Aims and intended learning outcomes

The aim of this article is to support nurses to consider their role in the prevention, identification and management of malnutrition in older people in the community. After reading this article and completing the time out activities you should be able to:

Introduction

Malnutrition is a common and significant issue among older people in the UK and a major cause of ill health (Elia and Russell 2009). In simple terms, malnutrition is an imbalance between what a person eats and drinks and what their body requires, and it can be caused by the lack of one or more nutrients (undernutrition) or by an excess of nutrients (overnutrition) (Hickson 2006). The European Society for Clinical Nutrition and Metabolism defines malnutrition as ‘a state resulting from lack of uptake or intake of nutrition leading to altered body composition (decreased fat free mass) and body cell mass leading to diminished physical and mental function and impaired clinical outcome from disease’ (Cederholm et al 2015). In this article, malnutrition refers to undernutrition.

Malnutrition is not an inevitable part of ageing or illness. However, unintended weight loss, which is characteristic of malnutrition, is associated with the loss of skeletal muscle mass and function with age, reduced immune function, frailty, falls, fractures and premature mortality (Schaible and Kaufmann 2007, Lorenzo-López et al 2017, Söderström et al 2017, Cruz-Jentoft and Sayer 2019).

More than three million people in the UK are malnourished or at risk of malnutrition, most of whom (93%) live in the community (Elia and Russell 2009). Due to the ageing population, alongside the increasing prevalence of dementia and other long-term conditions, the number of older people with malnutrition is increasing. In 2015, malnourished adults accounted for around 15% of hospital outpatient clinic attendances, 10% of people presenting to GPs, 30% of hospital admissions and 35% of care home admissions (Elia 2015).

This article discusses the causes and consequences of malnutrition in older people and considers the role of the nurse in screening, care planning and management.

Causes of malnutrition

Often the causes and consequences of malnutrition in older people are interlinked and can become a ‘vicious cycle’. Box 1 shows the medical, physical and social risk factors for malnutrition in older people.

The ageing process may precipitate malnutrition, for example due to: sensory impairment such as reduced smell and taste; inadequate dentition; and delayed gastric emptying or disturbed gut motility leading to functional decline of the ageing gut and altered colonic microbiota (Rémond et al 2015, An et al 2018). The coronavirus disease 2019 (COVID-19) pandemic has exacerbated the risk of malnutrition in older people due to public health protection measures such as social distancing and visiting restrictions. The psychological consequences of isolation, such as symptoms of depression and anxiety or altered mental state, can affect people’s appetite and interest in eating, thus reducing their nutritional intake (Boulos et al 2017).

Malnutrition and unintentional weight loss in older people can have a significant effect on their quality of life due to increased susceptibility to disease, negative clinical outcomes and mortality (Söderström et al 2017). Malnutrition is a risk factor for early admission to social care services and is associated with increased readmissions to hospital, longer hospital stays and increased GP appointments (Elia 2015).

The complexity and interlinking of causes of, and risk factors for, malnutrition in older people can make it challenging for nurses to identify the root cause and develop and implement a person-centred care plan.

Malnutrition screening

Malnutrition is a cause and consequence of ill health, as illustrated in the video in Time out 2, so there is a need for timely identification and interventions to improve patient outcomes and to reduce health and social care costs. The National Institute for Health and Care Excellence (NICE) (2017) guideline on nutrition support for adults recommends screening patients for malnutrition and risk of malnutrition in the community. According to Edington et al (2004), such screening can result in substantial cost savings by reducing healthcare resources. Screening should be undertaken by healthcare professionals with appropriate skills and training, integrated into existing pathways of care and followed up with appropriate actions to manage people identified as malnourished or at risk of malnutrition (NICE 2017).

The Malnutrition Universal Screening Tool (MUST) (Elia 2003) is the most commonly used validated malnutrition screening tool in the UK and is endorsed by the Royal College of Nursing and the British Dietetic Association. The MUST is a screening tool rather than a diagnostic tool, and it is used to identify patients at risk of malnutrition based on objective anthropometric measures, including body weight, height and amount of weight lost, as well as clinical judgement (Elia 2003). Support and treatment measures are implemented based on the outcomes.

The MUST is used to assess malnutrition in adults in multiple care settings. NICE (2017) guidelines state that in the community screening should be undertaken on a person’s initial registration with a GP practice, at other clinic opportunities such as during health checks or influenza vaccinations, and wherever there are clinical concerns, for example unintentional weight loss or loss of appetite.

Despite these national recommendations, there are challenges associated with the use of the MUST by healthcare professionals in the community, including limited time to undertake the process, low prioritisation of nutrition, lack of ease in using certain aspects of the tool, lack of nutritional knowledge and assessment skills, lack of suitable equipment such as weighing scales and lack of training in malnutrition screening (Bracher et al 2019, Harris et al 2019). Embedding and sustaining malnutrition screening and treatment in routine practice requires senior leadership teams to prioritise and commit to nutritional care (Murphy et al 2020a).

NICE (2017) guidelines do not specify the timing and frequency of malnutrition screening for older people living at home, and healthcare organisations should have local policies that cover this.

Person-centred care planning

A person-centred care plan should always be developed if screening identifies that a person is malnourished or at risk of malnutrition. The NICE (2012) quality standard on nutrition support in adults recommends that ‘people who are malnourished or at risk of malnutrition have a management care plan that aims to meet their complete nutritional requirements’. Older people identified at risk of malnutrition should be given ‘food-first’ advice, which means they should be encouraged to consume a range of nutrient-dense foods and to eat little and often (NICE 2017, Smith 2021).

Food fortification and oral nutritional supplements

Food fortification involves adapting meals and snacks by adding small quantities of everyday foods, such as cream, butter, olive oil, skimmed milk powder, soy protein powder, cheese, peanut butter or ground nuts, to increase energy and nutrient content without significantly increasing portion sizes. Using skimmed milk powder to fortify full-fat milk can increase protein intake and when made up can be stored in the fridge and used for cereal, drinks and desserts. Local dietetic departments may have resources on food fortification and recipes, while the British Dietetic Association has produced a fortified diet recipe book (Smith 2021). It is important that nurses seek specialist nutrition support from a dietitian where necessary (NICE 2017).

Prescribed oral nutritional supplements can be used in addition to a normal diet – not as food replacement – when diet alone is insufficient to meet a person’s daily nutritional requirements in disease-related malnutrition. Healthcare organisations’ local nutrition policies should contain information on when to commence oral nutritional supplements, but this is typically following a period of food-first.

There are various types of supplements available, for example milkshakes, juice, soups, shakes, puddings, powdered drinks and pre-thickened or high-fibre supplements. Healthcare organisations should have a local nutrition formulary that provides information on the most appropriate first choice of supplements, which is often based on cost-effectiveness and is updated regularly as new products become available and product prices change.

Conclusion

Malnutrition can have significant negative effects on older people’s health and quality of life. Nurses working in the community have an integral role in the identification and management of malnutrition in older people because they often have close and regular contact with this population and work as part of a multidisciplinary team and with community, public sector and voluntary organisations. Nurses working in the community are in an optimal position to provide person-centred nutritional care and to refer older people to appropriate support to meet their nutritional needs.