The recognition of nutritional problems in older people is important as these are associated with poor prognosis but are potentially treatable. Any assessment of frailty has to include some key questions about diet, appetite and weight, as these can indicate specific problems related to nutrition as well as being markers of other underlying medical conditions.
However first and foremost, it’s important to identify the signs of malnutrition, which include the following:
- Tiredness and low energy
- Loss of appetite
- Unintentional weight loss
- Clothes, jewellery or dentures becoming loose over time
Malnutrition can affect every system in the body and results in increased vulnerability to illness and complications which can lead to an increase in the need for community services, more visits to the doctor, prolonged hospital
stays and in some cases, death. The main consequences of malnutrition are:
- Fatigue and lethargy
- Difficulty coughing, which increases the risk of chest infection
- Heart failure
- Anxiety and depression
- Reduced ability to fight infection
Malnutrition is also associated with several psychological issues. Mental health problems such as depression and anxiety or a change in the cognitive status of a frail older person can result in a loss of interest in eating. If insufficient nutrients are consumed as a result of loss of appetite, a change in mood and energy levels will occur and a negative cycle of reduced calorific and nutrient intake may ensue.
Given the current coronavirus pandemic, social isolation is also more prevalent than ever among older people particularly those who are frail and have been encouraged to sheild. Immobility can significantly reduce appetite in frail older people and eating alone can also lead to lower than required nutritional intake. This can also lead to a reduction in the nutritional quality of the food consumed. Less thought is also given to selecting the right food when we shop alone, as convenience and haste are deemed more important than a nutritionally balanced diet. Dietetic research also suggests that eating the right food in the right setting positively improves both mental and physical well-being.
Equally important is the additional element of dining with dignity and the visual appearance of food. For those that live with dysphagia, this can be extremely challenging, as the ability to enjoy eating communally can often prove problematic. The potential embarrassment and social awkwardness which can accompany the feeling of eating something completely different to everyone else can be hugely debilitating for some. Again this contributes to an increased risk of developing malnutrition due to a drop in nutritional intake often accompanied by a reduction in the nutritional quality of the food consumed.
Some frail older people also choose to add liquid to meals and foods when they are home-blending. Whilst this may help achieve the correct texture, it also increases the volume and, depending on the type of liquid used, potentially decreases the nutritional content. Access to ready-prepared texture modified meals can provide a solution. Not only is nutritional content carefully controlled in such meals great care is also taken to ensure the meals look appetising. When texture modified meals resemble the appearance of regular food as far as possible, it makes it easier for the person with dysphagia to enjoy eating with others.
Due to the complex nature of malnutrition there are no blanket measures to prevent its occurrence. However, once the causes for each frail older person are recognised, there are steps which can be taken to manage, treat and prevent it.
So, once you’ve identified the signs, what are effective dietary solutions for malnutrition? If someone suddenly loses their appetite, becomes thinner, or steadily loses weight unintentionally it is important to speak to a GP or a dietitian. For some time now, the treatment for malnutrition has often included the prescription of oral nutrition supplements. However, for dietitians, the preferred first step to treating malnutrition is to encourage a ‘food first approach’ where possible. This is likely to focus on encouraging people to eat higher calorie and protein foods more often.
The food first approach seems straightforward but increasing food intake for frail people with a smaller appetite can be challenging. Adding things like a slice of cake, cheese and full fat milk to one’s diet can all be beneficial, as these are energy dense foods. Smaller and energy dense meals are crucial when cobatting a reduced appetite.
Malnutrition remains one of the most common nutritional challenges among frail older adults in the UK. Healthcare professionals have a key role to play in the recognition and prevention of this challenging disease, as they often have close and regular contact with older adults in the community. Anyone who comes into close or regular contact with an older person has the potential to spot the signs and symptoms of malnutrition and weight loss is not an inevitable part of ageing. It is always worth asking frail older adults some gentle questions about their dietary intake because reduced appetite often marks a decline in their health. There are also screening tools that can be completed, the most commonly used one being the Malnutrition Universal Screening Tool (MUST). The MUST tool is often used to guide appropriate referral to a dietitian.
Whilst a ‘food first’ approach, often with additional use of oral nutritional supplements, is the cornerstone of treatment for malnutrition, there are several key social aspects to consider as well. Simple strategies like attending a local lunch club, encouraging eating with friends or family members or a visit from volunteers from services such as Age UK’s Befriending Service, can all have a positive impact on the amount an older person eats at mealtimes.
When it comes to preventing and treating malnutrition, we should all be thinking of both the clinical and social interventions that can help.
This piece has been based on an article on the British Dietetic Association (BDA) website by Emily Stuart, a Dietitian fo Apetito & Wiltshire Farm Foods.
Other resources from the BDA that you may find useful
There is a Managing Adult Malnutrition in the Community malnutrition pathway which also includes a pathway for the appropriate use of Oral Nutritional Supplements. See:
The BDA earlier this year drew up an A4 leaflet listing a useful store of basic foods for older people who can’t easily get to the shops. Their ‘Older Peoples’ Store Cupboard Flyer’is available at the link given below.
The full BDA guidance for managing malnourished adults in the community, including their Policy statement can be found at:
This guidance website also has 4 sections worth exploring near the top. Click on the links to Introduction, Discussion, Examples, Conclusion and References while you are there.
The British Geriatrics Society also have a brief chapter from their resource ‘End of life care in Frailty’ on Nutrition which you may find useful.
The role of nutrition in the cycle of frailty diagram you will see on the page is interesting and worth considering.