Managing malnutrition in older adults in the community during the COVID-19 pandemic
Intended for healthcare professionals
Evidence and practice    

Managing malnutrition in older adults in the community during the COVID-19 pandemic

Sue Baic Registered Dietitian, Nutrition Basics, Bristol, England

Why you should read this article:
  • To understand the effects of COVID-19 on older adults’ nutritional status

  • To enhance your knowledge of how to undertake screenings for malnutrition during the COVID-19 pandemic

  • To learn about practical interventions that you could use to identify and manage malnutrition risk among older adults in the community during the COVID-19 pandemic

The COVID-19 pandemic has resulted in an increase in the number of older adults in the community who are at risk of malnutrition. Vulnerable groups include people recovering at home from mild-to-moderate COVID-19, those discharged from hospital after severe infection and those who have undergone extended periods of social isolation as a result of the public health measures in place to reduce the spread of infection. Various COVID-19-specific malnutrition care pathways and resources are available, and this article details practical interventions that can assist nurses caring for older adults in the community to identify and manage malnutrition risk.

Nursing Older People. doi: 10.7748/nop.2021.e1311

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

@suebaic

Correspondence

sue.baic@nutritionbasics.co.uk

Conflict of interest

Sue Baic is a registered dietitian and external consultant to Wiltshire Farm Foods, and has been commissioned by the company to write this article. The views expressed are those of the author alone

Baic S (2021) Managing malnutrition in older adults in the community during the COVID-19 pandemic. Nursing Older People. doi: 10.7748/nop.2021.e1311

Published online: 07 April 2021

Even before the advent of the COVID-19 pandemic in 2020, it was estimated that more than three million people in the UK are at risk of malnutrition. Of these people, approximately 1.3 million are adults over the age of 65 years, 93% of whom were living in the community (British Association for Parenteral and Enteral Nutrition (BAPEN) 2018).

The physical and psychosocial consequences of COVID-19 have predisposed previously healthy older adults to the risk of malnutrition, and this may persist long after the initial infection. The COVID-19 pandemic has also exacerbated this risk in non-infected but vulnerable groups as a result of public health measures such as social distancing, quarantine and shielding, which have been implemented by the UK government to prevent the spread of COVID-19 (Barazzoni et al 2020, NHS England 2020).

While COVID-19 is a new disease that requires ongoing research, the latest evidence suggests that older adults are at higher risk of severe illness (Barazzoni et al 2020, Lithander et al 2020). Evidence on the effects of COVID-19 on patients’ nutritional status has emerged and interventions for the prevention and management of malnutrition can be based on this, alongside research on the nutritional management of other respiratory conditions with similar characteristics, such as chronic obstructive pulmonary disease (COPD), lung cancer and acute respiratory distress syndrome (Merriweather et al 2016, Wright 2020, Wang et al 2020).

Key points

  • Malnutrition can be defined as a lack of food energy, protein and micronutrients, which leads to adverse effects on the body’s composition and function, and can also result in suboptimal health outcomes

  • The physical and psychosocial consequences of COVID-19 have predisposed previously healthy older adults to the risk of malnutrition

  • Nurses caring for older adults have an important role in identifying those who are at significant risk of malnutrition and emphasising the role of good nutrition in supporting their recovery

  • Nurses supporting older adults with COVID-19 can signpost them to resources that provide practical suggestions for meals and snacks, food fortification and the use of oral nutritional supplements

Malnutrition and the COVID-19 pandemic

Malnutrition can be defined as a lack of food energy, protein and micronutrients, which leads to adverse effects on the body’s composition and function. It can also result in suboptimal health outcomes, for example prolonging patients’ recovery from disease or surgery, as well as reducing their immunity and responses to treatment (BAPEN 2018). Malnutrition is also a risk factor for early admission to social care services and is associated with more readmissions to hospital, longer duration of inpatient stays, more frequent GP appointments and higher prescription costs (Elia 2015, BAPEN 2018).

The COVID-19 disease itself, together with the side effects of treatments such as mechanical ventilation, may create favourable conditions for the development of malnutrition (Barazzoni et al 2020, Managing Adult Malnutrition 2020a, Morley et al 2020). COVID-19 can lead to severe fatigue and breathlessness, increased nutritional requirements and reduced appetite, which subsequently may affect patients’ muscle strength and food intake. Box 1 shows some of the factors associated with COVID-19 that may increase patients’ risk of malnutrition.

Box 1.

Factors associated with COVID-19 that may increase patients’ risk of malnutrition

Symptoms of COVID-19

  • Respiratory issues, for example persistent cough and breathlessness (dyspnoea)

  • Inflammation and fever that increase patients’ nutritional requirements and anorexia

  • Gastrointestinal symptoms, for example nausea, diarrhoea, indigestion or constipation

  • Fatigue, which can affect activities of daily living such as shopping and cooking

  • Impaired cognitive function

  • Severe impairment of taste and smell (dysgeusia and anosmia)

Side effects of treatment for COVID-19

  • Dry mouth from ‘mouth breathing’ while using inhalers or oxygen therapy

  • Dysphagia (swallowing difficulties) following mechanical ventilation

  • Sarcopenia (loss of muscle mass and strength)

  • Pain or discomfort

  • Anxiety, stress and low mood

  • Lack of physical activity

(Adapted from Managing Adult Malnutrition 2020a)

Research has shown that COVID-19 may affect the central nervous system directly, potentially resulting in a profound and long-lasting loss of smell and taste that is more severe than that experienced by people with a common cold or influenza (Huart et al 2020). This can severely reduce appetite in older adults. In addition, many of the barriers that older adults may experience in maintaining their nutritional status, such as restricted social networks or access to nourishing and affordable food, have become increasingly challenging to overcome during the COVID-19 pandemic. For example, social isolation resulting from extended periods of shielding, quarantine or social distancing can contribute to mental and physical health issues such as loneliness, depression and fatigue, subsequently increasing the risk of malnutrition (Gale et al 2018, Lithander et al 2020).

These social restrictions have also resulted in a reduction in the provision of meals from lunch clubs and day centres, as well as lower levels of assistance or prompts to eat, cook or shop from family members, friends and/or carers (Boulos et al 2017, Managing Adult Malnutrition 2020a). The absence of friends, family members and/or carers at mealtimes has also been recognised as a significant risk for reduced food intake in older adults (Locher et al 2005, Conklin et al 2014, Ruddock et al 2019).

Several other factors associated with older age can contribute to malnutrition in those who contract COVID-19 – such as stress, anxiety, low mood, cognitive decline and confinement – and may also cause changes in eating and lifestyle behaviours. For example, an older adult with COVID-19 might replace meals with less nutritious snacks and have fewer opportunities for physical activity, which may in turn reduce their appetite (Macht 2008).

Sarcopenia (loss of muscle strength and mass) in older adults is a common side effect of respiratory infections. Sarcopenia can affect the skeletal and respiratory muscles, leading to frailty, challenges in returning to normal daily function, greater risk of falls and complications such as chest infections (British Dietetic Association (BDA) 2020, Brugliera et al 2020, Wright 2020).

Effects of diet in COVID-19

No specific food or dietary supplement is known to prevent infection with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus that causes COVID-19, or hasten recovery from it. However, a varied diet that provides sufficient calories and protein can support normal immune function and enhance recovery from infection (Stratton et al 2003, Holdoway et al 2017). Suboptimal food intake can also negatively affect the mental health of older adults, potentially leading to cognitive impairment, low mood and reduced quality of life, all of which may already be adversely affected by COVID-19 and social restrictions (Centre for Ageing Better and Ipsos MORI 2020).

Screening for malnutrition risk

Nurses caring for older adults have an important role in identifying those who are at significant risk of malnutrition, raising awareness that this is not an inevitable factor in their illness or ageing, and emphasising the role of good nutrition in supporting their recovery from COVID-19 and other conditions.

Nutritional screening is a simple method of identifying patients who may be at risk of malnutrition, after which assessment, support measures and treatment interventions can be implemented. Traditional validated screening tools, such as the Malnutrition Universal Screening Tool (MUST) (BAPEN 2003, 2020), assess malnutrition risk using objective anthropometric measures – for example height, normal weight and amount of weight lost (Barazzoni et al 2020).

Where infection prevention and control measures such as social distancing impede nurses from taking these measurements in person, patients can be asked to self-report these anthropometric measures. Alternatively, patients and their carers can use online self-screening tools such as the BAPEN malnutrition self-screening website (www.malnutritionselfscreening.org). Nurses can also use this website as part of their remote healthcare consultations, and using such tools can be empowering for patients and their carers.

Where it is not possible to obtain anthropometric measures from the patient, opportunistic screening using questions about more subjective criteria can also assist the nurse to formulate a clinical impression of a patient’s malnutrition risk (BAPEN 2020). For example, it can be useful to ask patients and carers about the presence of ‘red flags’ that can indicate malnutrition, including (Managing Adult Malnutrition 2020a):

  • Unintentional weight loss.

  • Appearance of ‘thinness’.

  • Clothes, rings or watches becoming loose-fitting.

  • Poor appetite or loss of motivation or interest in meals.

  • Reduced food intake or issues with eating or drinking.

  • Physical or financial challenges with shopping or cooking.

Individuals who report unintentional weight loss and/or appearing thin alongside a poor appetite and/or suboptimal food intake commonly present a medium-to-high risk of malnutrition (Holdoway et al 2017, BAPEN 2020).

Being overweight or obese appears to increase the risk of contracting COVID-19 and experiencing severe effects (NHS England 2020). People who are overweight or obese may still be at high risk of the physical and psychosocial effects of unplanned weight loss and malnutrition, so they should be screened where this is suspected (Volkert et al 2019).

Managing malnutrition

As a result of the COVID-19 pandemic, many local policies and care pathways for the management of malnutrition in the community have become increasingly flexible (Managing Adult Malnutrition 2020a), which has enabled healthcare professionals to work in an increasingly multidisciplinary way.

For most older adults at risk of malnutrition, a ‘food-first’ approach remains of primary importance as an effective intervention (BDA 2020), whereby individuals are encouraged to consume a range of nutrient-dense foods and to eat little and often. This can include regular meals alongside nutritious snacks, desserts and/or milky drinks every few hours. Even if the patient’s appetite is poor, this approach enables a gradual increase of the amount eaten on each occasion. Over-the-counter nutritious powdered drinks can also be purchased in supermarkets, pharmacies or online; however, these should be used to supplement a patient’s nutritional intake rather than to replace food (BDA 2020).

During older adults’ recovery from COVID-19 and/or malnutrition, it is important for nurses to recommend that patients consume an adequate fluid intake each day to maintain good hydration, alongside a protein intake that will enable them to regain muscle mass and strength, and repair tissues (Deutz et al 2014, Barazzoni et al 2020). Older adults considered to be at risk of malnutrition should also be encouraged to consume protein-rich foods such as meat, fish, eggs, dairy, beans or nuts as part of every meal (Managing Adult Malnutrition 2021).

In addition, fortifying a patient’s food with extra nutrients – for example adding four tablespoons of dried milk powder to a pint of whole milk – can assist in ensuring that even where a patient’s appetite is poor, the food they consume will significantly improve their nutritional intake (BDA 2020).

For many older adults, undertaking physical activity will also be important as part of their recovery from COVID-19 and/or malnutrition. Maintaining activities of daily living, for example bathing and/or showering and housework, as well as gentle, regular exercise, also have a role in stimulating muscle recovery and appetite (ICUsteps 2020).

Role of dietary supplements

A low level of vitamin D in the blood is relatively common in older adults, particularly in those with limited exposure to sunlight (NHS 2020). Vitamin D is found in few foods, but has an important role in bone and muscle health and in reducing frailty and the risk of falls (NHS 2020). Vitamin D may also have a role in increasing the immune response to respiratory viruses, although at the time of writing there was no evidence that vitamin D has a specific role in relation to COVID-19 (Lanham-New et al 2020). To protect musculoskeletal health, the NHS advises that all adults aged over 65 years should take a daily vitamin D supplement of 400 international units or 10 micrograms throughout the year (BDA 2019a, NHS 2020).

For individuals at medium-to-high risk of malnutrition due to COVID-19, and who are unable to meet their nutritional requirements via diet alone despite food-first interventions, the prescription of oral nutritional supplements may be appropriate. Oral nutritional supplements should provide approximately 400 calories and 30g of protein per day for 4-12 weeks, and represent a clinically beneficial and cost-effective management intervention (Stratton et al 2018, Barazzoni et al 2020).

Oral nutritional supplements should be consumed as an addition to meals rather than as a food replacement. They are available in a range of palatable flavours and types including juices and compact low-volume, high-energy formats, which are useful in patients whose appetite is highly restricted, such as those who are breathless or easily fatigued as a result of COVID-19 (Managing Adult Malnutrition 2020b). Some patients who have been discharged from hospital following COVID-19 will have been prescribed high-protein oral nutritional supplements until they are able to consume sufficient food to meet their nutritional requirements, and it is important that nurses encourage patients to take these.

Up to half of patients who have undergone mechanical ventilation as part of treatment for respiratory conditions such as COVID-19 may develop dysphagia (swallowing difficulties) that can persist for up to several months post-extubation (removal of an endotracheal tube) (Managing Adult Malnutrition 2020a). Those with severe dysphagia may require the texture of their meals and fluids to be modified for ease of swallowing – for example food may be softened or fluids thickened – alongside input from a speech and language therapist and a dietitian. Some people may find such texture-modified meals complicated and time consuming to prepare. In these cases, ready-to-eat, home-delivered, texture-modified meals can be a useful source of support and are available privately from companies, while oral nutritional supplements are available from medical nutrition support companies.

Providing information and resources

Nurses supporting older adults with COVID-19 can signpost them to resources that provide practical suggestions for meals and snacks, food fortification and the use of oral nutritional supplements. Evidence-based guidance and resources on malnutrition and COVID-19 have been produced to provide a consensus on how nurses can effectively meet patients’ individual needs, and some of these are summarised in Table 1.

Table 1.

Evidence-based resources for older adults at risk of malnutrition

ResourceIntended forContent
Managing Adult Malnutrition in the Community (2020) Eating Well During and After COVID-19 Illness
tinyurl.com/MAMC-green-leaflet
  • Patients at low risk of malnutrition, such as those with:

    • Good appetite

    • Absence of weight loss

  • Healthy eating in recovery

  • Accessing foods during social isolation

Managing Adult Malnutrition in the Community (2020) Improving Your Nutrition During and After COVID-19 Illness
tinyurl.com/MAMC-yellow-leaflet
  • Patients at medium risk of malnutrition, such as those with:

    • Poor appetite

    • Some weight loss

  • Optimising food intake

  • Managing symptoms

  • Accessing foods during social isolation

Managing Adult Malnutrition in the Community (2020) Nutrition Support During and After COVID-19 Illness
tinyurl.com/MAMC-red-leaflet
  • Patients at high risk of malnutrition, including those who are:

    • Underweight

    • Experiencing poor appetite

    • Experiencing weight loss

    • Living with a long-term health condition

  • Optimising food intake

  • Managing symptoms

  • Accessing foods during social isolation

  • Using food fortification

  • Using supplements

British Dietetic Association (2020) Nutrition at Home After Critical Illness
tinyurl.com/BDA-nutrition-at-home
  • Patients recovering at home after hospital discharge

  • Understanding common eating issues

  • Managing symptoms

  • Using food fortification

  • Increasing protein intake

  • Resuming healthy eating in the latter stages of recovery

Given the variation in patients’ symptoms, severity of the disease and treatment they may receive during the COVID-19 pandemic, there is not a ‘one-size-fits-all’ approach to dietary support. Rather, following an assessment, nurses should seek to assist patients with managing specific complications and symptoms such as weight loss, shortness of breath, loss of taste and smell, dysphagia or dry mouth. Many of the resources detailed in Table 1 can be shared with patients by email, which is particularly useful for patients in the community and/or those who may be self-isolating.

Where medium-to-high-risk individuals continue to experience issues such as weight loss, sarcopenia or suboptimal food intake despite first-line dietary advice, or where a person has complex co-morbidities that require multiple interventions – for example renal disease, type 2 diabetes or cardiovascular disease – then additional support involving referral to a local registered dietitian is indicated (Barazzoni et al 2020, Managing Adult Malnutrition 2020a).

Monitoring and further support

For nurses, other essential aspects of the effective long-term management of older adults with malnutrition in the community during the COVID-19 pandemic include (Managing Adult Malnutrition 2020a):

  • Undertaking regular progress reviews.

  • Supporting any person-centred goals the individual may have, such as returning to a desirable weight, improving their stamina or regaining normal functional independence.

  • Considering when to commence or discontinue oral nutritional supplements.

These interventions can be provided by nurses via remote and/or face-to-face consultations, depending on the social restrictions in place due to COVID-19.

Socio-economic factors

Nurses caring for older adults in the community should explore any social, psychological and economic reasons behind an individual’s weight loss or poor appetite. For example, during the COVID-19 pandemic some older adults may have altered their food shopping habits due to being either physically unable or unwilling to leave the house because of fear of infection or the social restrictions in place to reduce the spread of infection (Zhao et al 2020). In this case, appropriate support with accessing online food deliveries, including priority slots, can be useful. Those who are particularly vulnerable may require assistance to register with their local council to access essential supplies, including deliveries of food and medicines via NHS Volunteer Responders (nhsvolunteerresponders.org.uk). Support can still be accessed via local councils where there are local rather than national restrictions such as shielding measures in place.

In some areas, home delivery of ready-to-eat or frozen meals is available from local authority community services, for example ‘meals on wheels’ (www.gov.uk/meals-home). Nurses can also signpost patients and carers to a range of private companies that provide home deliveries of cooked meals, which are available across the UK. These home-delivery meals are designed to meet defined nutritional standards and can contribute to the management of malnutrition by promoting choice, variety and convenience for those individuals who remain able to prepare and heat the meals. Studies have shown increased nutrient intakes and improved health outcomes among vulnerable older adults who receive home-delivered meals (Roy and Payette 2006, Buys et al 2017, Denissen et al 2017, Cho et al 2018). Evidence has suggested that the familiarity, appeal and palatability of meals are particularly important considerations in the provision of home-delivered meals, as is the option to access smaller energy-dense meals and desserts (Locher et al 1998, Roy and Payette 2006, Buys et al 2017, Denissen et al 2017).

Nutritional intake can be promoted by eating with others, which also increases the quantity and variety of food consumed. Nurses can support this social aspect of eating by encouraging older adults to share home-delivered or home-cooked meals with friends or family members if possible (Conklin et al 2014, Ruddock et al 2019). At times when there are social restrictions in place to reduce the spread of infection, it is possible to do this remotely, using hands-free smartphone or video calls. If adequate technical support is not available, family members, friends, carers or healthcare professionals such as occupational therapists may be able to signpost older adults to sources of technological support.

Food insecurity (a lack of reliable access to sufficient affordable and nutritious food) has also increased since the beginning of the COVID-19 pandemic. For older adults in the community, this can lead to challenges with purchasing food and consuming sufficient nutrients to support immunity, optimal health and recovery from conditions such as COVID-19 (Public Health England and Food Standards Agency 2019).

Nurses can also support older adults who may have restricted food budgets, for example signposting them to factsheets that detail nutritious low-cost convenience foods, plant-based proteins, and providing ideas for affordable recipes (BDA 2019b). Nurses can also advise older adults, family members and carers on methods to reduce food waste, for example by using innovative recipes that include ingredients that would otherwise be discarded, as well as safe food storage and planning food shopping to reduce waste and maximise budgets (Love Food Hate Waste 2021).

Conclusion

Good nutrition has a crucial role in supporting the health of older adults during the COVID-19 pandemic, for example by promoting recovery from infection and contributing to the maintenance of immunity. Nurses caring for older adults can identify and monitor older adults’ risk of malnutrition, as well as providing dietary advice. Nurses can also signpost patients to practical support that will assist them in maintaining their nutritional intake during the pandemic.

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