MALNUTRITION in the

ELDERLY
Learning Objectives
• Understand the age-related factors that
affect dieteary requirements late in life
• Describe the components of a
comprehensive nutritional assessment
• Understand special nutritional needs
• Understand threats to good nutrition in late
life and ways to minimise them
Definition
• The World Health Organisation (WHO) defines
malnutrition as a deficiency, excess or
imbalance of a person’s energy and or nutrients
and broadly divided the condition into two
categories:
• undernutrition and overweight/obesity.
• When the word ‘malnutrition’ is used -it refers to
‘undernutrition’ caused by a lack of protein and
or energy
World Health Organisation (2019). "What is malnutrition? World Health Organization."
Retrieved August 15, 2019, from https://www.who.int/features/qa/malnutrition
Prevalence
• The Dietitian’s Association of Australia
calls malnutrition a “silent epidemic”
• It is estimated that 1 in 3 people admitted
to hospital are either malnourished or at
risk of being malnourished
• In aged care facilities, the prevalence is
estimated to range anywhere between 32-72 %

Dietitians Association of Australia (2019). “Is malnutrition an issue in Australia?” Retrieved July 20,
2019, from https://daa.asn.au/smart-eating-for-you/smart-eating-fast-facts/medical/is-malnutritionan-issue-in-austr
Malnutrition
Characterised by a deficiency of energy, protein,
vitamins, minerals or other micronutrients that
cause measurable adverse effects on the body
These effects can include changes to:
• body form (such as body shape, size, or
composition)
• body function (such as the ability to move or to
think)
• clinical outcomes (the body’s capacity to recover
from disease)
FerrariBravo, M., et al. (2018). "Assessment of Malnutrition in Community-dwelling Elderly
People: Cooperation among General Practitioners and Public Health."47(5): 633-640. IranianJournal of Public
Health 47(5): 633-640.
• Malnutrition may be present in a
person who is a normal weight
overweight or obese- not just those
who are underweight
Factors contributing to malnutrition
• Normal age-related changes
• Illness
• Impairment in ability to eat
• Dementia
• Medications
• Restricted diets
• Limited income
• Reduced social contact
World Health Organisation (2019). “Nutrition for older
persons.” Retrieved September 10, 2019,from
https://www.who.int/nutrition/topics/ageing/en/index1.
html
Malnutrition can result in:
Increased risk of
• Hospital admissions
• Post-operative complications
• Infections
• Placement into residential care
• Falls
• Pressure injuries and delayed healing
• Mortality
• Increased health care costs – to the service and
the individual
Malnutrition can result in:
Decreased
• Strength
• Mobility
• Independence
• Quality of life
Nursing intervention
• History -include medications
• Physical examination
• Pathology - including a urine
sample for screening specific
gravity
• Cognition and mood
• Anthropometric measurement
• Accredited Dietitian
involvement
Age related changes
• Teeth, saliva - reduction to approx 1/3 the
volume
• Ineffective digestion of starch due to
decreased salivary ptyalin
• Atrophy of endoithelial covering in oral
mucosa
• Approx 1/3 the number of functioning taste
buds
• Decreased thirst sensation, reduced hunger
contractions

12
Age related changes
• Weaker gag reflex, decreased oesphageal
peristalsis, relaxation of lower oesphageal
sphincter, reduced stomach motility, less
hydrochloric acid, pepsin and pancreatic acid
• Less fat tolerance
• Decreased colonic peristalsis, reduced
sensation for signal to defaecate
• Less efficient cholesterol stabilisation, increased
fat content of pancreas, decreased pancreatic
enzymes
Amarya, S., et al. (2015). "Changes during aging and their association with malnutrition." Journal of Clinical
Gerontology and Geriatrics 6(3): 78-84.
Presenting issues
• Impaired intake
• Loss of appetite
• Difficulty swallowing
• Nausea and vomiting
• Taste changes
• Poor oral health -ill-fitting dentures or poor
dentition
Presenting issues
• Large periods of time between meals
• Anxiety or depession
• Excessive alcohol intake
• Impaired absorption or increased metabolic
demand from medical conditions such as
inflammatory bowel disease, infection, coeliac
disease, fractures or cancer
Presenting issues
• Restricted diets such as low sodium or low-fat
diets
• Excessive or prolonged sadness
• Lack of energy
• Memory issues or oncoming dementia
• Getting sick often
• Bruised or dry, cracked skin
• Wounds that are slow to heal
Screening
• Carry out malnutrition risk screening
• Malnutrition screening tools have been
developed for specific population groups
• Malnutrition risk screening tools cannot
diagnose malnutrition
• They can indicate those who are likely to be at
risk of malnutrition and should be referred for
support
Screening
Examples include but are not limited to:
• Malnutrition Screening Tool (MST)
• Mini Nutrition Assessment (MNA)
• Malnutrition Universal Screening Tool
(MUST)
Screening
• Regular screening is the primary practice to
determine if an individual is at risk of malnutrition
• Simplest method is to track weight and weight
loss
• The per kilogram weight loss is only useful in
relation to the weight of the individual
• e.g- a 5kg weight loss in a person weighing
50kg is more significant than that of a 150kg
person
Indicators
• Weight loss greater than5% in the past
month or 10% - past 6 months
• Weight 10% below or 20% above ideal
range
• Serum albumin lower than 3.5g/100ml
• Hb below 12g/dl
• Haematocrit below 35%
Some physical signs of malnutrition
• Skin tugour - (best place to test is over forehead,
sternum)
• Muscle tone, strength and movement
• Eyes - changes in vision, night vision problems
(Vit A deficiency)
• Oral cavity - dryness (dehydration), lesions,
condition of the tongue, breath odour, condition
of teeth or dentures
Some physical signs of malnutrition
• Hair loss or brittlness
• Skin - note persistent 'goose bumps' (Vit A
deficiency)
• Pallor (anaemia)
• Purpura (Vit C deficiency)
• Brownish pigmentation (niacin)
• Red scaly areas in folds around eyes and
between nose and corner of mouth (riboflavin)
• Dermatitis (zinc)
• Fungal infections (hyperglycaemia)
Nursing Interventions
• Evaluate swallowing as well as functional
ability to manage eating
• Frequent, small meals which are nutrient
dense
• Nourishing snacks which are high in
protein (e.g. yogurt, cheese and tuna)
• Fortifying regular foods (e.g. adding milk
powder to mashed potato or cream to a
sauce)
• Ensure sufficient fluid intake -dehydration
Nursing Interventions
• Remove or substantially modify dietary
restrictions (ie, liberalise diet)
• Offer liquid nutritional supplements for use
between (not with) meals
• Have medications reviewed e.g. antidepressants
that do not aggravate nutritional problems
• Remove or have replaced medications that have
anorexia-producing side effects
Supplements
• Can compensate for inadequate intake of
nutrients
• NOT a panacea! Use with caution
• Vits, minerals and herbs -particularly in
high dosages can produce adverse side
effects and interact with many medications
• e.g. Vit E can cause weakness, fatigue,
headache and diarrhoea
• Vit K interfers with 'warfarin' medication
management.
Nursing Interventions
• Ensure that patients are equipped with all
necessary sensory aids (glasses, dentures,
hearing aids).
• Seated upright at 90°, preferably out of bed and
in a chair
• Eat in the dining room if possible
• Ensure that food and utensils are removed from
wrapped or closed containers and are positioned
within reach
Nursing Interventions
• If the patient requires assistance with eating-
allow adequate time for chewing, swallowing,
and clearing throat before offering another bite
• Cognitively impaired- may need to be reminded
to chew and swallow and may benefit from
availability of “finger foods”
Nutrition and Pressure Injury/Wounds

• Pressure injury prevalence has

been reported at 16–23% in
combined hospital and residential
aged care populations
• Impact of pressure injuries has
been recognised by mandating
collection of prevalence data in the
National Clinical Indicator program
from July 2019
Department of Health website www.health.gov.au National Aged Care Mandatory
Quality Indicator Program.2019
Nutrition and Pressure Injury/Wounds

• Chronic leg ulcers affect 1–3% of population

aged over 60 years,with incidence increasing
up to 5-10% of the over 80 years age group
• Wounds contribute significantly to costs in aged
care in wound supplies, in staff time associated
with treatment of wounds but also in assisting
individuals incapacitated by wounds
• Wounds drastically impact quality of life
Department of Health website www.health.gov.au National Aged Care Mandatory Quality Indicator Program.2019
Nutrition and Dementia
• Dementia includes a number of diagnoses
and symptoms which include reduced
appetite, apparent disinterest in food,
altered mood, elevated distractibility,
memory issues (e.g.forgetting if he/she has
just eaten), confusion and excessive activity
Nutrition and Dementia
• All of these can
negatively impact
food intake and
nutritional status
• Food related
problems are often
seen as routine and
that nothing can be
done to address
these problems
Nutrition and Dementia
• Approximately 50% of all people have lost
bodyweight in the year prior to diagnosis
• Weight loss is indicative of loss of lean body
mass and malnutrition
• Any loss of lean body (muscle) mass in an older
person potentially increases morbidity and
mortality
• Weight loss in someone living with dementia
rapidly impacts quality of life as well as physical
and cognitive capacity
Meet John
Meet John
85 years of age, was seen by his general
practitioner at an aged care facility where he
resided
He was a resident at the facility for more than
12 months and staff members had reported he
had become increasingly forgetful
Over a few weeks, John refused his meals and
lost 5 kg in weight ........BUT
Staff members were able to get him to take his
medications
He became increasingly confused and 4 weeks
later, he died
Meet John
• John had a significant past history of congestive
cardiac failure and was on
• aspirin (100 mg per day)
• frusemide (40 mg per day)
• digoxin (62.5 µg per day)
• spironolactone (25 mg morning)
• perindopril (2 mg morning)
• recently commenced on a nonsteroidal anti-
inflammatory agent for knee pain
Meet John

• John had been complaining of fatigue, anorexia

and had reduced his oral intake
• He then presented with a febrile illness and
urinalysis was positive for leucocyte esterase
Meet John
A full blood examination reveals
• a haemoglobin value of 10 g/L
• white cell count of 9 x 109 /L (3.8 x 109/L
neutrophils, 0.25 x 109 /L lymphocytes).
A urine sample is sent for culture
John was treated with a short course of
trimethoprim-sulfamethoxazole and his fever
improved
Meet John

• John possibly had several nonphysiological risk

factors for developing under nutrition
• Staff had complained that he was forgetful, and
so underlying dementia or depression was very
possible
• It was also noted that his oral intake was poor
and his body mass index was 21 kg/m2
Meet John

• John was on many medications which increased

his risk of developing anorexia, and was recently
commenced on a NSAID and therefore at risk of
developing peptic ulcers or gastritis
• This combination of medications also increased
the risk of renal failure which can result in
digoxin toxicity and anorexia
Take home message
• The elderly population is affected by many
causes of malnutrition, which can be reversed if
it is addressed early
• Management of malnutrition requires a
multidisciplinary approach that treats pathology
and uses both social and dietary forms of
intervention
• Nutritional deficiencies are more common
among hospitalised patients and aged care
facility residents
Take home message
• If intervention elicits only minimal
response,discussion with the patient and family
regarding end-of-life choices, including
nutritional intervention may be necessay
• Unintended weight loss and malnutrition that do
not respond to intervention are often important
clinical indicators of worsening health status
Royal Commission into Aged Care
Quality and Safety March 2019
• The provision of enjoyable nutritious food and
evidence-based nutrition care is a complex
undertaking. Improvements in all care settings
requires a ‘nutrition is everyone’s business’
approach to the development and
implementation of policies and procedures
related to nutrition care, food services and
hydration, including identifying any risks and
implementing interventions to mitigate and
manage those risks
REFERENCES
Amarya, S., et al. (2015). "Changes during aging and their association with malnutrition." Journal of Clinical Gerontology and
Geriatrics 6(3): 78-84.''

Department of Health website www.health.gov.au National Aged Care Mandatory Quality Indicator Program.2019

Dietitians Association of Australia (2019). “Is malnutrition an issue in Australia?” Retrieved July 20,
2019, from https://daa.asn.au/smart-eating-for-you/smart-eating-fast-facts/medical/is-malnutritionan-issue-in-australia/

Ferrari Bravo, M., et al. (2018). "Assessment of Malnutrition in Community-dwelling Elderly

People: Cooperation among General Practitioners and Public Health."47(5): 633-640. IranianJournal of Public
Health 47(5): 633-640.

Kramer SJ & Pochipin MB (2012) Gastroenterology & heptology 8(11), 770

Ramgoolie, P. & S. Nichols (2015). "Polypharmacy and the Risk of Malnutrition among
Independently-living Elderly Persons in Trinidad." West Indian Med J 65(2): 323-327.

World Health Organisation (2019). “Nutrition for older persons.” Retrieved September 10, 2019,from
https://www.who.int/nutrition/topics/ageing/en/index1.html

World Health Organisation (2019). "What is malnutrition? World Health Organization."

Retrieved August 15, 2019, from https://www.who.int/features/qa/malnutrition