Good and adequate nutrition is critical for the well-being and health of all individuals, but is particularly important for older adults. Up to 85% of individuals residing in long-term-care facilities experience some form of malnutrition. One in 10 community-dwelling older Americans living in their own homes suffers from malnutrition. In addition, individuals over the age of 65 increase their risk of becoming malnourished by 60% after hospitalization (American Geriatrics Society [AGS], 2018).
A loss of 10 or more pounds or 10% of body weight over a 6-month period can leave an older person at risk for malnutrition. A body mass index (BMI) below 18.5 is considered underweight, and a BMI of 17 or lower may indicate a state of malnutrition and lead to health complications (AGS, 2018). Accurate documentation at the start of care can provide the home care clinician with a baseline assessment of the patient's nutritional status.
Malnutrition is often thought of as undernutrition (not eating enough), but overnutrition (or eating too much) is also a form of malnutrition. In fact, one-third of adults over the age of 65 suffer from overnutrition. Despite a BMI over 30, individuals who are overweight may be delinquent in important nutrients and at risk for diseases such as arthritis; diabetes; and cardiovascular, bone, and joint disorders (AGS, 2018). Home care clinicians need to be aware of their patient's nutritional needs and respond proactively by providing education and interventions to prevent malnutrition.
There are a number of risk factors that predispose individuals to malnutrition as they age; the most prevalent stem from medical, physical, psychological, or social factors. Medical risk factors include: dementia or cognitive impairment, acute or chronic pain, surgery or hospital stays, inability to exercise, and decreased mobility (wheelchair-bound). Chronic diseases which dictate special diets that limit the intake of salt, sugar, protein, or fat potentially render food unpalatable for patients. Certain medications can decrease appetite or prevent absorption of nutrients. Other drugs may cause constipation, diarrhea, or gastrointestinal (GI) distress. Donepezil is a common medication used in dementia patients with side effects of GI distress and anorexia. Patients with dementia experiencing GI discomfort may be unable to articulate discomfort, which often leads to anorexia and a decrease in oral intake.
Physical risk factors include: poor dentition, inability or difficulty swallowing, or fear of choking. Older adults often experience altered or diminished sensory abilities such as smell and taste that affect their ability to eat and enjoy food. Loss of dexterity due to stroke or arthritis can make it difficult for the patient to hold or manipulate utensils needed to consume a meal.
Psychological factors that lead to malnutrition can include: alcohol or substance abuse as these conditions interfere with digestion and the absorption of nutrients. Loss of appetite associated with depression, grief related to the loss of a loved one or companion, loneliness and eating alone, as well as difficulty coping with the aging process or failing health may also play a role in malnutrition.
Social risk factors associated with malnutrition include: fixed and limited incomes, specifically for individuals who require costly medications and may need to choose where they spend their limited funds. Additionally, many older adults have limited or no access to local food sources due to an inability to drive or take transportation to purchase a variety of healthy and fresh foods. Older men living alone are at high risk for malnutrition because they often skip meals and do not enjoy or feel confident in their ability to cook.
Finally, religious or cultural traditions, food intolerances, or allergies also can limit the individual's intake of adequate nutrition (AGS, 2018; Mayo Clinic Staff, 2017). To provide a holistic assessment and treatment plan, home healthcare clinicians should assess for these predisposing variables and respond with appropriate education and interventions.
Signs of malnutrition are often insidious and difficult to identify; however, the earlier they are identified and treated, the better the outcome. The most obvious sign is a decreased appetite, decreased oral intake, and weight loss. Additional signs include dry eyes and mucous membranes; constipation and decreased urination; dull, brittle, and dry hair; receding gums; an overall gaunt appearance with decreased body fat; physical weakness; and loss of sensation (AGS, 2018). Individuals with malnutrition also often present with decreased cognition, confusion, and anemia.
Malnutrition can exacerbate or cause problems to the immune system by placing individuals at an increased risk for infections. Malnutrition can cause dental issues, poor wound healing, decreased bone mass, and general muscle weakness causing falls and fractures. Malnutrition can also lead to a decreased appetite, further compounding the problem. Finally, malnutrition can increase hospitalization and risk for death (Mayo Clinic Staff, 2017).
Providing education to loved ones and caregivers on the signs and symptoms of malnutrition can help with early identification, and provide an opportunity for intervention. Caregivers and family members should look for changes in eating habits, weight loss, loose clothing, new dental problems, and weakness (with or without falls). Keeping track of medications will be critical for the home care clinician, as many can cause GI distress, affect appetite, and alter the absorption of nutrients (Mayo Clinic Staff, 2017).
There are multiple interventions that can promote caregiver and family involvement and decrease the incidence of malnutrition in community-dwelling older adults. One way is to provide healthy snacks throughout the day that can provide nutrients and calories. Older adults often feel better when they graze through the day and forego large meals, which may be difficult to digest. Other methods include enhancing restricted diets through the use of lemon and herbs, and varying food textures and colors for visual appeal. Fortifying dishes by adding chopped nuts, egg whites, cheese, and use whole milk to provide nutrient-rich servings with extra protein and calories can help with caloric intake. Seek professional assistance to address oral pain and poor dentition, and consult with a speech and language therapist to assist with swallowing and choking concerns. Consult the patient's primary provider for weight loss and concerns regarding medications that may be influencing appetite. Discuss the need for and use of potential supplements that can provide additional nutrients. Support and encourage daily exercise that can strengthen muscles and bones and promote a healthy appetite.
Home healthcare clinicians need to educate caregivers and families on a balanced diet and adequate hydration. Older adults should be encouraged to drink five to eight glasses of water or other fluids daily, unless restricted by their physician for medical reasons. Emphasize that patients may not feel thirsty, but should drink fluids despite the lack of thirst to promote digestion and kidney function. Clinicians can assist caregivers, patients, and families in locating Meals on Wheels or senior nutrition programs in their community (AGS, 2018). Local Area on Aging can identify programs that offer nutritional support for older adults. Finally, visit or be available during meal times, join the individual and make the dining experience a social and pleasurable event that will promote appetite, oral intake, and feelings of satisfaction and well-being.
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