Nutrition at Risk: Combatting Malnutrition in Older Adults
What is Malnutrition?
The term malnutrition lacks a universally accepted definition. To address this, in 2016, the world's four leading clinical nutrition societies (ESPEN, ASPEN, FELANPE, and PENSA) established standardized criteria for malnutrition, applicable across diverse clinical settings (1). Malnutrition is a complex condition caused by inadequate nutrient intake or assimilation. Key diagnostic criteria include recent weight loss, low body mass index (BMI), reduced muscle mass, decreased food intake or assimilation, and the presence of inflammation or disease burden. Diagnosis requires at least one phenotypic criterion (e.g., weight loss, low BMI, or reduced muscle mass) and one etiologic criterion (e.g., reduced food intake or inflammation/disease burden). Additionally, prolonged energy intake below estimated requirements can also signal malnutrition.
Early diagnosis is essential to prevent malnutrition, particularly among older adults, where prevalence can reach up to 50% (2).
Malnutrition encompasses both undernutrition and overnutrition. It can result from insufficient food or drink intake or be triggered by disease-related inflammation or other mechanisms. Inflammation exacerbates malnutrition by reducing food intake and altering metabolism, which can increase resting energy expenditure and muscle breakdown. Factors contributing to hospital-acquired malnutrition include disrupted mealtimes, extended hospital stays, meal dissatisfaction, inadequate monitoring of food intake, and underlying illnesses. Similarly, nursing home residents face heightened malnutrition risks due to limited staff assistance during meals, inadequate recognition of nutritional needs, poor food service quality, mobility limitations, severe cognitive impairments, and dysphagia (1).
Screening for Malnutrition
Screening tools are invaluable for identifying older adults at risk of malnutrition. The Mini Nutritional Assessment (MNA) is the most widely used and extensively studied tool. However, its broad scope may reduce specificity and lead to overdiagnosis in older individuals. To enhance accuracy, the MNA can be used alongside the Global Leadership Initiative in Malnutrition (GLIM). GLIM employs phenotypic (e.g., body weight, BMI, lean mass) and etiologic (e.g., reduced food intake, disease burden) criteria consistent with leading malnutrition diagnosis approaches.
Effective screening tools include anthropometric measurements (BMI, calf circumference, mid-arm circumference) and questions about weight loss, appetite changes, and food intake (4). Individuals identified as at risk should receive frequent assessments and monitoring.
Key Indicators of Malnutrition
Chewing and Swallowing Issues
Poor dentition and weakened teeth due to aging can impair chewing ability, causing mealtime fatigue and reduced food intake. Soft-textured foods can benefit individuals with dental pain, edentulism, or chewing difficulties.
Dysphagia (difficulty swallowing) affects 10-33% of older adults, increasing risks of malnutrition, dehydration, and pneumonia (5). Monitoring symptoms like coughing during swallowing, reduced intake, food or drink avoidance, and vomiting is essential. Individuals exhibiting these symptoms should be referred to a speech-language pathologist.
Changes in Appetite
Aging is often associated with reduced food intake due to factors such as cognitive decline, sensory changes, physical limitations, or environmental factors.
Registered dietitians can assess appetite changes by asking questions like, “Is your mood affecting your intake?” or “Are there other foods that sound appealing?” Strategies such as reminders, feeding assistance, or appetite-stimulating medications may improve intake.
Olfactory impairment affects nearly 63% of individuals over age 80, diminishing interest in previously favored foods due to altered taste perceptions (6).
Dehydration
Signs of dehydration include dry lips or skin, dark urine, decreased urination frequency, dizziness, fatigue, and confusion. Addressing dehydration is critical in preventing malnutrition.
Weight Changes
Unplanned weight loss of more than 5% in one month, 7.5% in three months, or 10% in six months is significant. Registered dietitians can differentiate between intentional and unintentional weight changes, identifying potential nutritional risks.
Protein Intake
Older adults require increased protein intake (1.0–1.5 grams per kilogram of body weight) to prevent malnutrition and sarcopenia. Additional protein needs may arise from conditions such as wounds, burns, or illnesses.
Dietitians' Role in Preventing Malnutrition
Nutritional Supplements
Liquid nutritional supplements boost calorie and protein intake, especially for individuals with poor appetite or chewing difficulties. These can be consumed between meals or incorporated into foods like oatmeal, soups, or desserts.
Frequent, Smaller Meals and Snacks
Offering smaller, more frequent meals and snacks (e.g., sandwiches, cheese, peanut butter, or smoothies) helps prevent early satiety and improves overall intake.
Tailoring meal plans to individual preferences enhances meal enjoyment and intake. Non-dairy alternatives can be used for those with lactose intolerance, and preferred foods should be prioritized.
Dietary Liberalization
Relaxing restrictive diets, when appropriate, can increase intake. Dietitians assess lab values and risk factors to determine if dietary adjustments are needed, especially in cases of significant weight loss or reduced food consumption.
By implementing these strategies and consulting with a registered dietitian, you can help ensure your loved one receives the proper nutrition to maintain their health and well-being. Early intervention can significantly improve their quality of life.
