Nutrition in older people

Christine Eberhardie, TD ,MSc, RGN, RNT , FHEA, Cert HSM, is honorary principal lecturer in nursing, Faculty of Health and Social Care Sciences, Kingston University and St George’s Hospital Medical School

Causes of malnutrition

There are many reasons why older people become malnourished. Comprehensive assessments of the individual should identify the specific causes. Nutritional assessment and screening is discussed in a separate article but other factors, which contribute to malnutrition, should be addressed including:

• Bowel function;
• Continence;
• Swallowing;
• Oral health;
• Mobility;
• Dexterity;
• Respiratory function;
• Cognition and mood.

Identifying small but potentially influential problems can help to prevent malnutrition. The inability to unscrew jars or carry shopping; to walk to the shops because of sore feet or fear of incontinence all contribute to changes in diet which may lead to malnutrition. Other contributing factors may be due to lifestyle changes and life events. Some examples are:

• More sedentary lifestyle following retirement without a change in dietary intake can lead to weight increase.

• The financial implications of living on a reduced income.

• Social isolation which can come from any of the following reasons;
  – Loss of local shops
  – Inability to drive
  – Changes in public transport
  – Loss of a partner.

Physical problems may cause malnutrition. Many older adults have ill-fitting dentures and require dental treatment. Failing sight, hearing and smell may increase the older persons risk of storing decaying food and acquiring a gastrointestinal infection when these are consumed.

Normal ageing includes physiological changes such as a less acute sense of taste, a fall in basal metabolic rate, decline in muscle mass and tone, and impaired swallowing. Changes in the small intestine can result in lactose intolerance (McLaren and Crawley, 2000). Older people do not necessarily want large, heavy meals.

Mealtime patterns and environment

The timing and spacing of meals is a very individual experience but for this group of clients’ alterations in them can be very beneficial. For example if the patient has gastro-intestinal reflux a change to having the main meal in the middle of the day and a light snack no less than four hours before going to bed can reduce the risk of regurgitation and aspiration during the night.

The environment in which the patient is served the meal can encourage or dissuade him from eating it. In hospital, the sounds and smells of someone nearby having tracheal suction, a drain changed or using a bedpan can lead to a reduced appetite.

Reducing distractions and sensory stimuli can improve the eating experience for the person with dementia. This includes:

• Minimising the number of patterns and colours on the tablecloth and mats;
• Identifying a specific area for meals to be served;
• No television or radio playing although very restful background music may help (Hotaling 1990);
• Finger foods may be more suitable for the restless agitated patient.

Often the only thing stopping a patient with disability from being independent at mealtimes is the lack of eating or drinking aids. Cutlery with a larger grip, angled or combination cutlery, rubber non slip mats, egg cups with suction pads to attach them to the plate, cups with two handles or padded handled can make a big different to an individual’s independence (Eberhardie, 2005)

Nutritional supplements

Nutritional supplements are very popular and come in many forms such as fortified drinks, vitamin and mineral tablets and capsules. It is a key role of the nursing assessment of any patient is to discover what prescribed and over the counter nutritional supplements are being used but especially in older people who may be using a combination of prescribed drugs, over the counter, herbal remedies and nutritional supplements. There may be interactions between some of these that may be harmful for the patient.

Recent research shows how important it is to recognise the effects of non prescribed supplements preoperatively for example, high-dose vitamin E and some other remedies can increase the risk of haemorrhage (Skinner and Rangasami, 2002). Nutritional supplements are coming under greater control from the European Union (Eberhardie, 2007). Whether this legislation will help to reduce the effect of such dangerous cocktails has yet to be seen.

Involving the multiprofessional team

The risk of malnutrition in older people is great but there are many ways in which nurses can help to prevent malnutrition by careful assessment of all the possible factors, which could contribute to it. Some involve the wider healthcare team of speech and language therapist, dietitian, occupational therapist, doctor or dentist. Others can be managed by nurses, for example, rearranging the patient’s daily routine or environment, using domestic aids or helping the individual to make some life changes.

Conclusion

It is essential that nutrition in older people is seen as a therapy and not a social activity.

References

Eberhardie, C. (2005) Assessment of eating skills and the nutritional process in neurological disability, British Journal of Neuroscience Nursing; 1: 4, 172-176.

Eberhardie, C. (2007) Nutritional supplements and the EU: is anyone happy? Proceedings of the Nutrition Society; 66: 4, 508-511.

Hotaling, D.L. (1990) Adapting the mealtime environment: setting the stage for eating. Dysphagia; 5: 2, 77-83.

McLaren, S., Crawley, H. (2000) Managing Nutritional Risks in Older Adults. Nursing Times Clinical MonographNo 44. London: Emap.

Skinner, C.M., Rangasami, J. (2002) Preoperative use of herbal medicines: a patient survey. British Journal of Anaesthesia; 89: 5, 792-795.

Further reading

Neno, R. et al (2007) Older People and Mental Health Nursing :A Handbook of Care. Oxford : Blackwell.

Watson, R., Heath, H. (eds) (2005) Older People:Assessment for Health and Social Care. London: Age Concern

Websites

Age Concern

British Nutrition Foundation

European Food Safety Authority

Food standards Agency

Nutrition For Physically Frail Older People

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