Tools for Assessing, Managing Elderly With Cancer for Malnutrition

Malnutrition is associated with problems swallowing, vomiting, and appetite loss, as well as 3 cancer types: lung, upper digestive tract, and head and neck cancers. Geriatric assessments for cancer treatment decision making should always include nutritional status evaluation. Nutritional interventions involve the identification of specific nutrition impact symptoms such as difficulty swallowing or loss of appetite, other conditions associated with malnutrition (eg, sarcopenia, anorexia, or cachexia), and a proactive, multidisciplinary approach to managing a patient’s symptoms and nutritional status.

Poor nutrition is common and is associated with poor clinical outcomes among patients with cancer. Weight loss of just 5% of a patient’s body weight is associated with poorer tumor response to treatment and survival.¹ Malnutrition can involve anorexia, malnutrition-associated sarcopenia (the loss of skeletal muscle mass and associated weakening), and cancer cachexia (an involuntary weight loss of at least 5% within 5 months or body mass index [BMI] less than 20 kg/m² with weight loss exceeding 2%).^1-4 Malnutrition is particularly common among elderly patients, but it is also associated with lung cancer, upper digestive tract malignancies, and head and neck cancers among adult patients of all ages.^2-5 Assessing nutritional status is a key component of geriatric assessment to guide cancer treatment decisions for elderly patients; geriatric assessment should always include assessments of physical function and nutritional status.⁵

A recent evaluation of 4783 adult cancer patients in Brazil found that 45% had moderate or suspected malnutrition and 11.8% were severely malnourished.⁴ Not surprisingly, malnutrition was significantly associated with both specific, individual nutrition-impact symptoms (eg, appetite loss/anorexia, vomiting, and dysphagia/problems swallowing) and more than 3 nutrition-impact symptoms (which also include mouth sores, taste and smell alterations, stomach or abdominal pain, painful defecation, constipation, diarrhea, dyspnea, and fatigue).^4-6 Malnutrition is frequently underdiagnosed among older adult patients with gastrointestinal cancers, impairing functional status, treatment success, quality of life, and clinical outcomes.¹

Nutritional Assessment

Because biological senescence and functional aging vary between patients, the Society of Geriatric Oncology recommends that all older adults (aged 65 years or older) with cancer be evaluated with a comprehensive geriatric assessment (CGA) that includes comorbidity, functional, nutritional, and psychosocial evaluations.¹ Inventorying specific nutrition impact symptoms with a patient checklist that asks about the symptoms above on a scale of 1 (none) to 4 (a lot) can help health care teams to devise specific interventions to improve patients’ nutrition status.⁶

Several validated nutritional assessment tools are available, including the Malnutrition Screening tool (MST), the Mini-Nutritional Assessment Short Form (MNA-SF), the Nutrition Risk Screening (NRS-2002) form, the Malnutrition Universal Screening Tool (MUST), and the Patient- and Nutrition-Derived Outcome Risk Assessment (PANDORA) Score.^1,7-9 Each tool uses a scoring system to quantify factors such as weight loss, BMI, disease severity, fluid intake, and functional concerns that can affect nutritional status. There is no consensus on which of these tools is best, but screening with one of them should be undertaken at diagnosis, hospitalization, and at regular intervals throughout definitive and palliative care.¹