Geriatric Nursing and Nutritional Issues Introduction
Nutrition plays a pivotal role in the health and well-being of older adults. As individuals age, their nutritional needs and risks change significantly, necessitating specialized attention and care. Malnutrition is a recognized geriatric syndrome that impacts morbidity, mortality, and quality of life and is often unrecognized among the elderly population. This article delves into the nutritional problems commonly faced by older adults, their assessment, nutritional planning, and nursing interventions, all critical for maintaining and improving their overall health status.
What is Nutritional Status?
Nutritional status refers to the balance between nutrient intake, physiological demands, and metabolic rate (DiMaria-Ghalili, 2002). In older adults, this balance is often disrupted, putting them at risk for poor nutrition (DiMaria-Ghalili & Amella, 2005). Malnutrition, defined as faulty or inadequate nutritional status characterized by insufficient dietary intake, poor appetite, muscle wasting, and weight loss, is a significant concern in this demographic (Chen, Schilling, & Lyder, 2001). It is a precursor to frailty, further impacting the health and quality of life of older adults.
Malnutrition exists along a continuum and can affect older adults in various settings, including those admitted to acute care from the community or long-term care facilities. Many older adults are already malnourished or at risk of developing malnutrition during hospitalization, which significantly increases healthcare costs. The estimated additional cost of hospitalization for malnourished patients is approximately USD 1,726 per patient (Rowell & Jackson, 2010). Additionally, bed rest during hospital stays can lead to a loss of lean mass, further exacerbating malnutrition (English & Paddon-Jones, 2010).
Nutritional Problems in Older Adults
Malnutrition in older adults is highly prevalent, with studies indicating that about 38.7% of hospitalized older adults are malnourished, and another 47.3% are at risk of malnutrition (Kaiser et al., 2010). An international audit of 16,455 hospitalized patients revealed that more than half did not consume their entire meal, with decreased food intake associated with an increased risk of mortality (Hiesmayr et al., 2006). A national survey in the United States echoed similar findings, with 40% of hospitalized patients eating half or less of their meal (Nutrition Day in the US, 2011).
Traditional classifications of malnutrition, such as marasmus and kwashiorkor, were initially associated with famine but have since evolved to describe disease-related malnutrition. A consensus approach has redefined adult malnutrition in clinical settings into three categories: starvation-related malnutrition (without inflammation), chronic disease-related malnutrition (with mild to moderate inflammation), and acute disease or injury-related malnutrition (with severe inflammation) (Jensen et al., 2010). This new classification underscores the impact of muscle mass loss and inflammation, emphasizing the importance of understanding and addressing these conditions in older adults.
Risk Factors for Malnutrition
Several risk factors contribute to malnutrition in older adults, including dietary, economic, psychosocial, and physiological factors (DiMaria-Ghalili & Amella, 2005). Dietary risk factors encompass poor appetite, problems with eating or swallowing, inadequate nutrient intake, and limited meals (Carlsson et al., 2005; Reuben et al., 2005; Saletti et al., 2005). Economic factors, such as limited income, may restrict the quality or number of meals consumed (Souter & Keller, 2002).
Isolation, often resulting from living alone or the loss of a spouse, can lead to decreased appetite and desire to prepare meals (Shahar et al., 2001). Functional impairments may also prevent older adults from securing or preparing food, further contributing to malnutrition (Oliveira et al., 2009; Sharkey, 2008). Additionally, chronic conditions and cognitive impairments can negatively impact nutritional intake (Kagansky et al., 2005), while psychological factors like depression are closely linked to unintentional weight loss (Morley, 2001; Thomas et al., 2002).
Poor oral health and conditions such as xerostomia (dry mouth) also affect an older adult’s ability to chew and swallow food, while certain medications can further exacerbate these problems (Saletti et al., 2005). Changes in taste due to medications, nutrient deficiencies, or taste bud atrophy can also reduce food intake (DiMaria-Ghalili & Amella, 2005). Body composition changes, such as increased body fat and decreased lean body mass, are common in aging, leading to functional impairment and physical disability (Hughes et al., 2004; Janssen et al., 2002).
Malnutrition in hospitalized older adults is associated with prolonged hospital stays, increased risk of poor health outcomes, and greater likelihood of institutionalization (Margetts et al., 2003). Low scores on nutritional assessments are also predictors of prolonged hospital stays and mortality (Sharkey, 2008).
Assessment of Nutritional Status
Nutritional status assessment in older adults focuses on identifying malnutrition and its risk factors. The Mini Nutritional Assessment (MNA) is a comprehensive two-level tool designed for screening and assessing malnutrition in hospitalized older adults (DiMaria-Ghalili & Guenter, 2008). The MNA’s validity and reliability in this population are well-documented (Salva et al., 2004). If a patient’s score on the screening section is below 12, a more detailed assessment is recommended to compute a malnutrition indicator score.
The MNA’s screening section includes six questions that are easy to administer, while the assessment section requires measurements such as midarm muscle circumference and calf circumference. Although these measurements are simple to obtain, nurses may need training to use these tools effectively as part of routine assessments. Protocols should be in place to determine appropriate interventions, including consultations with dietitians, based on the data collected.
Additional assessment strategies include accurate measurement of height and weight and a detailed weight history. Direct measurement of height is preferred over patient self-report, with knee height and demi-span measurements being useful alternatives when standing height is not feasible (Salva et al., 2004). Calorie counts or dietary intake analyses are also effective methods for assessing nutritional intake during hospitalization (DiMaria-Ghalili & Amella, 2005).
Laboratory indicators of nutritional status, such as serum albumin, transferrin, and prealbumin, can provide insights into visceral protein levels, but their usefulness is limited during acute illness due to the effects of inflammation. Despite these limitations, albumin remains a strong prognostic marker for morbidity and mortality in older hospitalized patients (Sullivan et al., 2005). Future nutritional assessments may incorporate inflammatory biomarkers as research progresses.
Interventions and Care Strategies
Nursing interventions for malnutrition in older adults aim to enhance nutritional intake through a range of strategies, from basic care practices to advanced medical interventions such as parenteral or enteral nutrition. Before initiating any nutritional intervention, it is essential to determine if the patient cannot eat, should not eat, or will not eat (ASPEN, 2002). Factors to consider include the functionality of the gastrointestinal tract and any health conditions that may contraindicate normal food intake. If the gastrointestinal tract is functional, efforts should focus on promoting adequate oral intake.
Nursing Care Strategies
Nursing care strategies should aim to increase food intake and optimize the environment to promote eating. When functional or mechanical factors limit a patient’s ability to eat, interdisciplinary consultations with speech therapists, occupational therapists, physical therapists, psychiatrists, and dietitians can help develop strategies to improve self-feeding or provide necessary assistance.
Oral nutritional supplements have been shown to improve nutritional status in malnourished older adults (Capra et al., 2007). Such supplements should be administered at least 60 minutes before meals to maximize their effectiveness (Wilson et al., 2002). Specialized nutritional support, including parenteral or enteral nutrition, should be reserved for specific cases where oral intake is inadequate or contraindicated (ASPEN, 2002). The location and type of feeding tube used will depend on the patient’s medical condition, duration of tube feeding required, and risk of aspiration.
Patients receiving specialized nutritional support should be regularly reassessed for the continued need for these interventions and transitioned to oral feeding when feasible. Additionally, advance directives should be reviewed and updated, if necessary, before initiating specialized nutritional support (see Chapters on Health Care Decision Making and Advance Directives).
Enhancing Nutritional Intake in Older Adults
Improving nutritional intake in older adults requires targeted interventions that address both the physiological and psychological barriers to eating. This can involve adjusting meal times, enhancing the flavor and presentation of food, and creating a more conducive dining environment.
Modifying Mealtimes
Mealtimes can be modified to promote better nutritional outcomes, such as increasing the frequency of meals or offering nutrient-dense foods. The liberalization of therapeutic diets is often recommended, particularly for those with life-limiting illnesses or those who struggle to consume adequate nutrition (Dorner, Friedrich, & Posthauer, 2010). Smaller, more frequent meals may increase fluid intake but do not necessarily result in greater food consumption (Taylor & Barr, 2006). Some studies suggest that “smaller eaters” may benefit from enhanced caloric content in meals (Castellanos, Marra, & Johnson, 2009).
Research also indicates that dining room settings may encourage greater calorie consumption without necessarily impacting protein intake or weight gain (Gaskill et al., 2009; Wright, Hickson, & Frost, 2006). However, the social environment can play a crucial role, as social engagement during meals has been shown to improve intake and functional ability (Beck, Damkjaer, & Sorbye, 2010).
Feeding Assistance and Staff Training
Effective feeding assistance is critical for improving nutritional intake in older adults, particularly those with functional impairments. Studies have demonstrated that trained feeding assistants can significantly increase caloric intake and improve weight among older adults (Simmons et al., 2008). Unfortunately, training for feeding assistance is often inadequate in acute care settings, where it is most needed.
The implementation of formal dining assistant programs in nursing homes, such as the 8-hour New York State program, aims to improve nutrition by educating staff on effective feeding techniques (New York State Department of Health, 2007). While these programs focus primarily on safety and feeding tasks, they should also address interpersonal communication and environmental modifications to promote a positive dining experience.
In acute care settings, the absence of training materials for direct care workers regarding meal facilitation, environmental alterations, and personalized strategies is a significant gap. Staff shortages and concurrent meal breaks for personnel and patients further complicate mealtime management, as reported by hospital nurses in the UK who noted improved patient food intake when nurses took breaks at different times (Dickinson, Welch, & Ager, 2008).
Environmental and Social Interactions
The dining environment significantly affects the eating behaviors and nutritional intake of older adults. Simple changes, such as improving lighting, reducing noise, and playing calming music, can positively influence appetite (Hicks-Moore, 2005; McDaniel et al., 2001). Using contrasting colors for tableware and maintaining consistent table settings can aid those with visual impairments (Ellexson, 2004).
Proper positioning using supportive chairs rather than eating in bed can promote better eating posture, while family involvement during meals can enhance both food intake and social interaction (Altus et al., 2002; Nijs et al., 2006). In nursing homes, meals served in small groups that mimic family dining are ideal, although this approach primarily affects staff perceptions and their willingness to engage with the meal process (Kofod & Birkemose, 2004).
Interdisciplinary Collaboration for Nutritional Care
Nutritional health is best managed through an interdisciplinary approach, involving dietitians, healthcare providers, speech and language pathologists, occupational therapists, and social workers. Collaboration across disciplines allows for the development of comprehensive nutritional plans tailored to individual needs, particularly for older adults transitioning between care settings.
Strategies that have proven effective include “meal rounds” by dietitians and food service supervisors to identify and address potential nutritional risks early, especially for patients with swallowing difficulties or those requiring assistance during meals (Keller, 2006).
Cognitive Impairments and Nutritional Challenges
Cognitive impairments present unique challenges to nutrition, as individuals with severe cognitive deficits may exhibit behaviors that make it difficult to assist with meals. Such behaviors are significantly associated with increased mortality (Amella, 2002; Mitchell et al., 2009). High-calorie supplements have shown some success in increasing intake among those with cognitive impairments, although the evidence for other nutritional and social interventions remains weak (Hanson et al., 2011).
Instrumental in managing these challenges is understanding the stages of resistive eating behavior, as assessed by tools like the Edinburgh Feeding Evaluation in Dementia (EdFED) (Watson & Deary, 1997). Nurses can use these principles to tailor feeding strategies that accommodate the unique needs of cognitively impaired patients, promoting dignity and safety during feeding.
Summary
Addressing the nutritional needs of older adults in healthcare settings is complex and multifaceted. Effective assessment requires a comprehensive approach that considers the individual’s medical, psychological, and social circumstances, as well as the broader environmental factors that influence eating behaviors. Interventions should focus on enhancing mealtime environments, providing individualized assistance, and promoting social engagement to improve both nutritional intake and overall well-being. A patient-centered approach, involving a multidisciplinary team, is essential to optimize the nutritional health and quality of life for older adults.