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• To remind yourself of the importance of screening older people for malnutrition
• To enhance your awareness of the crucial elements of a holistic nutritional assessment
• To find practical guidance on how to undertake a holistic nutritional assessment with an older person
Rationale and key points
Nutrition is a fundamental aspect of nursing care, however older people cared for in hospital, in a care home or in their own home do not always receive adequate support with their nutritional needs, which can leave them at risk of malnutrition. Using a holistic, biopsychosocial framework to support a comprehensive nutritional assessment that includes malnutrition screening can support the nurse to identify the older person’s nutritional status and nutrition needs. Nurses undertaking this procedure must ensure they have the knowledge and skills to do so and work within the limits of their competence.
• Malnutrition in older people can lead to a decline in functional ability, reduced muscle strength, fatigue, impaired immunity, suboptimal wound healing, increased risk of infection and increased risk of falls.
• Screening for, and assessing the risk of, malnutrition is an important part of nursing assessments in any healthcare setting.
• A holistic nutritional assessment should incorporate physiological, psychological, emotional, spiritual, social and cultural elements.
Reflective activity
‘ How to’ articles can help to update your practice and ensure it remains evidence based. Apply this article to your practice. Reflect on and write a short account of:
• How this article might improve your practice when undertaking a holistic nutritional assessment with an older person.
• How you could use this information to educate nursing students or your colleagues on the appropriate techniques and evidence base for undertaking a holistic nutritional assessment with an older person.
Nursing Older People. doi: 10.7748/nop.2024.e1481
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
Waight S, Board M (2024) How to undertake a holistic nutritional assessment with older people. Nursing Older People. doi: 10.7748/nop.2024.e1481
DisclaimerPlease note that information provided by Nursing Older People is not sufficient to make the reader competent to perform the task. All clinical skills should be formally assessed according to policy and procedures. It is the nurse’s responsibility to ensure their practice remains up to date and reflects the latest evidence
Published online: 07 August 2024
Nutrition is a fundamental aspect of nursing care and nurses are responsible for ensuring that patients have adequate access to food and fluids and for providing assistance to those who cannot feed themselves or drink unaided (Nursing and Midwifery Council (NMC) 2018a). However, older people admitted to hospital, living in a care home or cared for in the community are at risk of not receiving adequate support with their nutritional needs (Malnutrition Task Force 2021), which can leave them at risk of malnutrition.
The British Association for Parenteral and Enteral Nutrition (BAPEN) (2024a) has defined malnutrition as ‘a state of nutrition in which a deficiency or excess of energy, protein and other nutrients causes measurable adverse effects on tissue/body form (body shape, size and composition), function and clinical outcome’. While malnutrition can refer to undernutrition and overnutrition, this article focuses on malnutrition as meaning undernutrition.
Malnutrition and the risk of malnutrition have been found to be prevalent in adults aged over 65 years who also have frailty, cardiovascular disease or neurological conditions such as stroke or dementia (Malnutrition Action Group 2023). The potential consequences of malnutrition in older people include a decline in functional ability, reduced muscle strength, fatigue, impaired immunity, suboptimal wound healing, increased risk of infection and increased risk of falls (Tait 2022).
Screening for, and assessing the risk of, malnutrition is an important part of nursing assessments in any healthcare setting (Craig 2019, Baic 2021). The National Institute for Health and Care Excellence (NICE) (2017) guideline on nutrition support for adults recommends that nutritional screening should be provided to:
• All hospital inpatients on admission (and weekly thereafter).
• All hospital outpatients at their first clinic appointment (and when there is clinical concern thereafter).
• People admitted to a care home on admission (and when there is clinical concern thereafter).
• People registering at a GP practice on registration (and when there is clinical concern thereafter).
‘Clinical concern’ in this context includes unintentional weight loss, fragile skin, poor wound healing, apathy, wasted muscles, poor appetite, altered taste sensation, impaired swallowing, altered bowel habits, loose fitting clothes and/or prolonged illness (NICE 2017).
NICE (2017) recommends that nutritional screening should include assessing the person’s body mass index (BMI), percentage unintentional weight loss, and time period over which there has been a reduction in nutrient intake. To conduct these assessments, NICE (2017) suggests using the Malnutrition Universal Screening Tool (MUST).
The MUST was developed to identify adults in hospital, community and other care settings who are malnourished, at risk of malnutrition (undernutrition) or obese. It includes management guidelines which can be used to develop a care plan (BAPEN 2024b). The MUST calculator (www.bapen.org.uk/must-and-self-screening/must-calculator) uses objective measures including height, weight and weight loss to obtain a score and risk category, or, when it is not possible to obtain objective measures, subjective measures including mid upper arm circumference (MUAC) and clinical impressions to estimate a risk category (BAPEN 2024c). The MUST toolkit is available online (www.bapen.org.uk/must-and-self-screening/must-toolkit).
Holistic nursing involves understanding the different aspects of the patient’s life (Frisch and Rabinowitsch 2019) and uses a biopsychosocial model of assessment, focusing on the unique contextual meaning of the person’s life beyond any disease and medical condition (Kitson 2018). A holistic nutritional assessment will therefore include physiological, psychological, emotional, spiritual, social and cultural elements. This will ensure that subsequent nutritional care and support are based on the person’s individual needs, thereby promoting person-centred care.
• Before you meet the patient, familiarise yourself with the MUST and how to use it to calculate the patient’s risk of malnutrition (if you are not already aware of how to use it or experienced in using it). If using the paper version of the MUST, ensure you have the paperwork ready.
• Ensure you have access to appropriate weighing scales and a tape measure.
• Ensure you have a working knowledge of food-based interventions to support the nutritional care plan and interventions you will need to develop following the assessment – for example, assistance during mealtimes, oral nutritional supplements, fortified foods and nutrient-rich snacks such as cheese and crackers and thick, creamy yoghurts.
• Ensure you are aware of how to refer the patient to other members of the multidisciplinary team – such as dietitians, speech and language therapists and medical professionals – depending on the outcomes of the assessment.
• Ensure you have access to nursing documentation to record the outcomes of the assessment.
• Prepare the environment to protect the patient’s dignity and privacy and to support them to communicate their needs.
• Ask the patient if they would like a family member or carer (referred to as family/carers throughout the rest of the article) to be present during the assessment. Family/carers can provide or expand on information regarding patients and can support them in implementing nutrition care plans and advice.
• Ensure the patient has access to any supports, such as hearing aids and glasses, to enable them to actively participate in the assessment.
• Explain the purpose and process of the assessment to help to reduce any anxiety or confusion about what it involves.
• Ask the patient to verbally consent to you undertaking the assessment.
During the assessment, it is important that you are attentive and listen to what the patient says, since this will help establish a trusting relationship. At the end of the assessment, you will need to document all findings in the patient’s notes.
1. Use the MUST (www.bapen.org.uk/pdfs/must/must-full.pdf) to assess the patient’s risk of malnutrition. Follow each of the five steps and document the outcomes. The five steps are:
• Measuring the patient’s height and weight to calculate their BMI.
• Noting the percentage of unplanned weight loss and score, using the tables provided in the tool.
• Establishing the acute disease effect and score.
• Adding scores from steps 1, 2 and 3 to obtain the overall risk of malnutrition.
• Developing a care plan, including referral as appropriate, using the management guidelines provided in the tool and/or local policy.
2. If you cannot obtain the patient’s height and/or weight, measure their MUAC to estimate their BMI. Use the MUAC alongside your clinical impression of the patient’s nutritional risk based on, for example, obvious wasting, loose fitting clothes and/or jewellery, history of decreased food intake, reduced appetite or swallowing difficulties, underlying health and/or psychosocial conditions (BAPEN 2011).
3. As an alternative screening tool you can use The Patients Association (2022) Nutrition Checklist (www.patients-association.org.uk/Handlers/Download.ashx?IDMF=db830c67-e823-4ed9-895d-d542dc4d247f). This tool was developed for use by formal and informal carers to help them identify older people at risk of undernutrition through engaging them in conversations on the topic. The questions in section A of the tool have been validated against the MUST. Sections B to D aim to help identify those at risk of malnutrition based on their answers to section A and provide a framework for offering basic nutrition advice and signposting to support services.
4. Measure and record the patient’s vital signs including pulse, blood pressure and respiratory rate. For inpatients, use a tool such as the National Early Warning Score (NEWS) 2 (Royal College of Physicians 2022) to ensure any signs of deterioration are detected quickly.
5. Explore physiological factors that may adversely affect the person’s ability to maintain optimal nutrition – for example, current health status, medicines, mobility, functional ability, bladder and bowel function, oral health and pain. Physical issues, such as nausea, loss of taste and smell, poor oral health and/or ill-fitting dentures can adversely affect the person’s nutritional intake.
6. Examine the patient for signs and symptoms of dehydration, such as dry mouth, lips or tongue. Dehydration can result in delirium and/or confusion, which in turn will adversely affect nutritional intake.
7. Enquire sensitively about the patient’s emotional state and well-being – for example, in the case of an older person living in their own home, by asking them whether they live alone and/or how they are coping. This can help identify factors such as loneliness, low mood or anxiety that can adversely affect their appetite. These factors can also be considered within the social and cultural element of the assessment.
8. If appropriate, for example in patients with new-onset confusion and/or suspected acute-onset delirium, use a tool such as the 4AT Rapid Clinical Test for Delirium (Bearn et al 2018, MacLullich 2024).
9. Ask the person ‘What’s most important to you right now?’ and ‘How can we help?’. These two simple questions can be used as an informal approach for assessing a patient’s spiritual needs (McSherry et al 2019). The absence or presence of factors that are important to the patient – for example a particular ritual they undertake before, during or after a meal – may influence their dietary habits and therefore nutritional health.
10. Social and cultural factors influence people’s dietary choices. To explore the social and cultural aspects of nutrition, ask questions such as (Purnell 2019):
• Do you avoid specific foods?
• Which foods do you eat to balance your diet?
• Which foods do you eat every day?
• What time do you eat each meal?
• What do you drink with each meal?
• Which foods do you eat as part of your cultural heritage?
• Who does the shopping in your household?
11. Other social and cultural factors to consider include the patient’s lifestyle, social environment, housing, ability to shop for and cook food, food affordability, social connectedness and social relationships. Explore these factors, as appropriate, in a sensitive manner.
Malnutrition in older people is associated with a range of biological, psychological, spiritual, social and cultural factors (Murphy 2022), therefore a holistic nutritional assessment is essential to identify the risk of malnutrition and support the provision of appropriate nutritional support and interventions. Undertaking a holistic nutritional assessment with an older person enables nurses to work in partnership with the person and their family/carers, and other healthcare professionals where appropriate, to eliminate or reduce the risk of malnutrition (Craig 2019).
Using a biopsychosocial framework and a person-centred approach should be integral to all nursing assessments (NICE 2017, NMC 2018b). Using a biopsychosocial framework and a person-centred approach for nutritional assessments will help nurses to identify and understand the patient’s individual nutritional care needs (Frisch and Rabinowitsch 2019) and suggest appropriate nutritional support interventions (Davis 2023).
As well as undertaking nutritional screening to assess the person’s risk of malnutrition, it is important to consider potential physiological factors that may increase the risk, or be an underlying cause, of malnutrition.
Malnutrition may be a consequence or side effect of a particular health condition, such as cancer; of certain medicines that may be causing nausea or reduced appetite, such as antibiotics or antidepressants; of a long-term condition that may make it challenging for the person to eat, such as dementia; or of a mechanical issue such as dysphagia. Moreover, physical issues, such as arthritis, sight loss or limited mobility, can make it challenging for the older person to shop, prepare and cook food independently while poor dentition can make it challenging to eat well (Malnutrition Task Force 2021). The Malnutrition Task Force (2021) has suggested that dehydration among older people appears to be widespread, is one of the most common reasons for hospital admission and is associated with falls, so it is vital to include this aspect in a holistic nutritional assessment.
Psychological and emotional issues can adversely affect an older person’s appetite and their relationship with food. Older people are more likely to eat less or eat less nutritious food when they are experiencing anxiety, low mood, apathy, stress or depression (Chelvanayagam et al 2020). Factors associated with a decline in mental health in later life include loneliness, bereavement, isolation and lifestyle changes such as retirement (Naylor et al 2016). Psychological and emotional health is therefore an important aspect of a holistic nutritional assessment. Using a person-centred approach can help establish trust (Kitson 2018), which may make it easier for the person to disclose psychological or emotional issues.
The NMC (2018b) standards of proficiency require nurses to consider people’s spiritual needs as well as their mental, physical, cognitive, behavioural and social needs when assessing needs and planning care. In the context of culture or religion, food can be associated with rituals, practices, symbols and meanings (Purnell 2019). A spiritual assessment involves enquiring positively about the person’s spiritual or religious needs (McSherry et al 2019) and exploring their faith and health beliefs, including what matters to them in times of illness and crisis (Timmins and Caldeira 2017). Establishing trust, for example by listening attentively and asking questions sensitively, can mean that the older person is more likely to communicate what is important to them (McSherry et al 2019). Nurses may not feel confident in undertaking a spiritual assessment, therefore McSherry et al (2019) suggested using an informal approach that consists of asking two simple questions: ‘What’s most important to you right now?’ and ‘How can we help?’.
Social and cultural factors influence people’s dietary choices, likes and dislikes and the way they consume food. They often also define the role of food in people’s life (Purnell 2019). Factors to consider in the context of a holistic nutritional assessment include the patient’s lifestyle, social environment, housing, ability to shop for and cook food and food affordability as well as their values and beliefs regarding food, such as what types of food are acceptable, edible or offensive, how food is prepared and when food is eaten (World Health Organization 2024). Exploring contextual factors such as social connectedness and social relationships in a sensitive manner can provide the nurse with information about the person’s mood and thought processes (Davis 2023). This information can, in turn, help the nurse identify factors that may adversely affect the person’s appetite, food choices and nutritional status (Chelvanayagam et al 2020).
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