Physicians, physician assistants, nurse practitioners, nurses, dietitians, and pharmacists are among the numerous healthcare professionals who manage malnutrition in patients (Table 2).2,21 Together, the team should develop a strategy that is specific and individualized for a given patient.2 The strategy should be compatible with the patient’s lifestyle, financial situation, and resources available for implementation.2,21 Regular evaluations using consistent nutritional parameters are imperative to ensure the best possible outcome is achieved.2 The patient’s healthcare team must communicate often and effectively to make certain an optimal plan is in place that maximizes patient adherence.12,21
Seven elements of patient management are advised for addressing malnutrition.
Speech-language pathologists and physical and occupational therapists work directly with patients, family members, and caregivers to support overall nutritional intake. Speech-language pathologists assist in the evaluation, diagnosis, and treatment of communication (eg, language comprehension and expression) and dysphagia. Speech-language pathologist interventions may include use of specialized compensatory strategies, altering the patient’s diet, and training and education to improve safe eating and drinking.
Physical therapists assist in the evaluation, diagnosis, and treatment of functional limitations such as pain; decreased strength, endurance, and flexibility; poor balance; and insufficient postural control that can compromise the ability to effectively consume meals. Physical therapist interventions may involve exercises and activities that focus on the reduction of physical impairments to improve performance and functional mobility.
Occupational therapists evaluate and provide interventions that consider physical, cognitive, social, emotional, environmental, and cultural elements of feeding, eating, and swallowing. Occupational therapist interventions may focus on the reduction of positioning problems, psychosocial needs, and use of adaptive equipment that improve a patient’s ability and willingness to acquire nutrition.
This method is generally used as a first-line approach in patients who are deemed mildly malnourished or at risk for malnourishment and who do not have dysphagia.3 If a patient is unable to give reliable information regarding food and nutrient intake, this information should be obtained from a caregiver or another reliable source.21 This approach calls for 6 small meals to be eaten at approximately equal intervals throughout the day, and for individuals to have access to foods and beverages that meet their nutritional needs and taste preferences.2 Oil, butter, margarine, cream cheese, sauces, honey, and sugar may be added to foods to increase caloric content and improve taste.2 Plain water should be substituted with drinks with more nutritional content such as milk or juices.2 Food should look appealing and have a texture and taste that the individual is able to tolerate well.2 Meals should be consumed in a comfortable and relaxed environment to promote maximum food intake.2
For patients who are unable to consume enough protein and nutrients, oral drink supplements are an alternative source to aid in the achievement of daily nutritional requirements.2,18 A variety of different supplements provide a range of nutritional benefits including high energy, high protein, and high fiber; these should be chosen on the basis of individual need.2 Supplements come in many forms and flavors, and should be chosen based on the individual’s ability to properly prepare the supplement and taste preferences.2
Although results have not been conclusive, data from studies suggest that nutritional supplements be given at a midway point between meals for optimal results.2 The use of nutritional supplements should be regularly evaluated to ensure the patient is tolerating it well and receiving proper nutritional benefit.2 In the elderly, high-quality supplements have been shown to promote healthy aging and improve age-related problems and diseases.18
A continuous program of physical activity including aerobic exercise and resistance training can provide a broad range of physiologic benefits that help maintain or improve overall functional mobility.22,23 Muscle mass is the largest reservoir of body protein and its preservation is important for maintaining nutritional status and physical function.24 Older malnourished patients are at increased risk for muscle mass loss, and a combination of exercise and high protein intake is recommended to help maintain and build these stores.18,24 Strength exercise conducted 2 to 3 times per week over the course of 9 weeks has been shown to be effective in increasing muscle mass in healthy to moderately impaired individuals.24 Consuming a protein supplement directly after exercise has been shown to increase the effect of exercise on muscle mass.18,24 Patients with serious disease complications or a recent catastrophic event may not be able to tolerate exercise and should consult with a physician before beginning a regimen.24
Appetite stimulants are rarely indicated to help patients achieve increased appetite because of interactions with other medications, resulting in unwanted adverse effects.2 Antidepressants can improve mood and overall well-being and increase the desire to eat and maintain health in elderly patients who demonstrate signs of depression.15 Dentures may be appropriate for individuals with poor dentition to increase the range of foods that can be easily consumed.19 Other pharmacologic therapy and medical interventions should be prescribed according to individual needs.
Programs that provide food to the elderly have been shown to help prevent malnutrition and ensure nutritional needs are met. The Administration on Aging (AOA) provides communal and personal, home-delivered meals and other nutrition-related services to elderly individuals.25 The AOA stipulates that all meals generated with their funds must provide one-third of an individual’s daily nutritional requirements.25 The elderly nutrition program provides a range of other services including helping participants learn how to shop, save, and prepare meals that are economical and healthy.20 Volunteers and paid staff who deliver these meals often spend time with individuals to alleviate loneliness and to identify any additional unrecognized medical problems that should be reported to the appropriate provider.25
As described earlier, malnutrition can lead to increased vulnerability to illness and poor clinical outcomes, and can increase mortality.2 Better outcomes can be achieved through preventive measures in at-risk individuals, rather than attempting to cure malnutrition after its onset. Elderly individuals who are not malnourished or who are at low risk for malnourishment should be regularly monitored for weight loss and screened for signs of malnutrition in an effort to decrease overall incidence. Clinicians should be aware of the signs and symptoms of malnutrition, along with the screening tests that help recognize and diagnose the condition, to prevent further progression.
James Haines, MPAS, PA-C, specializes in emergency medicine at Lake West Hospital in Willoughby, Ohio. David LeVan, DHSc, OTR/L, CSRS, is an associate professor in the Occupational Therapy Program at Gannon University in Erie, Pennsylvania. Michele M. Roth-Kauffman, JD, MPAS, PA-C, is the founding program director of the Physician Assistant Program at Gannon University in Ruskin, Florida.
2. Burton-Shepherd A. Preventing malnutrition in the home-dwelling elderly individuals. Br J Community Nurs. 2013;18(10):25-31
3. Legrain S, Tubach F, Bonnet-Zamponi D, et al. A new multimodal geriatric discharge-planning intervention to prevent emergency visits and rehospitalizations of older adults of older adults: the optimization of medication in aged multicenter randomized controlled trial. J Am Geriatr Soc. 2011;59(11):2017-2028.
4. Bell CL, Tamura BK, Masaki KH, Amella EJ. Prevalence and measures of nutritional compromise among nursing home patients: weight loss, low body mass index, malnutrition, and feeding dependency: a systematic review of the literature. J Am Med Dir Assoc. 2013;14(2):94-100.
5. Morley JE. Assessment of malnutrition in older persons: a focus on the mini nutritional assessment. J Nutr Health Aging. 2011;15(2):87-90.
6. Poulia K-A, Yannakoulia M, Karageorgou D, et al. Evaluation of the efficacy of six nutritional screening tools to predict malnutrition in the elderly. Clin Nutr. 2012;31(3):378-385.
7. Jeejeebhoy KN, Keller H, Gramlich L, et al. Nutritional assessment: comparison of clinical assessment and objective variables for the prediction of length of hospital stay and readmission. Am J Clin Nutr. 2015;101(5):956-965.
8. Kane R, Shamliyan T, Talley K, Pacala J. The association between geriatric syndromes and survival. J Am Geriatr Soc. 2012;60(5):896-904.
9. Riches K, Jeanes Y. The prevalence of malnutrition in elderly residents in a warden-assisted setting compared with home-living environment. Br J Community Nurs. 2014;19(7):324-327.
10. Rose KM, Lorenz R. Sleep disturbances in dementia: what they are and what to do. J Gerontol Nurs. 2010;36(5):9-14.
11. Ronqve A, Boeve BF, Aarsland D. Frequency and correlates of caregiver-reported sleep disturbances in a sample of persons with early dementia. J Am Geriatr Soc. 2010;58(3):480-486.
12. Cole CS, Richards KC. Sleep in persons with dementia: increasing quality of life by managing sleep disorders. J Gerontol Nurs. 2006;32(3):48-53.
13. Solemdal K, Sandvik L, Willumsen T, Mowe M, Hummel T. The impact of oral health on taste ability in acutely hospitalized elderly. PLoS ONE. May 2012;7(5):e36557.
14. McQuaid K, Gastrointestinal disorders. In: Papadakis M, McPhee S. Current Medical Diagnosis and Treatment. 53rd ed. San Francisco, CA: McGraw Hill; 2014;66:556-562.
15. Yoshimura K, Yamada M, Kajiwara Y, Nishiguchi S, Aoyama T. Relationship between depression and risk of malnutrition among community dwelling young-old and old-old elderly people. Aging Ment Health. 2013;17(4):456-460.
16. Cartwright A. Time to recognise dysphagia as a contributing factor to malnutrition. Br J Community Nurs. 2013;Suppl Nutrition:S6.
17. Ekberg O, Hamdy S, Woisard V, Wuttge-Hannig A, Ortega P. Social and psychological burden of dysphagia: its impact on diagnosis and treatment. Dysphagia. 2002;17(2):139-146.
18. Bauer J, Biolo G, Cederholm T, et al. Evidence-based recommendations for optimal dietary protein intake in older people: a position paper from the PROT-AGE study group. J Am Med Dir Assoc. 2013;14(8):542-559.
19. Lopez-Jornet P, Saura-Perez M, Llevat-Espinosa N. Effect of oral health dental state and risk of malnutrition in elderly. Geriatr Gerontol Int. 2013;13(1):43-49.
20. Heuberger RA, Caudell K. Polypharmacy and nutritional status in older adults. Drugs Aging. 2011;28(4):315-323.
21. White JV, Guenter P, Jensen G, Malone A, Schofield M. Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition. J Acad Nutr Diet. 2012;112(5):730-738.
22. Pahor M, Guralnik JM, Ambrosius WT, et al; for the LIFE study investigators. Effect of structured physical activity on prevention of major mobility disability in older adults: the LIFE study randomized clinical trial. JAMA. 2014;311(23):2387-2396.
23. Yeom HA, Keller C, Fleury J. Interventions for promoting mobility in community-dwelling older adults. J Am Acad Nurse Pract. 2009;21(2):95-100.
24. Carlsson M, Littbrand H, Gustafson Y, et al. Effects of high-intensity exercise and protein supplement on muscle mass in ADL dependent older people with and without malnutrition-a randomized controlled trial. J Nutr Health Aging. 2011;15(7):554-560.
25. Administration for Community Living (ACL). Nutrition services. ACL website. https://acl.gov/programs/health-wellness/nutrition-services. Updated November 13, 2019. Accessed December 26, 2019.