Managing Malnutrition in Older Populations

According to the World Health Organization (WHO), one out of every six people in the world — roughly 1.4 billion people — will be 60 years of age or older by 2030. In 2020, one billion people were at least 60 years old; by 2050, that number will have doubled. The number of people passing 80 is also expected to triple between 2020 and 2050, reaching 426 million.1 And as the age of the global population continues to increase, so will the prevalence of common health concerns associated with aging.

Malnutrition is an understated problem in the elderly. Among seniors, malnutrition typically presents as undernourishment caused by inadequate diet or poor appetite. A range of factors contribute to poor diet or eating habits, and without intervention, a number of troubling symptoms usually occur, leading to diminished overall health and quality of life. Anything from an injury to depression to significant life changes can be a catalyst for behaviors that lead to malnutrition. There’s little doubt that malnutrition, an often poorly defined concept, also affects morbidity and mortality.2

In this guide, we’ll illuminate some of the common signs, causes, effects, and preventive measures related to malnutrition to help you support the older adults in your life.

The most common cause of malnutrition is a lack of vitamins, minerals, and other nutrients the body needs to function properly. Typically, malnutrition occurs when an individual is either undernourished (their diet lacks essential nutrients or is calorie deficient) or overnourished (their diet consists of too many calorie-dense foods lacking essential nutrients).3

Common signs and symptoms associated with malnutrition across all age groups include:4

Malnutrition can also cause behavioral symptoms, including:4

• Depression or irritability
• Lethargy
• Difficulty concentrating
• Diminished cognitive functioning
• Anorexia or inappetence (lack of appetite)

Both internal and external factors influence the dietary habits of older people. Researchers from the Department of Food Science and Technology at the Agricultural University of Athens, Greece, refer to the most common of these factors as the “9 Ds”:5

1. Dentition (teeth)
2. Dysgeusia (a distorted sense of taste)
3. Dysphagia (difficulty swallowing)
4. Diarrhea
5. Depression
6. Disease
7. Dementia
8. Dysfunction
9. Drugs (medications)

The concept makes sense; it’s hard to consistently get enough nutrients when you have dental problems that cause pain (or no teeth at all) or if you struggle to care for yourself because of a physical or mental health problem. The rates of all these issues increase with age.

Two other significant parts of our daily lives make a big difference in our ability to get adequate nutrition: our environment and socialization.

The day-to-day environments of seniors often have a significant impact on nutrition. If an older adult lives in a hospital or care facility, they are more likely to develop malnutrition than those living at home with family or in a more communal setting. One study found that 81% of nursing home residents were at risk for malnutrition, compared to 40% of community-dwelling older adults (those living in their own homes).11 Direct care and compassion make a big difference in the amount of individualized care an older person at risk of malnutrition receives.

Loneliness can also significantly increase one’s risk of malnutrition. Lacking companionship or living without an engaging social network decreases appetite while making it more difficult to make regular food purchases.6 Grocery shopping is especially challenging for seniors who struggle with mobility or lack the cognitive functioning necessary to navigate to the grocery store.

Physically going to the store (if possible) to shop is also important — not only does it allow people to acquire their groceries, but it also provides an opportunity to socialize. Accumulating a wider social network can create more opportunities for eating meals with others, building community support and significantly increasing one’s nutritional intake.

Low income or financial strain can also negatively impact an older adult’s ability to afford groceries, even more so if they have medical bills or take expensive medications. If someone has difficulty taking care of themselves, then their risk of food insecurity and possible malnutrition is even higher.15 16

Illness and inflammation

The body’s natural inflammatory response — provoked by things like an operation, illness, or infection — makes it more difficult for older adults to ward off bouts of malnutrition. Not having enough energy from a lack of nutrients makes it harder to heal from injury or disease, creating a negative cycle. Illnesses and diseases compromise nutritional intake in three primary ways:7

1. Chronic starvation without inflammation (such as anorexia nervosa)
2. Conditions with sustained mild inflammation (including cancer or rheumatoid arthritis)
3. Acute diseases with significant inflammation (pneumonia, for example)

Inflammation can even lead to a condition associated with decreased mobility called disease-related malnutrition (DRM), a complex web of problems with signs like functional impairment from a decrease in lean body mass. Many neurological and neurodegenerative disorders, such as Alzheimer’s and Parkinson’s, can increase inflammation and lead to malnutrition.7

Researchers determined some disease-specific aspects or predictors that can put older adults at higher risk for malnutrition. The risk-increasing elements of three diseases (stroke, dementia, and epilepsy) are detailed below, but you can find additional information in the study’s full list and in the study itself.7

Prolonged hospitalization may also contribute significantly to the development of malnutrition, according to a December 2020 study on patients with confirmed cases of COVID-19. Researchers found that 42% of patients hospitalized in non-intensive medical units developed malnutrition, according to Global Leadership Initiative on Malnutrition (GLIM) criteria. When admitted to a step-down unit from the ICU, the prevalence of malnutrition in patients increased to 67%.8

Malnutrition comes with an increased risk of poor overall health and chronic diseases, such as sarcopenia (decreased muscle mass) and cardiovascular disease, especially in the elderly. This set of age-related changes is commonly referred to as the “anorexia of aging.” In older populations, these changes often come with a range of other health problems, including:9

• Nutrient deficiencies
• Decreased bone and tissue mass
• Osteoporosis
• Immune dysfunction
• Slower healing
• Longer recovery times

According to GLIM criteria, a person can be diagnosed with malnutrition if one phenotypic sign is present (non-volitional weight loss, low body mass index (BMI), or reduced muscle mass) and one etiologic sign is present (reduced food intake or disease burden/inflammation).12 Similarly, the American Society for Parenteral and Enteral Nutrition (ASPEN), as well as the Academy of Nutrition, will make a diagnosis of malnutrition if two of the following six criteria are present:13

• Low energy intake
• Weight loss
• Loss of muscle mass
• Loss of subcutaneous fat
• Fluid accumulation
• Reduced hand grip strength

Some of the other common issues associated with malnutrition include:9

Effective screening, or careful observation of an at-risk person’s daily routine, is one of the best ways to prevent malnutrition. When an older adult has age-related risk factors, it’s essential to begin appropriate interventions as soon as inadequate dietary intake is detected. Dietary modifications and supplementation are both crucial in reducing the risk of chronic diseases and other harmful conditions related to malnutrition, as well as increasing their overall quality of life.10

General nutrition

Individuals at risk of developing malnutrition should eat six small meals at equal intervals of time throughout the day. To add calories (and improve taste), you can add herbs, spices, oil, butter, margarine, cream cheese, sauces, honey, or sugar to foods. Sometimes, you can substitute water with drinks with more nutritional content, like Huel, Soylent, or Ensure. Don’t forget about dehydration, though, as not getting enough water runs its own health risks.10

Foods that look appealing and have an agreeable taste and texture are the most likely to be eaten, and people are more likely to eat in a comfortable, relaxed environment. Nutritional value and pleasure should be in balance to promote a healthy diet.

There are thousands of supplements on the market, many of which can provide a range of nutritional benefits for at-risk individuals who can’t get enough protein and nutrients from their diet. Of particular importance for older adults are vitamin D, B12, and calcium, and there are different forms available, like liquids and patches, that can make adding nutrients easier for those who can’t follow a medication regimen or swallow pills. That said, supplements should be secondary to dietary changes and used based on the individual’s needs per a doctor’s advice.

Food-delivery programs that provide meals and other nutrition-related services to the elderly have been shown to help prevent malnutrition, especially for those who can’t regularly access a grocery store. Through both communal and personal programs, participants can learn how to shop, save, and prepare economical and healthy meals. Staffed typically by volunteers, these programs can help prevent malnutrition and provide some socialization for people who may be getting little otherwise. These brief interactions can also lead to identifying other commonly overlooked medical issues.10

For help finding programs, you can contact a county social worker or your local Area Agency on Aging (AAA), a non-profit agency covering either a city, county, or multi-county district, to assist older adults. The Administration for Community Living offers a website to search for information on your local AAA, including phone numbers, physical locations, email addresses, hours, and more.

Caregiver responsibilities

Whether you’re a caregiver, child of an older adult, or both, there are some precautions and steps you can take to prevent or reduce the chance of malnutrition.

Professional rehabilitation

Preventing malnutrition is the responsibility of every medical professional — including physicians, physician assistants, nurses, nurse practitioners, dietitians, physical therapists, and pharmacists — who takes part in treating an elderly patient.

Take the physical act of swallowing, for example. If an elderly patient is malnourished because of difficulty swallowing, they might see an occupational therapist, physical therapist, or speech-language pathologist.

While they all cover similar ground, their specific techniques differ and each professional brings a unique point of view to what might look like a simple issue.

First and foremost, however, general practitioners and other outpatient clinicians should be familiar with the signs and symptoms of malnutrition to recognize and diagnose it before it impacts a patient’s health. A general practitioner should personalize any pharmacologic therapy or medical intervention prescribed for malnutrition to the individual’s needs and under a knowledgeable professional’s strict supervision.10

Antidepressants, when used appropriately, can generate slight improvements in mood, potentially increasing one’s desire to eat and maintain their health. Even a simple intervention such as dentures can do a lot of good by increasing the range of foods one can comfortably eat.10

Ultimately, your team of doctors will use a tailored strategy that’s appropriate to your lifestyle, financial situation, and resources. They should communicate regularly with each other and the patient to maximize effectiveness and treatment adherence to heal from malnutrition.10

Proper nutrition and supplementation are crucial in both treating and preventing malnutrition. Maintaining adequate nourishment, however, isn’t just about age and food. Factors such as environment, social connection, medication side effects, resource availability, physical impairment, and even your sense of taste and smell all contribute to the likelihood of developing malnutrition.

It’s much harder to cure malnutrition than to stop it from happening, so preventive measures and proper screening are two of the best ways to avoid malnutrition, especially among at-risk populations like the elderly. The risk of malnutrition increases during periods of hospitalization, so caretakers should closely monitor any individual at risk of becoming malnourished to ensure they stay as healthy as possible and avoid a hospital visit.