Call for mandatory screening to cut the risk of malnutrition in older people

Old age comes with many challenges, including concerning levels of malnutrition. The issue is particularly worrying among older people recently admitted to residential care.

Better diet can reduce the risk of age-related diseases and allow older people to remain independent. Yet simple screening and early intervention to improve older people’s nutrition are often overlooked, even though they could make a substantial difference. They could reduce needless burden for individuals as well as saving money from health budgets.

Our study, published in the Australasian Journal on Ageing today, assessed the nutrition status of 167 participants within a district health board region in Auckland, New Zealand. We found that a quarter of older adults were malnourished and 35% were at high risk of malnutrition.

Almost half of the older people recently admitted to residential care were malnourished, compared to 23% for those in hospital and just 2% for those living in the community. The latter tended to be younger.

The Australian and New Zealand Society for Geriatric Medicine has published a position statement on under-nutrition and the older person, suggesting screening should occur in all settings.

In New Zealand and Australia, nutrition screening is not mandatory. While some processes for reporting malnutrition are in place in Australia, the issue is under-reported and poorly documented in New Zealand.

Changing taste and appetite

Older people are known to be at disproportionate risk of malnutrition. As people age, a number of physiological changes can compromise their ability to eat a healthy diet.

Loss of appetite and changes to the sense of taste contribute to the risk of malnutrition. Inefficiencies in the absorption of essential nutrients mean people need to eat more of a nutrient-dense diet even though they need less energy.

Dental and chewing problems make people avoid certain foods, and reduced mobility can make access to high-quality, fresh foods more difficult.

Nutritional risk is commonly defined as a combination of factors that impair food intake and can eventually lead to malnutrition. A review of longitudinal studies identified several key risk factors, including age, frailty, a general decline in health, loss of interest in life, difficulty swallowing and institutionalisation.

Health conditions can contribute to inadequate food intake, but they can also result from it. Malnutrition is associated with higher infection rates, loss of muscle mass, strength and function, longer hospital stays, as well as increasing risks of disease and premature death.reference?

Malnutrition in older people is a global issue

Like other OECD countries, New Zealand has a rapidly ageing population, due to an increase in life expectancy and lower fertility rates.

Our study reflects the results of international research, which showed the highest prevalence of nutrition risk during early admission to aged residential care (43% at nutrition risk and 47% malnourished).

International analysis also showed levels of malnutrition of 5.8% in the community, 38.7% in hospital, 50.5% for rehabilitation facilities and 13.8% in nursing homes.

In Australia, about half of the residents in aged care are reported to be malnourished. Similar or higher levels are reported internationally.

In the same settings that we studied – community living, residential care or hospital – overseas research has shown that between 15% and 71% of older residents are malnourished, and between 40% and 60% are at risk of under-nourishment. The fact that the prevalence of malnutrition tends to increase with the length of stay is of particular concern.

Other international studies also report that up to 60% of elderly hospital patients are malnourished.

At least in one international study, poor care does not play a direct role in the residents’ malnutrition. However, evidence suggests paying attention to how much residents eat, providing rich and protein-dense foods and using nutritional supplements can help those at risk of malnutrition.

The next steps towards improvement

Our study was a pilot, which aimed to take a snapshot of malnutrition risk in three accommodation settings. We are now recruiting larger numbers of older adults living independently or in early admission to hospital or aged residential care to gain a better understanding of the issue.

We want to investigate how the problem differs for people living in different types of accommodation to develop a targeted approach for effective intervention.

In the community, poor nutrition affects older people before ill-health appears. Early detection of malnutrition to counteract the decline of health is therefore a cost-saving strategy.

Similarly in hospitals or residential care, awareness that an older person is eating very little should warrant referral to a dietitian for nutritional intervention.

Our study highlights the need for mandatory screening in all settings. Nutrition risk screening is a simple and cost-effective way of identifying malnutrition early and reducing the burden on people and health care facilities.