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Senile anorexia in different geriatric settings in

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Article in The Journal of Nutrition Health and Aging November 2011
Impact Factor: 3 DOI: 10.1007/s12603-011-0048-y Source: PubMed

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SENILE ANOREXIA IN DIFFERENT GERIATRIC SETTINGS IN ITALY

L.M. DONINI1, L.J. DOMINGUEZ2, M. BARBAGALLO2, C. SAVINA3, E CASTELLANETA3,
D. CUCINOTTA4, A. FIORITO4, E.M. INELMEN5, G. SERGI5, G ENZI5, C. CANNELLA1
1. Department of Medical Physiopathology (Food Science Section) University of Rome La Sapienza (Italy); 2. Geriatric Unit, Dept. of Internal Medicine and Emergent Pathologies,
University of Palermo (Italy); 3. Rehabilitation Clinical Institute Villa delle Querce - Nemi (Rome Italy); 4. S. Orsola-Malpighi Hospital, Bologna (Italy); 5. Department of Medical
and Surgical Sciences, Geriatrics Section, University of Padua (Italy); Correspondence to: Lorenzo M. Donini, University of Rome La Sapienza, Department of Medical
Physiopathology Food Science Section, P.le Aldo Moro, 5 00185 Rome (Italy), e-mail: lorenzomaria.donini@uniroma1.it, tel.: +39.06.4969.0216, fax: +39.06.4991.0699

Abstract: Objectives: Anorexia is the most frequent modification of eating habits in old age, which may lead to
malnutrition and consequent morbidity and mortality in older adults. We aimed to estimate the prevalence and
factors associated to anorexia in a sample of Italian older persons living in different settings. Our secondary aim
was to evaluate the impact of senile anorexia on nutritional status and on eating habits, as well as on functional
status. Design and Setting: Observational study in nursing homes, in rehabilitation and acute geriatric wards, and
in the community in four Italian regions (Lazio, Sicily, Emilia-Romagna, and Veneto). Participants: 526 over 65
years old participants were recruited; 218 free-living subjects, 213 from nursing homes, and 96 patients from
rehabilitation and acute geriatric wards in the context of a National Research Project (PRIN) from the Italian
Ministry of Instruction, University and Research (2005-067913 Cause e Prevalenza dellAnoressia senile).
Measurements: Anthropometric and nutritional evaluation, olfactory, chewing, and swallowing capacity, food
preferences, cognitive function, functional status, depression, quality of life, social aspects, prescribed drugs, and
evaluation of gastrointestinal symptoms and pain. Laboratory parameters included prealbumin, albumin,
transferrin, C-reactive protein, mucoprotein, lymphocyte count, as well as neurotransmitters leptin, and ghrelin.
Anorexia was considered as 50% reduction in food intake vs. a standard meal (using 3-day "Club Francophone
de Griatrie et Nutrition" form), in absence of oral disorders preventing mastication. Results: The overall
prevalence of anorexia was 21.2% with higher values among hospitalized patients (34.1% women and 27.2%
men in long-term facilities; 33.3% women and 26.7% men in rehabilitation and geriatric wards; 3.3% women and
11.3% men living in the community) and in the oldest persons. Anorexic subjects were significantly less selfsufficient and presented more often a compromised nutritional and cognitive status. Diet composition analyses of
anorexic older adults revealed a lower intake of all food groups and a general tendency to a monotonous diet.
Conclusion: Anorexia is a frequent condition in older Italians, particularly those hospitalized, with important
consequences in the nutritional and functional status. The analysis of dietary components and its quality along
with the frequency of intake of single food groups may be useful to plan intervention strategies aiming to
improve the nutritional and health status of older adults with anorexia. An early detection of anorexia followed
by an adequate intervention in older hospitalized patients to avoid further worsening of clinical and functional
status is warranted.
Key words: Anorexia, aging, malnutrition, elderly.

Introduction

(increased cytochines induce anorexia), chronic obstructive

pulmonary disease (dyspnea while eating), stroke (residual
dysphagia), angina abdominis (severe abdominal pain after
eating), chronic constipation (with fullness feeling), and
dementia (lack of interest on food) (1). Anorexia associated
with disease is more frequent in institutionalized elderly, may
be aggravated by polypharmacy and repeated hospitalization
(9), and in some cases may lead to cachexia (10). In addition,
anorexia may depend on financial, social and psychological
factors, mainly depression, which is the most common cause of
protein/ energy malnutrition in older persons (11, 12).
The aim of the present study was to estimate the prevalence
and to evaluate factors associated with anorexia in a sample of
Italian older adults from different regions (Lazio, Sicily,
Emilia-Romagna, Veneto), in three different settings (freeliving, nursing homes, and rehabilitation/acute wards). A
secondary aim was to evaluate the impact of senile anorexia on
nutritional status and on eating habits, as well as on functional
status.

Aging is frequently associated with modifications in eating

habits with significant changes in appetite and food intake (1).
This phenomenon has been called anorexia of aging since first
described by Morley and Silver in 1988 (2). The aspects
involved in this condition are multiple including age-associated
modifications in taste and smell (3), delayed gastric emptying
leading to increased satiation (4), altered gastrointestinal
hormone secretion and responsiveness with increased
cholecystokinin levels and activity (5), and reduced
testosterone levels in men leading to elevated leptin levels (6).
Other age-related changes are decreased efficiency of chewing
function often due to edentulism, and spontaneous
gastroesophageal reflux (1, 7). Reductions in gastric and
pancreatic exocrine secretions limit the capacity to digest
proteins, which is added to a reduction in amino acid intestinal
absorption (i.e. lysine, tryptophan and threonine) (7, 8).
Anorexia may be associated to diseases such as cancer
1

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Subjects and Methods

thickness (TSF), arm circumference (AC), arm muscle

circumference (AMC). Waist circumference was measured
at the midpoint between the lower rib margin and the iliac
crest while the participant was standing upright. The
anthropometric measurements were performed according to
the Standard Manual for Anthropometric Measures (16);
- Laboratory parameters included prealbumin, albumin,
transferrin, C-Reactive protein (CRP), mucoprotein,
lymphocyte count; quantitative measurement of leptin in
serum was performed using a leptin ELISA kit (Diagnostics
Biochem Canada), intra-assay CV<6%, interassay CV<7%;
Ghrelin concentrations in plasma were assessed with a
ghrelin ELISA kit (BioVendor, Czech Republic), intra-assay
CV <10%, interassay CV <10%. Biochemical parameters
were performed in one centre (University La Sapienza
Rome).
- Characteristics of food intake (meal composition, food
variability, raw meals, number of meals taken, snacks, use of
multivitamins/mineral pills, preferred or refused food, etc.);
- Handgrip strength was measured in kilograms by using a
handheld dynamometer (C.I.: <10%).

From April 2006 to June 2007, 526 over 65 years old

subjects were randomly recruited (218 free-living persons, 213
subjects from hospitals or long-term facilities, and 96 subjects
from rehabilitation wards or acute geriatric wards) in four
Italian institutions located in Rome (Clinical Rehabilitation
Institute Villa delle Querce - Nemi), Bologna (S.OrsolaMalpighi Hospital), Padua (Department of Medical and
Surgical Sciences, Geriatric Section), and Palermo (Geriatric
Unit, Department of Internal Medicine and Emergent
Pathologies). This study was performed as a Research Project
of National Interest (PRIN) sponsored by the Italian Minister of
Education, University and Research (MIUR) (see
acknowledgment). A preliminary meeting with researchers
involved in each of the centers was carried out before the
beginning of the study in one of the centers (University La
Sapienza Rome) with the aim of receiving training on the
details of the study and on how to perform the evaluation in a
standard manner, including anthropometric measurements,
blood drawing, sample conservation, functional scales, dietary
questionnaires, etc.
At the time of recruitment, food intake was recorded for
three days using the "Club Francophone de Griatrie et
Nutrition" form (13); at the end of each meal dietitians
estimated the portion of food that had been truly eaten and
quantified it in quarters (0 to 4/4) compared to a standard meal.
A diagnosis of anorexia was considered in case of absence of
disorders preventing mastication (i.e. dysphagia, oral pain,
reduced wakefulness) together with three or more days of
reduction in food intake, equal or greater than 50% of a
standard meal. Exclusion criteria included: 1) patients requiring
parenteral and/or enteral nutrition; 2) patients with medical
conditions precluding reliable nutritional assessment (liver,
renal and/or heart failure, presence of severe edema) or affected
by severe comorbidity (grade 4: severely incapacitating or lifethreatening conditions) according to the Cumulative Illness
Rating Scale (CIRS) (14).
In anorexic subjects and in a random sample of age- and
gender-matched subjects without anorexia, a comprehensive
geriatric assessment was performed including the following
domains: nutritional status, depression, social factors, health,
functional and cognitive status, quality of life, chewing and
swallowing capacity, olfaction and taste functions. Scales used
for the comprehensive geriatric evaluation are described below.
Nutritional status was assessed by:
- Mini Nutritional Assessment (MNA), a well-validated tool,
extensively used worldwide, to identify patients at risk for
malnutrition, with high sensitivity, specificity, and
reliability. MNA has been also validated for the follow-up of
nutritional intervention and is currently recommended by
many national and international clinical and scientific
organizations (15).
- Anthropometric parameters included body mass index (BMI:
kg of body weight/squared height in m), triceps skin-fold

Depression was evaluated using a subjective

(GeriatricDepression Scale) (17) and an objective scale
(Cornell Scale for Depression) (18).
Patients justification of anorexia was classified as:
- problem denial: I have always eaten as I do currently;
- opposition: the patient barely eats and then refutes to
continue eating because he/she feels full or has stomachache or nausea;
- refusal: rejection of food and of persons who want to help
him/her to eat.
Social status: anamnesis regarding the 6 months before the
admittance were collected. The investigations were focused on
civil status and on the presence of people helping to shop
and/or to cook, bereavement, and abandonment feelings. The
number of visits and telephone contacts during hospitalization
period were recorded, as well as the number of persons with
whom meals were taken.
Health status: the grading of clinical status, comorbidity and
severity levels were assessed using the CIRS (14). This scale
classifies comorbidity by 13 organ systems and grades each
condition from 0 (no problem) to 4 (severely incapacitating or
life-threatening condition). The CIRS index is given by the
number of situations graded 3. The severity index is the mean
value of the severity scores for the 13 organ systems.
Prescribed drugs: number and type of medications taken by
the patients were recorded and examined for their impact on
anorexia and malnutrition. These included non-steroidal antiinflammatory drugs, dietary supplements, medications that alter
central nervous system, taste and smell functions, and drugs
acting on respiratory and cardiovascular systems.
Gastrointestinal symptoms: symptoms potentially affecting
food intake were registered as follows: constipation (weekly
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frequency of bowel movement), diarrhea (yes/no) and
complaints of epigastric pain (yes/no).
Pain, potentially affecting food intake, was evaluated using
the following questionnaire:
a) I can bear pain without using drugs. My normal activities
of daily living (ADL) are not aggravated by pain and are not
influenced by pain.
b) I feel pain, but I am still able to lead a normal life without
drugs.
c) Drugs give me relief from pain, and just using them I can
manage my ADL.
d) Drugs give me moderate relief from pain. I need help, but
I can do most of my ADL by myself.
e) Drugs give me a little bit of relief, but I need help to do all
but the simplest ADL.
f) Drugs dont help me. I cannot do any ADL.
Functional and cognitive impairment were assessed using
ADL (19), Instrumental Activities of Daily Living (IADL) (20)
and Mini Mental State Examination (MMSE) tests (21).
Chewing function: a research staff member counted the
number of natural teeth. Presence, fit, and usage of dentures
were also assessed. Chewing function was evaluated with a bicolor chewing gum; the patient was invited to chew for 10 min
and the degree of mixing of the two colors was evaluated with
a visual scale from 1 to 8.
Swallowing function was evaluated using the SWAL-QOL
instrument (22), which gives information about the swallowing
capacity for solid food and liquids (beverages).
Olfaction and taste functions were assessed using an
ascending-series staircase methodology. The task is a two
alternative (test stimulus & control), forced-choice, ascending
concentration, single series procedure. The stimuli presented
during this task were menthol dissolved in light odorless
mineral oil and phenethyl alcohol dissolved in deionized water.
Taste thresholds were assessed for basic tastes using sucrose
(sweet), sodium chloride (salty), citric acid (sour), and quinine
hydrochloride (bitter). Similar to the olfaction thresholds, the
tastes were assessed in ascending-series with replications for
each concentration.
Diet variety was assessed by confrontation of participants
food intake and frequency with mean intake indicated in
National Italian guidelines of INRAN (Italian National Institute
of Nutrition, 2003) (23). Diet variety was measured by adding
the number of food groups (dairy; meat, fish, and eggs; cereals
and derivatives; fruit and vegetables) present daily in the
participants diet. An adequate intake for each food group was
considered as follows: for dairy, a frequency equal or greater
than 7 days/week; for meat, fish and eggs, at least once a day;
for cereals and derivatives, at least 7 days/week; for fruit and
vegetables, at least 7 days/week.
Neurotransmitters: ghrelin and leptin, implicated in hunger
control and concentration of gastrointestinal factors and
previously linked to senile anorexia (1) were measured.
Statistical analyses were performed using SPSS 12.0
statistical software (SPSS Inc Wacker Drive, Chicago, IL,

USA). Data are expressed as means standard deviation. The

comparisons between clinical, functional and laboratory
characteristics of subjects with anorexia vs. those with normal
eating habits were performed with unpaired Students t-test for
continuous variables, and with chi-square statistics for
comparisons of proportions. Comparisons of proportions
among the different settings were assessed with Chi-square
statistics, and differences in numerical variables (i.e. age,
laboratory parameters and tests scores) among different settings
were assessed with ANOVA statistics. Differences were
considered to be statistically significant for p <0.05.
Results
General characteristics of participants recruited from the
different geriatric settings are described in Table 1 (for
different geriatric settings according to sex) and Table 2 (for
anorexic subjects vs. controls). As shown, age was similar for
men and women in the different groups and school education
level was low both in men and women (i.e. 56.8% to 83% of
the whole group attended primary school while 0.9% to 6.7%
had received higher education). The low frequency of
participants with high education may be explained by the fact
that older populations in Italy, both men and women, lived their
younger years during the World War conflicts, leaving them
with few opportunity to get education. In particular, women
from that generation had very little chances to get high
education. Some, but not all of the participants come from rural
areas, where it is possible that the education level is even
lower. Another possibility is that more educated people have a
higher standard level, and more often live at home, either with
their family or have the capacity of paying for assistance at
home. Nevertheless, participants in the free-living group had
more frequently secondary education as compared to
hospitalized patients, but there was a small number of
graduates also in this group. There were no significant
differences in education level between anorexic and controls
(Table 2). Most of the subjects were single or widowed, and in
the whole group, the clinical status was characterized by a high
level of comorbidity and severity both in men and women.
Prevalence of anorexia was 21.2% in the whole group. As
seen in Table 1, it was significantly higher in hospitalized
subjects (both nursing homes and acute/rehabilitation wards
31.3% and 31.5%, respectively), particularly in women.
Prevalence was higher in the oldest patients who needed higher
assistance for buying and preparing food.
Considering the whole group, participants with anorexia are
significantly older than normal eating subjects and present a
higher degree of disability. In particular, they were more
dependent for grocery shopping and cooking (Table 2).
Anorexic subjects had significantly higher GDS and Cornell
scores indicative of depression; they had lower scores for
cognitive status evaluated with MMSE, and presented a higher
degree of comorbidity (Table 3). Self-sufficiency was
significantly more compromised in anorexic subjects; over half
3

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of anorexic elders had lost more than two ADL and had a
significantly lower IADL score (Table 3). In addition, there
were significantly reduced chewing efficiency and more
swallowing difficulties along with more sensorial functional
alterations in anorexic subjects (Table 5).

Table 3
Clinical, depression, cognitive, and functional status of patients
affected by senile anorexia vs. controls (normal eating subjects)
in the whole group of participants

Table 1
General characteristics of men and women of participants from
different geriatric settings
Rehabilitation/Acute
wards
Men
Women
n
Age (years)
Education level
Primary (%)
Secondary (%)
Graduate (%)
Marital status
Single (%)
Widowed (%)
Clinical status
Comorb. Index
Severity Index
N drugs
Anorexia (%)

Nursing homes

Clinical status

Depression
Functional status

Free living

Men

Women

Men

Women

81

132

97

121

30

66

81.8 8

81.5 7

70.0
23.3
6.7

68.2
28.6
3.2

75.4
23.2
1.4

83.8
15.4
0.9

56.8
38.7
4.5

63.8
32.7
3.4

16.7
50.0

17.2
37.5

34.5
24.7

37.9
45.5*

7.5
20.8

7.3
53.7*

3.4 2
1.8 0,4
6.3 2
26.7

2.6 2*
1.7 0.5
6.0 3
33.3

77.7 9 78.8 10 75.6 6#

2.8 2 2.3 1* 1.5 1#

1.6 0.4 2.6 0.3 1.4 0.4#
6.0 3
5.9 4
3.6 2#
27.2
34.1
11.3#

Cognitive status

Rehabilitation/Acute
wards
Anorexia Normal
eating
Clinical status
Comorb. Index
Severity Index
N drugs
Constipation (%)
Diarrhea (%)
Epigastric pain (%)
Pain ( 3) (%)
Depression
GDS
CORNELL
Functional status
IADL score
ADL (> 2 lost
functions) (%)
Cognitive status
MMSE score

* means p<0.05 vs. men; # means p<0.05 vs. other settings (for each sex)

Table 2
General characteristics of the sample according to the presence
or absence of anorexia

Sex
Age
Education level

Marital status
Need of assistance

Men (n)
Women (n)
years
Primary (%)
Secondary (%)
Graduate (%)
Single (%)
Widowed (%)
Grocery Shopping (%)
Cooking (%)

41
71
83.0 7
73.5
25.0
1.0
24.8
46.8
84.0
81.1

167
248
76.6 8*
72.0
24.8
3.2
16.2
37.0
72.4*
67.2*

2.4 2
1.6 0.5
5.5 4
6.7 5
12.1 7
4.2 5
55.5
18.5 9

2.1 2*
1.9 0.6
53
4.7 4*
8.7 7*
7.9 6*
31.8*
23.8 5*

Table 4
Clinical, depression, cognitive, and functional status of patients
affected by senile anorexia vs. controls in different geriatric
settings

1.7 1#
1.5 0.5#
4.1 2#
3.3*#

Normal eating

Normal eating

IADL: Instrumental Activities of daily living; ADL: Activities of daily living; GDS:
Geriatric Depression Scale: MMSE: Mini Mental State Examination; * means p<0.05 vs.
anorexia (subjects with senile anorexia)

76.2 7#

Anorexia

Comorbidity index
Severity index
N of drugs
GDS
CORNELL
IADL score
ADL (> 2 lost functions) (%)
MMSE score

Anorexia

Nursing homes

Free living

Anorexia Normal Anorexia

eating

Normal
eating

2.3 2
2.6 2
1.5 0.4 1.6 0.6
6.1 3
5.5 5
18.2
28.5
15.2
4.9*
16.7
12.5
30.4
15.3*

1.7 1
1.4 1
3.9 2
42.9
0
50
42.8

1.6 1
1.4 0.4
3.9 2
24.3
9.6*
29.9
40.9

3.1 2
1.8 0.4
62
73.3
6.7
36.7
45.5

2.7 2
1.7 0.6
63
53.0*
7.7
21.2
70.3*

53
11 7

65
10 8

8.4 7
7.6 5 5.6 4#
12.9 7 18.9 9* 12.4 5

3.5 3#
6.8 5*#

6.7 4

9 4*

2.7 5

3.1 4

6.5 6#

11.3 4*#

27.6

43.8

65.7

48.3

42.9#

13.8*#

22.3 6

24.2 4*

14.8 9 20.3 7* 22.2 8# 25.3 4*#

IADL: Instrumental Activities of daily living; ADL: Activities of daily living; GDS:
Geriatric Depression Scale: MMSE: Mini Mental State Examination; * means p<0.05 vs.
anorexia (subjects with senile anorexia); # means p<0.05 vs. other settings (for anorexic or
normal eating participants)

* p<0.05 vs. anorexia (subjects with senile anorexia)

In analyses by setting, participants with anorexia enrolled in

acute and rehabilitation wards had significant impairment in
chewing and swallowing efficiencies (11.1% vs. 4.8%, p<0.05),
while no differences were found for sensorial perceptions (taste
and olfaction). In nursing homes, swallowing difficulties were
also more frequent in anorexic subjects (13.8% vs. 0, p<0.05).
There were no differences for sensorial perceptions (taste and
olfaction). In free-living subjects the number of natural teeth
was lower in anorexic subjects and the frequency of prosthesis
use was higher.

Table 4 illustrates differences between anorexic and normal

eating subjects in different geriatric settings. As shown, in
rehabilitation/acute wards there is a tendency to a higher
comorbidity that did not reach statistical significance. Anorexic
subjects reported more frequently constipation in acute wards
and pain in acute wards and nursing homes. Both in acute
wards and free-living subjects anorexic had more compromised
IADL scores. In all settings, cognitive status was significantly
worse in anorexic subjects. In nursing homes there were no
differences in comorbidity and number of drugs for anorexic
vs. normal eating subjects. However, anorexic subjects more
frequently reported diarrhea and pain.

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Table 5
Sensorial perceptions (taste, olfaction), chewing, and
swallowing functions of patients with senile anorexia vs.
controls (normal eating subjects) in the whole group of
participants

Table 7
Eating habits of patients affected by senile anorexia
Rehabilitation/Acute Nursing homes
Free living
wards
Anorexia Normal Anorexia Normal Anorexia Normal
eating
eating
eating
Food frequency
Milk (<1/day) (%)
Red meat (<4/week) (%)
Poultry (<5/week) (%)
Fish (<3/week) (%)
Eggs (<2/week) (%)
Cereals (<4/day) (%)
Pulses (<2/week) (%)
Fruit (<2/day) (%)
Vegetables (<2/day) (%)
Dietary supplements (%)
Reduced consistency
meals(%)

Anorexia Normal eating

Chewing efficiency N of natural teeth
Prosthesis wearing (%)
Swallowing test
SpO2 post test (%)
Swallowing difficulties (%)
Taste
Sweet (sucrose >0.032 M) (%)
Salty (NaCl >0,032 M) (%)
Sour (citric acid >0,0011 M) (%)
Bitter (quinine >0,32x10-5) (%)
Olfaction
Menthol (>1.6 x 10-3 g/ml) (%)
Phenetyl alcohol (1.5 x 10-3 g/ml) (%)

7.1 9
35.8
94.8 3
11.9
65.5
72.2
62.3
63.5
57.9
55.1

12 11*
28.9
96 2*
3.8*
80
80
78.2
60
76.5
59.1

MNA score
Anthropometric
parameters

Screening
Global
Total
BMI (Kg/m2)
Hand grip strength (Kg)
AC ( 22 cm) (%)
AMC ( 18.9 cm W,
22 cm M) (%)
TSF ( 9.7 mm W,
5.2 mm M) (%)

Albumin (g/dl)
Prealbumin (mg/dl)
Transferrin (mg/dl)
Mucoprotein (mg/dl)
CRP (mg/l)
Total cholesterol (mg/dl)

6.1 3
6.9 3
13 5
22.6 5
7.6 7
43.5
48.2

10 3*
12.2 2*
21.9 5*
26.7 4*
10.2 7*
7*
9.5*

34.8

14.3*

3.4 0.6
18.4 8
196 56
1.26 0.6
24.2 45
170 44

3.5 0.5
21.5 13
204 59
1.24 0.4
12.9 16*
209 36*

51.8
47.8
86.6
89.4
88.9
12.9
50
62.7
68.7
52.2
35.8

8.9*
6.8*
27.4*
42.5*
39.7*
0*
21.9*
7.5*
33.6*
1.4*
17.1*

64.3#
42.9
78.6
78.5#
85.7
0#
21.4#
35.7#
64.2
21.4#
42.9

26.5*#
3.9*#
40.3*
47.7*
53.9*#
0#
6.5*#
5.7*#
6.8*#
8.4#
2.5*#

Table 8
Leptin and ghrelin concentrations among different settings in
anorexic vs. normal eating participants

Table 6
Nutritional status according to MNA, anthropometric, and
laboratory parameters of patients with senile anorexia vs.
controls (normal eating subjects) in the whole group of
participants
Normal eating

15.3
14.6*
30.4*
56.4*
88.2*
62.5*
37.3*
95.4*
93.8*
10.7*
16.7*

* p<0.05 vs. anorexia (subjects with senile anorexia)

SpO2: oxygen saturation obtained from pulse oximetry; * p<0.05 vs. anorexia (subjects
with senile anorexia)

Anorexia

21.8
44.8
78.5
96.3
85.7
34.3
78.6
79.2
68.9
25
51.7

Rehabilitation/Acute
wards
Anorexia
Normal
eating
Ghrelin
Leptin

231 173
8.2 9

Nursing homes
Anorexia

Normal
eating

Free Living
Anorexia

Normal
eating

255 214 258 191 221 219 252 187 235 213
4.3 4*
8 20 17.5 23* 8.1 18 12.5 19#

* p<0.05 vs. anorexia (subjects with senile anorexia); # means p<0.05 vs. other settings
(for normal eating participants)

Intake in all food groups were generally lower in anorexic

subjects, but the variations were not homogeneous for the
different groups (Table 7). In particular, there were significant
differences in food reach in proteins; for example, 27.6% of
anorexic subjects vs. 5.5% of normal eating subjects did not
consume red meat; 10.7% vs. 3.6% did not eat poultry; 55.6%
vs. 10.9% did not eat fish; and 82.1% vs. 33.3% did not eat
eggs, respectively. Conversely, there was no reduction in
carbohydrate intake in anorexic vs. non-anorexic subjects. The
frequency of intake of pulses, fruit, and vegetables were
significantly lower in anorexic vs. non-anorexic subject.
Elderly with anorexia often use oral nutritional supplements
(41.3 vs. 5.9%) and reduced consistency meals (40.9 vs.
21.7%). As shown in Table 7, the patterns of food frequency
were similar in all geriatric settings.
There was a large variability in measurements of leptin and
ghrelin circulating concentrations (Table 8), perhaps reflecting
the heterogeneity of older populations living in different
settings. No significant differences between subjects with and
without anorexia was found for ghrelin in the different settings.
Even if there were some significant differences for leptin (as
indicated in the table), they were not consistent across the
different groups and the variability was very high (Table 8).

MNA: Mini Nutritional Assessment; BMI: body mass index; AC: arm circumference;
AMC: arm muscle circumference; TSF: triceps skinfold thickness; CRP: C-reactive
protein; * p<0.05 vs. anorexia (subjects with senile anorexia)

In subjects with anorexia the nutritional status was more

frequently deteriorated, as shown by MNA scores,
anthropometric parameters (BMI, TSF, AC, AMC), and
handgrip strength, all of which were significantly lower in
anorexic subjects (Table 6). Laboratory parameters confirmed
the presence of undernourishment with lower values for
anorexic subjects, even if for many parameters a statistical
significance was not reached. As shown in Table 6, there was a
significantly higher level of CRP and a lower concentration of
plasma total cholesterol. When considering the different
settings the results were similar, that is, a tendency to worse
nutritional parameters (MNA, anthropometry, blood
parameters) in anorexic subjects that were worse for
hospitalized patients vs. free-living and for patients in nursing
homes vs. patients in acute and rehabilitation wards (data not
shown).

Discussion
The results of our study indicate that the prevalence of senile
anorexia is high among different geriatric settings in Italy and it
is particularly elevated in institutionalized elders (hospitalized
5

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SENILE ANOREXIA IN DIFFERENT GERIATRIC SETTINGS IN ITALY

in rehabilitation wards, acute wards and long-term facilities)
when compared to free-living subjects. The finding that senile
anorexia is frequent in geriatric populations (over a third of the
hospitalized patients in our study) calls for the need to
recognize this condition, especially because it is associated with
a worse nutritional status and significant functional, cognitive
and emotional impairment.
The age-related decline in appetite and food intake or
anorexia of aging (2) has been demonstrated in different
studies. The Baltimore longitudinal study showed a decrease in
daily energy intake of 25% over 30 years in community
dwelling men (24). The National Health and Nutrition
Examination Survey (NHANES III) reported a mean decline in
energy intake between ages of 20 and 80 years of 1321 cal/day
in men and 629 cal/day in women (25). Undernutrition and
weight loss as a result of a reduced food intake are among the
most prevalent and distressing problems in older populations.
Intentional or unintentional weight loss in older persons is
predictive of institutionalization, increased hip fracture risk,
and mortality (26-28). Nevertheless, the prevalence of
undernutrition varies greatly according to the population
studied and the criteria used to define malnutrition. It has been
estimated that 32-50% of hospitalized patients, 23-85% of
nursing home residents, and 5-20% of community dwelling
elders are malnourished (29). The prevalence of undernutrition
can be worse in developing countries as illustrated by results
from a study conducted in Cuba where 91.6% of hospitalized
patients and 95.3% of nursing home residents were
undernourished (30).
There are few reports that specifically address prevalence of
anorexia in older populations. A study conducted in 236
community dwelling over 70-year-old Spanish subjects
considering anorexia as self-reported low usual appetite found a
global 30% prevalence of anorexia (37.1% in females and
17.9% in males) (31). A multinational European one-day crosssectional survey in 16290 adult hospitalized patients showed
that over half of the patients did not eat their full meal provided
by the hospital (32). A study conducted in the UK examined
adequacy of food intake (at least _ of their standard diet) in
100 elderly hospitalized patients anorexia was present in 38%
malnourished patients as compared to 23% of well-nourished
patients (33). The results of our study specifically addressing
anorexia as less than 50% of standard food intake over 3 days,
found a prevalence of 31% in hospitalized patients and only
6.9% in community dwelling elder. Differences with previous
above-mentioned studies may be due to dissimilar assessment
of anorexia, i.e. self-reported, one-day report of not eating the
full meal offered, or eating _ of a standard diet. Nevertheless,
anorexia has been shown to be an independent predictor of
mortality (34) stressing the utmost importance of early
detection and aggressive intervention to arrest the downward
spiral of negative consequences.
Undernutrition in older populations is promoted by a series
of factors including the socio-economical condition, civil
status, solitude, disability, and lack of assistance, as confirmed

in our study. All these aspects may influence food choices in

older adults and contribute to determine significant nutritional
deficits (1). Extensive evidence shows that a large number of
elders do not get enough amount and types of food necessary to
meet the essential energy and nutrient requirements (35).
Decreased food intake and weight loss are prevalent problems
in older populations and are independent predictors of
morbidity and mortality in different geriatric settings (32, 36).
Older people tend to a monotonous diet, and variety in diet
composition has been linked both to a higher food intake (37),
and to better outcomes (38, 39). Disability may be associated
with difficulty in purchasing and cooking, as observed in our
study, contributing to a poor nutrition (40). Social and
psychological unfavorable conditions frequently seen among
older populations constitute also key determinants of
malnutrition in this age group (10), with depression probably
being cause and consequence of a poor nutritional status (1,
41). In institutionalized patients, the lack of environmental
stimuli, scarce physical activity, and monotony of food, further
influence negatively the food choices (42).
The most worrisome consequence of senile anorexia
observed in our study is the alteration of nutritional status. Most
of anorexic subjects in our sample were significantly
malnourished or at risk of important nutritional deficit,
according to MNA and several nutritional parameters
examined. Our results in the Italian sample examined verify
previous data in the literature among other populations.
Previous data has demonstrated that people 65 years old and
older frequently present nutritional deficits, in particular on
several micronutrients (1, 35, 43, 44). One third of free-living
older adults have a micronutrient deficit and over 4% present
proteic-caloric malnutrition. This percentage increases when
older populations living in long-term facilities and hospitalized
persons are considered, according to the Euronut-Seneca survey
(43).
We observed a higher use of oral supplements (41 vs. 22%)
in elderly patients with anorexia. It is possible that a more
frequent use of supplements is due to the fact that the
institutions involved in the present study were geriatric
facilities where more attention is posed to possible specific
deficits. It is also possible that the general practitioner (in Italy
all citizens have one assigned to cope with primary needs in a
regular basis), family or friends have noted a lack of desire to
eat or noticed weight loss and tried to compensate by giving the
patients a vitamin supplement.
During aging, several functional modifications occur that
may influence the nutritional status. Reduction in taste and
olfaction perception, dental problems, reduction in visual and
hearing acuity, along with age-associated pathologies that
negatively influence autonomy and limit the interest and
capacity to choose and properly prepare food (1, 40). Our
results showing that anorexic elders had more swallowing
difficulties, were more disabled, and had more comorbidity
confirm the role that functional autonomy may play on the
preservation of an adequate nutritional status. We observed a
6

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THE JOURNAL OF NUTRITION, HEALTH & AGING

significantly worse cognitive decline in subjects with anorexia
in all the geriatric settings studied suggesting that this as an
important factor associated with inadequate food intake
possibly contributing to the development of nutritional deficits.
Cognitive decline is frequent among older populations,
especially in nursing homes, where its prevalence has been
reported to be as high as 34 to 70% (45, 46). Older adults with
cognitive decline are at risk of malnutrition because of both
physical and neuropsychological disorders; aphasia and apraxia
may compromise the possibility that a person may express
his/her own needs; olfactory agnosia may determine appetite
modifications, hence, nutritional needs may not be entirely
satisfied.
Several studies have demonstrated a progressive reduction in
daily caloric intake with aging, linked to an important reduction
in intake of food with high fat content (47), Conversely, in our
sample the lower caloric intake may be attributed to a lower
intake of all food groups. The exclusion of one or more food
groups from the diet may determine a lower variety that is
associated with a worsening of nutritional status in the older
population (38, 39).

12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.

Conclusion

27.

Prevalence of senile anorexia is particularly elevated in

institutionalized elders, frequently associated with a poor
clinical status, with significantly compromised self-sufficiency,
cognitive decline, and with reduction of sensory functions. This
condition represents an important risk for malnutrition that
entails a reduced immunocompetence and further worsens selfsufficiency with the development of a vicious circle in which
anorexia, malnutrition, and their consequences are perpetuated.
Hence, an early detection of anorexia followed by an adequate
intervention in older hospitalized patients to avoid further
worsening of clinical and functional status is warranted.

28.

Acknowledgement: Funding: the study was funded as a National Research Project

(PRIN) from the Italian Ministry of Instruction, University and Research (2005-067913
Cause and Prevalence of Senile Anorexia).

35.

29.
30.
31.
32.
33.
34.

36.
37.

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