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CE 1HOUR
Continuing Education
Malnutrition in
Older Adults
An evidence-based review of risk factors, assessment, and intervention.
ABSTRACT: Older adults are at risk for compromised nutritional status because of physical changes associ-
ated with aging, as well as cognitive, psychological, and social factors such as dementia, depression, isolation,
and limited income. Malnutrition negatively affects quality of life, increases health care costs, and increases
the risk of short-term mortality. Nurses and other members of interdisciplinary health care teams play impor-
tant roles in preventing malnutrition in community-dwelling older adults and in older adults in long-term care
settings. This article provides an overview of screening tools and interventions nurses can use to minimize
the risk of malnutrition in older adults.
Keywords: dehydration, malnutrition, nutrition, older adults
n 2015 (the most recent year for which data communal meals in the dining room. She has a
are available), the number of Americans age 65 small microwave and refrigerator in her apartment
Ior older was 47.8 million—a figure that repre- and her daughter shops for her every few weeks.
1
sented a 30% increase since 2005. According to Because of dental problems, she can eat only soft
estimates from the Centers for Disease Control and foods. She has difficulty opening packages and cans
Prevention, by 2050, one in five Americans will be and has forgotten how to operate the microwave.
2
65 or older, and the United Nations anticipates Her aides are concerned about her limited food
that the number of adults who were 60 and older choices; they report that she primarily eats peanut
in 2015 will double worldwide by 2050 to nearly butter and hot cereal. Over the past three months,
3
2.1 billion. she has lost 10 pounds and is now classified as un-
Generally, older adults perceive themselves as derweight for her height.
healthy, with more than three-quarters of Americans After Harold Brinker’s wife died, he moved
ages 65 and older assessing their health as good to in with his son. Mr. Brinker, age 87, no longer
4
excellent. Despite their healthy self-image, however, drives and relies on his son for transportation. Be-
many older adults are at risk for malnutrition, a con- cause of the remote location of his son’s apartment,
dition that can occur in frail, underweight older adults Mr. Brinker is no longer able to take neighborhood
as well as in overweight and obese older adults whose walks and now spends most of his time watching
nutritional needs are unmet. Consider for example the television. His son travels frequently for business.
following two composite cases, which represent some Mr. Brinker never learned to cook and has little in-
of the factors that put older adults at risk for malnu- terest in food. Without his wife’s encouragement
trition. to eat well, Mr. Brinker rarely eats fruits or vegeta-
Rachel Jackson, a 91-year-old who was recently bles. Most of his meals are microwaveable frozen
widowed, lives alone in an apartment in an assisted- dinners his son purchases for him. Mr. Brinker
living facility. Ms. Jackson has become increas- also consumes a lot of desserts and snack foods.
ingly confused and reclusive. She no longer attends His blood pressure and blood glucose levels are
34 AJN ▼ March 2018 ▼ Vol. 118, No. 3 ajnonline.com
By Ann Reed Mangels, PhD, RD, FADA
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elevated. Over the past six months, he has gained mass is accompanied by a decline in muscle strength
15 pounds. and function11 and may be followed by decreased mo-
A number of studies have investigated malnutri- bility. Among community-living older adults, loss of
tion in older adults. A 2016 systematic review of 54 mobility can interfere with food shopping and prepa-
studies that used validated tools to screen community- ration. While a loss of muscle mass reduces calorie re-
living adults ages 65 and older for malnutrition sus- quirements, it does not decrease needs for vitamins,
ceptibility concluded that up to 83% are at risk for minerals, or protein, which often increase with aging,
5
malnutrition. A 2013 systematic review of 77 studies making it more challenging for older adults to meet
on nutritional problems in nursing home residents these needs with a lower-calorie diet.12
found that malnutrition prevalence rates varied widely, Dehydration. In advanced age, adults also experi-
though most studies found that 20% to 39% of resi- ence a reduction in total body water.10 This reduction,
dents were malnourished and 47% to 62% were at in conjunction with reduced kidney function, dimin-
6
risk for malnutrition. ished mobility, and a decreased perception of thirst,
Malnutrition diminishes quality of life, is a strong puts older adults at elevated risk for dehydration,
predictor of short-term mortality, and is associated especially those who are over age 85 or institution-
with higher health care costs.7-9 This article reviews the alized.12
many cognitive, psychological, social, and economic Dentition. More than 20% of adults ages 65 and
4
factors that can affect the nutritional status of older older report they have no natural teeth. Problems
adults and discusses how nurses can intervene to pre- with teeth and gums, as well as poorly fitting dentures,
vent and address malnutrition in these patients. can limit food choices, reducing consumption of fruits,
vegetables, whole grains, and meats.
PHYSICAL CHANGES ASSOCIATED WITH AGING Sensory changes that can affect dietary intake, in-
Both a loss of muscle tissue and an increase in cluding altered taste, smell, and vision, frequently oc-
body fat are associated with advanced age, even cur in older adults. Altered taste can occur with taste
in people whose weight is stable.10 A loss of muscle receptor cell dysfunction, medication use, difficulty
ajn@wolterskluwer.com AJN ▼ March 2018 ▼ Vol. 118, No. 3 35
maintaining teeth and gum health, chronic illness, because of difficulty with shopping and preparation.
or diminished sense of smell.13 Altered taste primar- Eventually, people with dementia may be unable to
ily affects perception of bitter and sour flavors and express or recognize hunger and thirst, forget to eat or
may trigger a dislike of citrus fruits and some vege- drink, or be unable to recognize food.25, 26 These adults
tables or a preference for sweets.13 In addition to af- may also have difficulties with feeding, chewing, and
fecting taste, olfactory dysfunction, which is more swallowing. Any of these factors may precipitate in-
common in older than in younger adults,14 may re- adequate nutritional intake and malnutrition.25, 27
duce enjoyment of food, though its effects on nutri- Depression. The connection between nutrition and
tional status are not clearly established.15 Impaired depression in older adults is complex. Depression can
sight can limit the ability to select or prepare food compromise nutritional status, and poor nutrition can
and create self-feeding challenges. put people at risk for depression.28 Depression is not
Metabolism and absorption of such nutrients uncommon in older adults. In 2014, nearly 15% of
as iron and vitamins A, D, and B12 are altered in ad- American women and more than 10% of American
4
vanced age, which can increase risk of deficiency or men age 65 or older reported depressive symptoms.
toxicity.16 In a cross-sectional, population-based Finn- Symptoms of depression can include both increases
ish study of more than 1,000 adults ages 65 and older, and decreases in appetite and weight. Medications
Loikas and colleagues found a 12% prevalence of used to treat depression may also affect nutritional
vitamin B12 deficiency and a 38% prevalence of status through such adverse effects as nausea, diar-
17 28
borderline-to-low vitamin B12. Older adults are at rhea, and anorexia.
increased risk for vitamin B12 deficiency because of
their higher rates of atrophic gastritis, a condition ECONOMIC AND SOCIAL ISSUES
that inhibits absorption of protein-bound vitamin The food choices of older adults may be limited by
B from such foods as meat and dairy products.18 For factors such as income, transportation options, and
12
this reason, the Food and Nutrition Board of the In- social isolation.
stitute of Medicine has recommended that adults over Income. Older adults with modest incomes often
age 50 obtain most of their recommended dietary al- have to choose whether to spend their money on food,
lowance (RDA) for vitamin B12 from fortified foods housing, or medications. The 2013 National Survey of
or vitamin B12–containing supplements.19 Compared Older Americans Act Participants found that 14% and
with their younger counterparts, older adults also re- 29%, respectively, of participants receiving congre-
quire more of certain nutrients. gate meals or home-delivered nutrition services do
• Adults ages 51 and older require more vitamin not always have enough money or food stamps to
19 29
B . purchase the food they need. One study found that
6
• Women ages 51 and older and men over age 70 elderly, low-income adults had a lower mean calorie
require more calcium.20 consumption and ate fewer servings of whole grains,
• Adults over age 70 require more vitamin D.20 vegetables, and fruits than elderly adults who had
• Recent metabolic and epidemiologic studies sug- higher incomes.30
gest increasing dietary protein intake may help Transportation options have also been associated
older adults reduce their risk of sarcopenia.21, 22 with increased nutritional risk.31 For example, older
Chronic health conditions such as cardiovascular adults who rely on bus transportation and find it dif-
disease, hypertension, arthritis, and type 2 diabetes ficult to carry heavy shopping bags filled with fruits
are more prevalent among older than younger adults and vegetables may choose instead to purchase boxes
and can affect nutritional needs, dietary choices, and of cereal or packaged snacks, which are lightweight
food intake. Long-term medication use in conjunc- and easier to carry. Older adults who rely on family
tion with the digestive and metabolic changes that or friends for grocery shopping may have limited ac-
occur in advanced age may increase the potential for cess to such perishable foods as dairy products, fruits,
drug–nutrient interactions.12 and vegetables because of the infrequency of shop-
ping trips.
PSYCHOLOGICAL AND COGNITIVE FACTORS Social isolation, a frequent result of inadequate
Dementia, a broad term used to describe symptoms transportation, is common among older adults. While
related to memory and other cognitive deficits, affects a strong network of friends tends to be correlated
the ability to perform daily tasks, including food se- with better diet quality, eating alone on a regular basis
lection, food preparation, and eventually, self-feeding. has been consistently associated with an elevated risk
One study estimated that 17% of community-dwelling of inadequate nutrition and reduced enjoyment of
people with dementia needed assistance with eating meals in older adults.32 Other causes of social isola-
and drinking.23 And a study of 323 nursing home resi- tion include recent widowhood and the resultant
dents found that 86% of those with advanced demen- grief, both of which are also associated with reduced
tia had eating problems.24 In seniors with dementia diet quality, appetite, and enjoyment of food.33 In ad-
who live independently, food choices may be limited dition, socially isolated older adults have been found
36 AJN ▼ March 2018 ▼ Vol. 118, No. 3 ajnonline.com
to rely predominantly on physical feelings of hunger, or to improve their health by potentially lowering
ignoring such social conventions as eating three meals their risk of cardiovascular disease, hypertension, hy-
a day,34 which may reduce overall food intake as hun- perlipidemia, type 2 diabetes, overweight, and obe-
ger sensations decline in advanced age.35 sity.37-41 If approached correctly, a vegetarian diet can
provide the same essential nutrients as a balanced
FOOD CHOICES nonvegetarian diet. A vegetarian diet that emphasizes
In a survey of 185 homebound older adults, the three whole grains, beans, fruits, vegetables, and nuts, with
factors most often cited as influencing food choices optional dairy products and eggs, can meet an older
were convenience, taste, and price.36 Health issues, fol- adult’s dietary needs.
lowing a special diet, and being unable to shop for
themselves were the barriers to food choice most fre- ASSESSING RISK OF UNDERNUTRITION
quently reported by survey respondents. Food choices Tools have been developed to help nurses assess the
made primarily for the sake of convenience were the nutritional status of their older patients. The first step
most likely to result in a lower-quality diet.36 Many in this process is a screening performed to identify
older adults find it comforting to eat familiar foods, those at risk for malnutrition. The Mini Nutritional
such as those eaten during childhood. This practice Assessment–Short Form (MNA-SF), the Malnutri-
can have varying effects on dietary quality. For exam- tion Screening Tool (MST), and the Malnutrition Uni-
ple, foods from childhood may be nutritionally defi- versal Screening Tool (MUST) are often used in acute
cient sweets and fried foods, or they may be the less and ambulatory care settings, and a cross-sectional
processed, nutrient-dense foods that were eaten de- observational study by Isenring and colleagues found
cades ago. Regardless of what influences a patient’s they can be used to triage nutritional care in the long-
food choices, it’s important to remind older adults term care setting as well.42 All three tools ask about
that their diet should include all essential nutrients unintentional weight loss because, while weight loss
(see Table 1). is not the only indicator of malnutrition risk, it can
Vegetarianism. Older adults may follow vegetar- be measured objectively and signals the need for addi-
ian diets for a variety of reasons, including religious or tional probing to determine potential causes. Weight
moral precepts, having a distaste for meat, experienc- should be measured regularly and accurately in older
ing digestive or chewing difficulty when eating meat, adults.
Table 1. Components of a Healthy Eating Plan for Older Adults
Component Comments Food Safety
Vegetables Choose a variety of vegetables, including Monitor spoilage, especially in fresh vegeta-
those that are green and deep orange. Fresh bles. If using canned vegetables, choose re-
vegetables are the most perishable; frozen duced sodium versions.
vegetables offer variety and reduce the risk of
spoilage; canned vegetables may be higher
in sodium.
Fruits Choose a variety of fruits rather than fruit Monitor spoilage, especially in fresh fruits.
juice. Frozen fruit is less perishable than fresh
and may provide variety. If using canned
fruits, avoid those packed in syrup.
Grains Includes breads, cereal, pasta, and products Watch for expiration dates and spoilage.
such as rice and quinoa. Choose whole grains
at least half the time.
Protein Can include seafood, lean meats, and poul- Keep seafood, meats, and poultry refrigerated
try, as well as beans, peas, soy products, nuts, or frozen, cook properly, and use promptly.
seeds, low-fat milk, cheese, yogurt, and other Foodsafety.gov provides a guide for storage
dairy products. times (go to www.foodsafety.gov/keep/charts/
storagetimes.html).
Calcium Can include fat-free or low-fat dairy and for- Keep refrigerated and monitor expiration
sources tified soy beverages. Other sources of well- dates.
absorbed calcium include kale, broccoli,
Chinese cabbage, and fortified juices.
ajn@wolterskluwer.com AJN ▼ March 2018 ▼ Vol. 118, No. 3 37
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