Malnutrition Awareness – Older Adults in the Community

By Anne Wright, Registered Dietitian, Reviewed by Harriet Smith, Registered Dietitian

Introduction

The spotlight is on malnutrition in the United Kingdom (UK), during “Malnutrition Awareness Week” (5th-12th October). Malnutrition is a significant public health problem in the UK with more than 1.3 million older adults (>65yrs) either malnourished or at risk of malnutrition (1). The vast majority of these people (93%) live at home or in the community (2).

 

The COVID-19 pandemic, places older people in the community at even greater risk of malnutrition, due to shielding restrictions. Shielding impacts the ability to purchase food, exercise, and socialise (3). Identification and treatment of malnutrition can be difficult as physical access to patients by health care professionals (HCPs) and carers is restricted (2). Here we discuss malnutrition, its impact, and how to recognise and manage patients at risk.

What is Malnutrition?

Malnutrition, or undernutrition for the purposes of this blog, refers to a state of nutrition in which there is a deficiency of energy, protein or other nutrients causing measurable adverse effects on the body and its functions (1) .

 

Malnutrition may be defined as any of the following (4):

 

• Body Mass Index (BMI) < 18.5 kg/m²
• Unintentional weight loss > 10% within the last three to six months
• BMI < 20 kg/m² and unintentional weight loss > 5% within the last three to six months

Consequences of Malnutrition in Older Adults

On an individual level, malnutrition in older adults is associated with poor health outcomes including:

 

• Loss of muscle mass and strength (5)
• Falls (6)
• Decreased mobility and independence (7)
• Poor wound healing (8)
• Increased infection risk (e.g influenza, urinary tract infections) (6), (9).
• Depression and low mood (10)
• Body temperature regulation problems (5)
• Vitamin/mineral deficiencies leading to problems such as osteoporosis or anaemia (11).

 

On a wider level, malnutrition has been associated with increased hospital admissions and healthcare costs (1).

Recognising and Preventing Malnutrition

Screening for malnutrition should be carried out by trained health care professionals (HCPs), using tools such as the Malnutrition Universal Screening Tool (MUST) (12). In the community, screening usually takes place on initial registration at general practice surgeries, or on admission for those residing in care homes. Further screening should take place where there is a clinical concern (4).

 

Where physical access to patients by trained HCPs is restricted, it is important for carers to recognise common signs and symptoms of malnutrition. These include (9):

 

• Loss of appetite
• Dry skin
• Weight loss (slow, gradual weight loss may not be recognised – look for signs such as loose clothing and jewelry) (13)
• Tiredness, irritability, loss of energy
• Difficulty concentrating
• Changes in mood (e.g anxiety and depression)
• Delayed wound healing
• General sense of weakness.

 

If physical measurements (i.e. body weight) cannot be taken, simple checklists such as The Patients Association Nutrition Checklist can be used by patients and carers to recognise malnutrition risk.

 

Early intervention is important in preventing malnutrition. Older adults should be encouraged to have regular food and drink and be provided with social help when needed (i.e. assistance with grocery shopping or meal deliveries).

 

Interventions for Malnutrition

A “food first” approach should be used for people at risk of malnutrition (14).This approach includes the encouragement of frequent meals, snacks and nourishing drinks, and fortifying food with the addition of fats and sugars. Fortifying foods involves using everyday foods to enrich the diet with energy and protein. For example, adding butter, cream, cheese, full fat milk, skimmed milk powder, oils, crème fraiche to meals to boost their energy and protein content.

 

If this is not sufficient, the addition of oral nutritional supplements (ONS) and over-the-counter nutritional shakes can improve nutritional status (15). People with or at risk of malnutrition should receive 25-35 kcal/kg body weight/day (adjusted for individual differences)  (16, 9). Protein intake of at least 1.0 g/kg/day is recommended for older people to maintain muscle mass, increasing to 1.2–1.5g/kg/day for those with acute or chronic illness (17). Additionally, patients should maintain adequate fluid intake of 30–35 ml fluid/kg/day (9).

Summary

Malnutrition is a significant problem in older people living in the community and is associated with poor health outcomes. Early identification via screening is recommended. Where physical access to patients by trained HCPs is restricted, it is important for carers to recognise the common signs and symptoms of malnutrition.

 

Carers should encourage regular food and drink and ensure social help (such as assistance with shopping or meal deliveries) is provided. The “food first” approach should be used for people at risk of malnutrition. This approach includes the encouragement of frequent meals, snacks and nourishing drinks, and fortifying food with the addition of fats and sugars. If oral intake remains insufficient, there is evidence to suggest that the use of ONS and over-the-counter nutritional shakes can improve nutritional status.

References

 

1. Elia M. The cost of malnutrition in England and potential cost savings from nutritional interventions (full report). Bapen [Internet]. 2015;1–22. Available from: www.bapen.org.uk
2. Stratton R, Smith T, Gabe S. Managing malnutrition to improve lives and save money. 2018;(October):1–16.
3. Covid- MAG. © BAPEN. MAG Covid-19 Update, May 2020. 2020;(May).
4. National Institute for Health and Care Excellence (NICE). Nutrition support in adults overview. 2016;(February):1–8. Available from: http://pathways.nice.org.uk/pathways/nutrition-support-in-adults
5. Vega A. Nutritional issues in older adults. Top Clin Nutr. 2015;30(3):247–63.
6. Roberts HC, Lim SER, Cox NJ, Ibrahim K. The challenge of managing undernutrition in older people with frailty. Nutrients. 2019;11(4):1–17.
7. Amarya S, Singh K, Sabharwal M. Changes during aging and their association with malnutrition. J Clin Gerontol Geriatr [Internet]. 2015;6(3):78–84. Available from: http://dx.doi.org/10.1016/j.jcgg.2015.05.003
8. Molnar JA, Underdown MJ, Clark WA. Nutrition and Chronic Wounds. Adv Wound Care. 2014;3(11):663–81.
9. Volkert D, Beck AM, Cederholm T, Cruz-Jentoft A, Goisser S, Hooper L, et al. ESPEN guideline on clinical nutrition and hydration in geriatrics. Clin Nutr [Internet]. 2019;38(1):10–47. Available from: https://doi.org/10.1016/j.clnu.2018.05.024
10. Al-Rasheed R, Alrasheedi R, Al Johani R, Alrashidi H, Almaimany B, Alshalawi B, et al. Malnutrition in elderly and its relation to depression. Int J Community Med Public Heal. 2018;5(6):2156.
11. Siddique N, O’Donoghue M, Casey MC, Walsh JB. Malnutrition in the elderly and its effects on bone health – A review. Clin Nutr ESPEN [Internet]. 2017;21:31–9. Available from: http://dx.doi.org/10.1016/j.clnesp.2017.06.001
12. Elia M, Normand C, Norman K, Laviano A. A systematic review of the cost and cost effectiveness of using standard oral nutritional supplements in the hospital setting. Clin Nutr [Internet]. 2016;35(2):370–80. Available from: http://dx.doi.org/10.1016/j.clnu.2015.05.010
13. Willis H. Causes, assessment and treatment of malnutrition in older people. Nurs Older People. 2017;29(2):20–5.
14. Forbes C. The ‘Food First’ approach to malnutrition. Nurs Resid Care. 2014;16(8):442–5.
15. Nieuwenhuizen WF, Weenen H, Rigby P, Hetherington MM. Older adults and patients in need of nutritional support: Review of current treatment options and factors influencing nutritional intake. Clin Nutr [Internet]. 2010;29(2):160–9. Available from: http://dx.doi.org/10.1016/j.clnu.2009.09.003
16. Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition. NICE Guidel. 2020;(February 2006).
17. Bauer J, Biolo G, Cederholm T, Cesari M, Cruz-Jentoft AJ, Morley JE, et al. Evidence-based recommendations for optimal dietary protein intake in older people: A position paper from the prot-age study group. J Am Med Dir Assoc [Internet]. 2013;14(8):542–59. Available from: http://dx.doi.org/10.1016/j.jamda.2013.05.021