. J Nutr 2003;133:2868-73.

11. Bischoff-Ferrari HA, Dawson-Hugues B, Baron JA, Burckhardt P, Li R, Spiegelman D et al. Calcium intake and high fracture risk in men and women: a meta-analysis of prospective cohort studies and randomized controlled trials. Am J Clin Nutr 2007, 86:1780-90.

12. Borsheim E, Bui QU, Tissier S, Kobayashi H, Ferrando AA, Wolfe RR. Effect of amino acid supplementation on muscle mass, strength and physical function in elderly. Clin Nutr 2008, 27:189-95.

13. Volkert D, Berner YN, Beery E, Cederholm T, Coti Bertrand P, Milne A et al. ESPEN guidelines on enteral nutrition: geriatrics. Clin Nutr 2006;25:330-60.

14. Campbell WW, Johnson CA, McCabe GP, Carnell NS. Dietary protein requirements of youngers and older adults. Am J Clin Nutr 2008, 88:1322-9.

15. Bernstein MA, Tucker KL, Ryan ND, O’Neill EF, Clements KM, Nelon ME et al. Higher dietary variety is associated with better nutritional status in frail elderly people. J Am Diet Assoc 2002;102:1096-104.