Most people mistakenly believe that Americans become malnourished because they do not have the financial resources to buy food, but malnourishment is usually caused by dozens of interconnected factors like disease, prescription medications, poor nutrient absorption, difficulty chewing or swallowing, and depression.
Malnourishment can happen at any age, but seniors are at the highest risk of malnourishment. Elderly malnutrition is a hidden epidemic that affects almost 1 out of every 2 older adults.
Elderly nutrition problems can be hard to recognize but need to be taken seriously. The effects of malnutrition in adults can be wide-reaching and life-threatening, especially in older adults. Seniors can be malnourished even if they are a normal weight or overweight and even if they do not look malnourished or sick.
Here is what seniors, caregivers, and family members need to know about malnutrition in elderly adults including what causes malnourishment, how it can be recognized, and treatment options.
What Does Malnutrition Mean?
There is no widely accepted definition of “malnutrition” but it’s generally accepted to mean under-nourished. Malnutrition most often refers to any of the following that result in an adverse effect on someone’s health, function, or body composition:
- Caloric deficiency
- Deficiency of nutrients, vitamins, or minerals
- Imbalance of nutrients, vitamins, or minerals
Someone may be malnourished if they are not getting enough calories and experience involuntary weight loss. It can also refer to someone who is not getting enough protein, vitamin C, or other necessary nutrients.
Malnutrition can come in many forms. Protein energy malnutrition or protein-energy undernutrition in seniors is most common.
Elderly Malnutrition & Why It Happens
As we age, we usually become more sedentary. Combined with natural changes to body composition and bodily functions, this leads to reduced muscle mass and increased body fat. While this naturally comes with a reduced caloric need, seniors are at high risk of malnutrition.
Anorexia of aging, or the reduced appetite and food intake in the elderly, is a major factor in malnutrition with serious consequences. This term was coined to describe a number of conditions common among frail elderly people that aren’t simply part of a traditional syndrome or disease.
Nutritional concerns for elderly people are complicated. Along with natural changes in appetite and nutritional needs, seniors often have health concerns that make it hard to get the nutrition they need. Geriatric nutrition is also complicated by medications and unique issues like bereavement, depression, finances, and living conditions.
Causes & Risk Factors for Malnutrition in Older Adults
Malnutrition in older adults is a complicated issue. There is rarely a single cause; most malnourished seniors are dealing with interconnected issues that contribute to malnourishment. Natural changes that come with aging already contribute to nutritional concerns for elderly people, but disease, medical interventions, and external factors can combine to make malnutrition a greater threat.
There are many risk factors for malnutrition in elderly people ranging from environmental to psychological and physiological. The most common risk factors and underlying causes of malnutrition are often called the “nine D’s” of geriatric weight loss. Other factors can also be involved in malnutrition including living conditions, financial resources, accessibility of food, and whether the senior has a social and family network.
Dysphagia (Difficulty Swallowing)
A common problem experienced by the elderly is an inability or difficulty swallowing, eating, or drinking. It affects about 15% of seniors. Along with malnutrition and dehydration, dysphagia can even cause pneumonia as liquids and food are misdirected to the lungs.
Dysphagia can be caused by:
- Natural loss of throat muscle and function
- Medication side effects
- Gastroesophageal reflux disease (GERD)
- Neuromuscular disorders like ALS
- Cancer of the esophagus, throat, or mouth
Dysgeusia (Reduced Sense of Taste)
Changes in taste are common in older people. Some experience a persistent bitter, salty, or metallic taste while others find their sense of taste muted, completely absent, or familiar tastes dramatically changed. Dysgeusia can be caused by medications, smoking, changes in the tongue, oral health problems, nutritional deficiencies, inflammation, neurological disorders, and nerve damage. Beyond the age of 50, taste bud cells also lose their sensitivity and regenerate less frequently.
Reduced sense of taste can decrease appetite by affecting quality of life and the enjoyment of eating. Up to 17% of adults experience dysgeusia at some point, but it’s even more common in seniors. One study found up to 11% of elderly people taking multiple medications experience this side effect.
Many forms of physical dysfunction can contribute to malnutrition. Reduced gut integrity and function can cause intestinal infections and impair nutrient absorption. Immune system dysfunction can cause more frequent and severe infections and reduced wound healing, both of which can cause malnutrition. Seniors with physical disabilities may struggle to get and prepare food.
Drugs (Medication Side Effects or Drug Interactions)
Medications are a commonly overlooked cause of malnutrition in the elderly. Because older adults are more likely to have one or more chronic medical conditions, the rate of polypharmacy (using multiple drugs) increases. One study found that 43% of surveyed seniors took more than one medication and 51% of them were taking five or more medications. The more medications an older adult takes, the greater the risk of nutritional problems.
The most commonly used classes of medications to treat seniors are:
- Gastrointestinal agents such as laxatives, anti-diarrheals, and antacids
- Diuretics to treat high blood pressure, renal disease, and heart failure and reduce excess fluid
- Antihypertensives to control blood pressure
- Antihyperlipidemics to treat high cholesterol
- Analgesics including NSAIDs and opioids for pain management
- Beta-adrenoceptor antagonists (Beta blockers) designed to reduce blood pressure
Many medications can cause nutritional concerns for elderly patients. Drugs can reduce nutrient absorption, affect appetite, make it difficult to swallow, lead to dry mouth and oral health problems, and other complications that directly lead to malnutrition in seniors.
Virtually any diseases or conditions can contribute to malnutrition in the elderly. Older adults who have had a stroke or have chronic obstructive pulmonary disease (COPD) or cardiac disease have a higher nutritional need yet they frequently fail to reach protein and nutrition goals. The dietary recommendations for diabetes can also be challenging for geriatric patients. Health conditions can contribute to nutritional imbalance or malnourishment which can worsen the underlying conditions and lead to microvascular disease.
Chronic diarrhea is a major risk factor for weight loss, malnutrition, and dehydration. It affects about 10% of seniors and can be disabling. It can be caused by everything from colorectal cancer, inflammatory bowel disease, and irritable bowel syndrome to medications. Malnutrition can happen when seniors avoid foods that seem to trigger diarrhea, experience impaired nutrient absorption, or due to side effects of medications to treat chronic diarrhea.
Dementia doesn’t just impair memory and activities of daily living; it also affects everything from posture to physical function. Weight loss due to malnutrition often precedes dementia’s onset and it tends to worsen as the disease progresses. People who have dementia may not remember to eat and develop changes in appetite, preferences for food, and difficulty swallowing. Between 13% and 57% of dementia patients have difficulty swallowing.
New research even shows that malnutrition is a good predictor for faster functional loss in dementia.
About 1-5% of older adults who are living in the community experience major depression. 11.5% of hospitalized seniors and 13.5% of seniors who require home health care experience depression. Older adults living in nursing homes may be at the highest risk of depression.
One study found 14.4% of participants in nursing homes had major depression, 14.4% had minor depression, and 18.6% were diagnosed as “depressive” according to records and physicians. However, less than half of nursing home residents with major depression were diagnosed as depressive, half were receiving antidepressants, and almost 18% were receiving antidepressants without a diagnosis.
Depression can be caused by chronic pain, financial issues, abuse, chronic health conditions, reduced function, loneliness, and bereavement. It can lead to reduced appetite and has been shown to be a predictor for poor nutrition and weight loss that leads to malnutrition.
Tooth loss, poor oral health, and poorly fitting dentures can all limit a senior’s choice of food and their ability to chew. Malnutrition also affects oral health and may lead to tooth decay, gum disease, and other issues when bacteria and acids in the mouth become imbalanced.
About 57% of older adults between 65 and 74 wear dentures, according to the American Dental Association. About 70% of seniors have at least one lost tooth. The use of complete dentures, especially improperly fitting dentures, is associated with malnutrition in geriatric people. However, using partial dentures is associated with better nutrition compared to older adults who do not wear dentures.
Changes in Hunger Hormones
A hormone known as peptide YY tells the brain when you’ve had enough to eat. Research shows that this hormone may be overactive in elderly people who then feel full long before they have eaten enough food. A University of Plymouth study found that participants over 80 had the highest levels of peptide YY. Interestingly, aging doesn’t reduce level of ghrelin, or the hormone that tells the brain we’re hungry, as previously thought.
Living in a Nursing Home
Sadly, older adults living in a long-term care setting are at high risk of becoming malnourished. According to estimates, 12-50% of seniors in hospitals are malnourished compared to 23-60% of seniors in nursing homes and other long-term care facilities. Some estimates place the rate of malnutrition in nursing homes at 40 to 85%.
Symptoms of Malnutrition in Elderly People
Malnutrition in the elderly is a shockingly common problem that’s often missed, not just by families but even medical professionals. There are many validated tests for nutritional screening, but the signs of malnutrition in adults are frequently missed which can increase the risk of mortality and morbidity, reduce quality of life, and cause more frequent and longer hospital stays.
Important malnutrition in elderly symptoms include:
- Unintended weight loss (5% or more of body weight) even in overweight people
- Reduced strength
- Weakening hand grip
- Unsteady gait
- Clothes appearing baggy
- Dentures that look like they are floating in the mouth or changes in how dentures fit
- Eating less at meals than usual
- Wounds that are slow to heal
- Getting sick more frequently
- Swelling in the belly, ankles, or legs
- Frequent or recurring diarrhea, vomiting, or nausea
Unintentional Weight Loss: One of the Most Crucial Malnutrition Symptoms
The most obvious sign of malnutrition to watch for is unintentional weight loss. This is usually defined as 5% or more of body weight over 1 to 12 months. It’s estimated that up to 7% of the general population experiences involuntary weight loss of 5% or more, about 27% of frail seniors 65 and older experience unintentional weight loss.
Unintended weight loss can be caused by many things, but malnutrition should be one of the first suspicions in elderly adults. Unfortunately, this is one of the most misunderstood malnourishment symptoms.
Even overweight adults can become malnourished, especially older adults. Yet seniors who are perceived to be at a healthy weight or overweight are often not even assessed for malnourishment. Weight loss may even be viewed positively in overweight adults.
Using a Malnutrition Screening Tool for Elderly People
If you are concerned and believe a loved one may be malnourished, there are several geriatric nutrition screening tools you can use. The results of these assessments can then be discussed with your loved one’s healthcare professional.
- MNA Mini Nutritional Assessment Tool. This validated geriatric nutrition assessment tool can be used to identify seniors who are malnourished or at risk of malnourishment. There are two versions: the MNA Mini Nutritional Assessment and the Self MNA Mini Nutritional Assessment for older adults to use themselves. This is the go-to senior malnutrition screening tool among geriatric dieticians and medical professionals.
- DETERMINE Checklist. The DETERMINE Your Nutrition Health Checklist is an acronym for Disease, Eating poorly, Tooth loss/mouth pain, Economic hardship, Reduced social contact, Multiple medications, Involuntary weight loss, Needs assistance with self-care, and Elder years over 80. There are 10 yes-or-no questions.
The MNA assessment tool is used by many dieticians and medical providers because it’s validated and designed specifically for geriatric patients. The DETERMINE Checklist is also a helpful assessment tool but it isn’t appropriate for all cases, especially nursing home residents.
The results of the screening tool should be discussed with a medical provider so necessary intervention can be taken as quickly as possible.
Nursing Interventions for Malnutrition in the Elderly
Nurses play a critical role in preventing, recognizing, and treating malnourishment in seniors. Dieticians and other medical professionals are also involved in malnutrition intervention or monitoring patients at very high risk.
Research shows that multifactorial interventions are most effective at treating malnutrition in elderly people to improve function and frailty than any single treatment. Malnutrition treatment for elderly patients can include:
- Exercise, including neck and throat exercises
- Assessing and reducing medications
- Provide oral nutrition supplements
- Providing multiple, smaller meals that are nutrient-dense
- Offering foods the senior enjoys and can eat without discomfort or difficulty
- Assessing and treating underlying conditions that contribute to malnourishment
- Addressing oral health and ensuring dentures are properly fit
- Evaluating environmental changes that can make eating more enjoyable or easier
- Provide adaptive devices for seniors who have physical impairments
- Assess seniors for depression and loneliness and provide counseling, therapy, social meals, and other interventions
How long does it take to recover from malnutrition?
Early intervention is very important with elderly malnutrition. If caught early, malnourishment can be reversed fairly quickly. The longer it goes on, the harder it is to treat malnutrition in the elderly. It can take several months to recover from malnutrition, but frail elderly people may suffer serious consequences even after treatment.
Elderly Malnutrition Consequences
The effects of malnutrition in elderly people are serious, long-lasting, and affect everything from physical function and independence to quality of life, ability to heal, and overall health.
Potential consequences of malnutrition in the elderly include:
- Increased risk of falls
- Greater risk of hospitalization
- Longer hospital stays
- Loss of independence
- Increased mortality
- Increased morbidity
- Worsening of other existing conditions including dementia
- Reduced ability to heal from injuries and illnesses like sepsis, burns, and surgery
Death from malnutrition in the elderly is the biggest risk. Unintentional weight loss is a major predictor of mortality with 9% to 38% of people passing away within 1 to 2.5 years of losing 5% or more of their body weight. People who experience 5% or more unintended weight loss within one month have a 4x higher mortality rate.
Malnutrition in Nursing Homes – a Potential Sign of Neglect
If you suspect a loved one in a nursing home is malnourished, it’s important to take action quickly. Like dehydration in the elderly, malnourishment can be a sign of nursing home neglect. Nursing homes have a duty to provide residents with adequate medical care and supervision which includes recognizing risk factors for malnutrition, assessing patients regularly, developing customized treatment plans, and treating malnourishment quickly to prevent serious complications. Unfortunately, neglect is often the result in understaffing in nursing homes.
If you believe your loved one is at immediate risk of harm, you can call 911 for help. Otherwise, your long term care ombudsman can help investigate your concerns and find a resolution.
Your next step may be contacting a nursing home neglect lawyer to help. An attorney can help you hold the negligent nursing home accountable to recover compensation for the harm your loved one has suffered. This can be used to ensure your loved one receives the care and quality of life they deserve.
Berman & Riedel, LLP is a San Diego law firm specializing in nursing home abuse and neglect. We represent nursing home residents and their families throughout California. Contact our law office today to discuss your case and how we can help with a free case review.