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
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
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
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
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
Older individuals who have experienced a moderate to severe stroke have an increased risk of developing malnutrition. The heightened risk is partly due to the likelihood of dysphagia, immobility, and other stroke-related complications (such as pneumonia, thrombosis, and depression). After two weeks, 90% of stroke patients typically regain the ability to swallow. However, some lingering complications may persist, including aspiration, pneumonia, recurrent cough, choking, prolonged hospitalization, or rehabilitation time. All of these make it more likely that a person will develop malnutrition.
Given their higher demand for care and need for assistance when eating and drinking, patients with dementia have a 10% higher chance of developing malnutrition than their cognitively healthy counterparts. Their lack of autonomy negatively affects their emotional and psychological well-being and nutritional intake. Higher nutritional requirements for patients with dementia, compared to elderly patients in general, can also contribute to malnutrition. Therefore, the recognition and prevention of impairments to mobility and eating behaviors, as well as a focus on emotional well-being, is critical.
The need for antiepileptic drugs (AEDs) is often higher in older populations. Long-term use of AEDs, however, can sometimes result in difficult-to-manage metabolic changes, including weight gain or weight loss depending on the medication, which may be a sign of malnutrition.
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
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
Some of the other common issues associated with malnutrition include:9
Sarcopenia is a musculoskeletal disease marked by the progressive, age-related loss of skeletal muscle mass, strength, and function. Experts recommend physical activity (especially resistance training) and consuming 20-35g of protein per meal to provide your body with enough amino acids to reduce age-related muscle loss.14
Cachexia is “a complex metabolic syndrome associated with underlying illness and characterized by a loss of muscle with or without loss of fat mass.”9 It is also commonly associated with chronic conditions such as cancer, chronic obstructive pulmonary disease (COPD), heart failure, and rheumatoid arthritis. Malnutrition, immobility, and sarcopenia in the elderly increase their risk of cachexia.
This decrease in functioning presents as a diminished sense of taste and smell and, in the elderly, is generally related to age or certain medications. As a result, appetite, interest in food, and variations in a person’s diet are all reduced, increasing the risk of malnutrition.
Common age-related changes in the gastrointestinal tract, including decreased saliva and gastric acid production, can easily affect one’s nutrient intake. Elevated insulin levels, also commonly found in older populations, can amplify leptin (a hormone associated with satiety) while inhibiting ghrelin (a hormone known to stimulate hunger).
Most often, reduced intake and absorption of nutrients can result in deficiencies in vitamin B12, vitamin D, and calcium. Vitamin B12 deficiency is generally linked to the reduction of gastric intrinsic factors brought on by age, which reduces the gut’s capacity for absorption. Insufficient levels of vitamin D and calcium (primarily due to reduced food consumption and gastrointestinal changes) can also affect bone density and mobility, which can increase the risk of falling.
Caused by insufficient levels of vitamin D and calcium, as well as the general deterioration of bone that comes with age, osteoporosis can increase a person’s risk of severe bone fractures. Fractures are already a concern for malnourished individuals, who typically experience longer healing and recovery times.
Exacerbated by age and malnutrition, having a diminished immune response increases one’s risk of developing sepsis and other serious infections. Immunosenescence, the gradual deterioration of the immune system brought on by age, inhibits immune function and vaccine response while increasing the risk of cancer, chronic illness, and autoimmune disease. Vitamin E and zinc deficiency related to malnutrition contribute to the general decline of immune function among older populations.
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
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.
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.
Assisting the older adult(s) in your life with meal planning can ensure they’re getting essential nutrients and calories. You can do the shopping yourself, go along with the older adult, or write up a shopping list for them in advance. Try to plan nutrient-rich meals with a variety of healthy components, such as lean proteins, fortified soy products, seafood, whole grains, fruits, and vegetables. And providing healthy snack options, like pre-cut vegetables or fruit and yogurt, can add a more nutritious alternative to snack foods with added sugar, saturated fats, or too much sodium. The National Institute on Aging offers a guide with tips on meal planning for older adults.
Eating with the older adult in your care can allow you to watch out for any patterns that might contribute to malnourishment. Some of these habits include: eating the same foods repeatedly (without variety), not consuming vegetables, fruit, or dairy, and eating either too much or too little.17
Unintended weight loss or gain can be a sign of potentially inappropriate food intake. Ask the older adult to weigh themselves weekly and keep a record. Malnutrition might not immediately be apparent and can develop over time. If you notice any alarming trends that persist, bring up your concerns with their doctor.17
Exercise may increase appetite in some people, and it’s a great way to maintain well-being. Strive to have the older adult complete some form of exercise each day. It doesn’t have to be strenuous exercise, either — it can be walking, chair exercises, or even stretching. If they’re able to, moderate weight-bearing exercise can help prevent functional decline and reduced independence from aging-related muscle loss.17
Consider keeping records of what medications the older adult takes, what the medicine is for, what the dosage is, how often they take it, and any potential side effects. Some medicines can alter your sense of taste, make you nauseous, or affect your appetite or weight.17 Knowing what to watch out for can help you prevent malnutrition in older adults before it happens
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.
A speech-language pathologist plays an essential role in evaluating, diagnosing, and treating malnutrition by safely managing the eating, drinking, and communication challenges often related to dysphagia, implementing compensatory strategies, and making dietary adjustments accordingly.
A physical therapist’s primary role is to evaluate, diagnose, and treat functional limitations, often caused by chronic pain, as well as decreased strength, endurance, and flexibility, that might affect a person’s ability to eat.
An occupational therapist typically works to improve the physical, cognitive, social, emotional, environmental, and cultural elements of feeding, eating, and swallowing. Interventions tend to focus on psychosocial needs, reducing posture and positioning issues, and using adaptive equipment to improve the patient’s ability to swallow.
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.
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