Much of the litigation involving the elderly in nursing homes includes allegations of malnutrition. But malnutrition is not necessarily a sign of negligence. Instead, aging—and its many side effects—is a major contributor to the problem.

The physiology of aging can affect body function in many ways that negatively impact nutritional health. Take, for example, these six side effects of aging:

• Sensory loss—particularly reduced sense of taste and smell—can often cause a diminished or absent desire to eat.
• Decreases in metabolic rate can lead to slowing of digestion and less frequent hunger.
• The slowing of digestion may in turn cause constipation, which often leads to under-eating due to discomfort and/or feelings of fullness.
• Slow digestion may subsequently result in decreased absorption of calcium and Vitamin D, which can lead to bone loss and pain. This pain may cause decreased activity and further diminish the need and desire for nutritional intake.
• Bone loss can also lead to dental problems that result in pain or difficulty chewing and a consequent decrease in eating.
• Slowing of function in the esophagus can lead to difficulty swallowing and a voluntary curtailment of nutritional intake.

Often, the co-morbid conditions that exist challenge even the best efforts to support nutrition in the aged. Another common factor is age-related loss of muscle mass, which can lead to decreased activity. The lack of activity can, in turn, contribute to further breakdown of muscle mass, leading to greater decreases in strength, exertion, and activity with consequential reduction of nutritional intake. It is common for the body to increase fat stores in response to the loss of body mass and/or muscle mass. Consequently, there may be no evidence of weight loss, or there may even be a gain in weight. This makes it difficult to evaluate and diagnose nutrition issues in the elderly.

Decreases in cardiovascular and renal function can also contribute to malnutrition. With aging, there are changes at the cellular level that can cause organs to slowly lose function, with the greatest changes occurring in the heart, lungs, and kidneys. As these organs lose function, there is a corresponding decrease in the transfer of essential nutrients—causing additional strain on the body and impacting overall nutrition.

Acute or chronic disease processes can also cause or contribute to malnutrition. The incidence of atrophic gastritis, a form of chronic inflammation of the stomach, appears to increase with age and can decrease the desire to eat. The presence of diverticulosis—small pouches in the colon that can at times cause discomfort or pain—also increases with age. When elderly patients suffer from diseases that make eating an uncomfortable prospect, it becomes very difficult to ensure they have adequate intake. Further, diseases such as urinary tract and other infections, decubitus ulcers, and malignancies may cause the development of elevated resting metabolic rates and an accelerated loss of body cell mass, loss of appetite, decreased intake, and wasting.

When taking into account the myriad pathophysiological effects of aging on nutrition, it is clear that maintaining the nutritional health of the elderly can be a challenging and sometimes impossible task for the healthcare provider, even in the presence of excellent clinical care. Because the factors contributing to malnutrition are often complex, expert medical review can help defense attorneys distinguish cases that are the result of neglect from those that are unavoidable due to physiological issues.