Registered nurse and Age UK Malnutrition Task Force lead Lesley Carter explains how to identify and prevent malnutrition in older people in the community
Malnutrition in older people is not an inevitable part of ageing or illness. It is a serious condition and both a cause and consequence of ill health that, in most cases, is preventable.
Being malnourished leads to increased morbidity and reduced health-related quality of life, for example due to poor wound healing. It also puts older people at increased risk of admission and longer stays in hospital. However, many of us simply accept weight loss as a part of ageing so the signs of malnutrition can often go unnoticed until they have had a negative impact on a person’s health or wellbeing.1
The fact that so many people are now living into late old age should be a cause for celebration. However, living longer means nothing if you are not living well, and poor nutrition is a key factor affecting quality of life.
Furthermore, the failure to prevent malnutrition is costly for the NHS and social services. One study found the total health and social care costs for an individual who is malnourished are around three times those of someone who is not (£7,408 compared with £2,417 per year).2 Addressing the causes of malnutrition – and dehydration – is vital at a time when we all need to take the pressure off health and social care.
Malnutrition is preventable
There are three main reasons for malnutrition:
- Medical factors. Diseases such as cancer or chronic liver disease can lead to malnutrition, and will require highly specialist support.
- Physical factors. These include arthritis and other causes of limited mobility, sight loss, acute and chronic pain, dentition and oral health problems, chewing and swallowing difficulties.
- Social factors. These are possibly the most complex, difficult to diagnose and tricky to solve, and include low income, isolation or bereavement.
Disease-related malnutrition should usually be picked up and managed by the patient’s specialist hospital team. This article will focus on preventable malnutrition for older people in the community, which is usually related to physical or social risk factors, as significant numbers of at-risk older people live in their own homes or in care homes.
In a society encouraged to worry more about the health effects of obesity, it’s easy to overlook how serious malnutrition can be for older and more vulnerable people. Public health messages and policy are preoccupied with reducing levels of obesity, so weight loss has come to be seen as desirable.
More needs to be done to ensure that the public and health and care staff understand the risks of unintentional weight loss. Staff working in the community should be able to give clear and helpful advice to older people and their families.
Nurses have an important role in identifying and tackling the problem, and in making proper nutrition and hydration priorities in practice. The benefits of improving nutritional care and providing adequate and appropriate hydration are considerable, especially for those living with long-term conditions and the consequences of problems such as stroke, pressure ulcers or falls. The evidence shows clearly that if nutritional needs are ignored health outcomes are worse.3
How to take action in local communities
Older people and our local communities are facing some exceptionally tough challenges. The ongoing impact of Covid-19, as well as the cost-of-living crisis, means that even more older people are vulnerable and at risk of becoming malnourished. Within this context and as we approach winter, hydration and nutrition risks need to be identified and tackled in a timely way.
To do this, it is important for nurses and other healthcare professionals to screen systematically for malnutrition in vulnerable patients. Validated tools such as the Malnutrition Universal Screening Tool (MUST)4 can help to identify those at risk, who can then be referred for specialist support if required, signposted to appropriate advice and provided with support to eat and drink. In particular, for patients discharged from hospitals or clinics, information about their nutritional status must be passed on to their community care team.
What to look out for
The most obvious sign of malnutrition is unexpected weight loss. This may be gradual or sudden, and may be the result of illness or other factors. Subtle signs to look out for include:
- Ill-fitting clothing, tightened buckles, loose-fitting dentures or jewellery.
- Unusual feelings of lethargy or fatigue.
- Difficulty in planning, accessing and cooking food.
- A loss of, or reduction in, appetite.
- Difficulties with chewing or swallowing, or coughing and spluttering when eating.
- Recent ill health or diagnosis of a long-term condition, or another physical or mental health issue.
- Taking on a caring role.
- Other warning signs may be less evident but can be associated with malnutrition that develops slowly and goes unnoticed. These include:
– A change in personal circumstances, such as a bereavement.
– Symptoms of anxiety or depression.
How can nurses make an impact?
We are in difficult and challenging times and the rapidly growing number of vulnerable older people in the community makes tackling preventable malnutrition more important than ever. Nurses working in the community have a prominent position and responsibility to identify the risks.
Nurses can take the lead on this by:
- Making nutrition and hydration priorities in nursing practice to increase awareness of the need to keep older people well nourished in the community.
- Understanding that good nutrition and hydration underpins people’s health and wellbeing and supports them to stay healthy and independent for longer.
- Raising awareness to help all healthcare professionals, older people and their families and carers to recognise signs of unplanned weight loss, ensuring they have the information to spot a problem early on.
Practical approaches and tools
Sometimes, starting a conversation, giving a resource or signposting to local voluntary service organisations may be all that is needed to give a person the confidence to resume adequate eating and drinking.
Lunch clubs are opening again, and signposting older people to these will help them with loneliness and lack of confidence, as well as access to better nourishment (see Resources, below).
It is also worth linking up with local voluntary sector organisations like Age UK, who are making home visits and telephone calls specifically to help older and vulnerable people with nutrition.
We know there are barriers to using existing validated screening tools in the community. However, as well as the MUST tool, there are now other, simpler options available that have no need for scales and can still help to identify risks and start conversations. These tools have been developed for use in all community settings and there is guidance available on how to use them.5
In particular, the Patients Association Nutrition Checklist, and its interactive version the Nutrition Wheel⁶, offer a new approach to identifying ‘clinical concern’ for malnutrition risk at an early stage and the need for MUST screening in accordance with NICE.7
The Malnutrition Task Force (MTF), an initiative from Age UK and the British Association for Parenteral and Enteral Nutrition (BAPEN), in association with the Royal Voluntary Service and others, has a website that provides information for the public and professionals. All the resources are available to download or as hard copies, which can be given to people in the community.
The MTF is asking everyone to look for signs of risks of preventable malnutrition in the older people we love or care for, and is running a UK Malnutrition Awareness Week from 10-16 October, with the theme ‘Ask, Look, Listen’:
Ask. Ask how is the person’s appetite, has it changed, and are there any difficulties with cutting, chewing or swallowing food? Do they feel they are eating and drinking enough? Have they noticed any unplanned weight loss? Do they have any new or long-term concerns?
Look. Look carefully to assess how well the older person is doing, being on the lookout for tell-tale signs of unplanned weight loss such as looser clothing, rings or dentures. Note how they climb stairs, walk short distances and perform other activities of daily living. Also consider any caring role they might have, and keep your eyes open for signs such as empty fridges or cupboards, and appliances like fridges or cookers not working. Factors such as a local shop closing, inadequate access to public transport and whether they still have the ability to do their own shopping are also important.
Listen. Listen carefully to what older people are telling you. It may not be directly about eating and drinking but could be about loss, feeling lonely and low, losing interest in things or a lack of energy to take part in activities that usually give pleasure.
As part of the awareness week, the MTF will host a the MTF will host a conference, including a virtual, ‘Sharing of Practice’ learning day on 10 October.
Tackling malnutrition is everyone’s responsibility. We really are all in this together, especially as the effects of the cost-of-living crisis bite. Nurses can take the lead in the prevention and identification of malnutrition and helping to keep older people healthy and out of hospital for as long as possible this winter.
Lesley Carter is a registered nurse. She is clinical lead, professionals and practice, and Malnutrition Task Force Programme lead at Age UK
- Volkert D et al. ESPEN guideline on clinical nutrition and hydration in geriatrics. Clin Nutr 2019;38:10-47. Link
- Elia M. The cost of malnutrition in England and potential cost savings from nutritional interventions. Malnutrition Action Group, 2016. Link
- Stratton R, Green C, Elia M (Eds). Disease-related malnutrition: an evidence-based approach to treatment. CABI Publishing, Wallingford, UK, 2003.
- BAPEN. ‘MUST’ Calculator. Link
- Malnutrition Task Force. Using tools to start conversations about eating well in later life. Video, 2021. Link
- Malnutrition Task Force. The Nutrition Wheel. Link
- The Patients Association. Nutrition Checklist, 2021. Link
- Age UK. Social activities. Link
- Malnutrition Task Force.malnutritiontaskforce.org.uk. MTF resources include:
– The BAPEN self-screening tool Link
– Booklet: Eating well in later life. Link
– Case study: Lyn’s Story. Link
– UK Malnutrition Awareness Week. #UKMAW2022. Link
– UK Malnutrition Awareness Week Conference. Link